1. (a) the name of the nursing facility employee who is requesting the authorization;
2. (b) the Retroactive Authorization request submission date;
3. (c) the requested Medicaid admission date;
4. (d) a description of why Retroactive Authorization is being requested;
5. (e) the name, age, and Medicaid identification number of the nursing facility applicant;
6. (f) the PASRR Level I screening; except the screening is not required for admission to an intermediate care facility for people with mental retardation;
7. (g) the PASRR Level II determination as required by 42 CFR 483.112;

8. (h) a history and physical;

   1. (i) signed and dated physician's orders, including the physician certification;
9. (j) MDS assessment that covers the time period for which Medicaid reimbursement is being requested; and
10. (k) a copy of a Medicare denial letter, a Medicaid eligibility letter, or both, as applicable.

A nursing facility may complete a written request for Retroactive Authorization. If approved, the authorization period will begin a maximum of 90 days prior to the date the authorization request is submitted to the Department. The request for Retroactive Authorization will include documentation that will demonstrate the clinical need for nursing facility care at the time of the requested Medicaid admission date. The documentation must also demonstrate the clinical need for nursing facility care as of the current date. This documentation will allow the Department's medical professionals to determine the clinical need for nursing facility care during both the retroactive period and the current period. Documentation will include:

KEY: Medicaid

Date of Last Change: June 19, 2025

Notice of Continuation: June 4, 2024

Authorizing, and Implemented or Interpreted Law: 26B-1-213; 26B-3-108