Michigan Medicaid Nursing Facility Level of Care Determination
Contents
1. Door 5 Skilled Rehabilitation Services Help Exit Application Door 5 contains three areas specific to skilled Michigan Medicaid Nursing Facility Level of Care Determination rehabilitation Services Provider ID Provider Type 63 Beneficiary ID 0 Applicant s First Name GHKJ Middle Name GHK Last Name GHKJ Date of Birth 12 12 1926 1 Speech Therapy Door 5 Skilled Rehabilitation Therapies Is the person currently receiving any skilled rehabilitation therapies Record the total minutes each of the following therapies were 2 Occu pational Therapy administered or scheduled for at least 15 minutes a day in the last 7 calendar days Enter zero if none or less than 15 minutes daily 3 Physical Therapy A Total number of minutes provided in last 7 days B T otal number of minutes scheduled but not yet administered Skilled rehabilitation services have a 7 day eo NN look back period 2 Occupational Therapy 3 Physical Therapy Column A For each therapy enter the Submit Reset total number of minutes therapy was provided in the last 7 days Enter zero if no minutes were provided or if less than 15 minutes were provided Column B For each therapy enter the total number of minutes therapy was scheduled but not yet administered Enter zero if no minutes were scheduled or if less than 15 minutes were scheduled Select Submit If the beneficiary qualifies through Door 5 the Freedom of Choice f2. Care Determination 01 01 2007 Page User Manual Department of T Selecting Continue will open Bi the User Enrollment Confirmation For LOC Determination screen Review your information before selecting Submit If you need to User Info correct data select Back and mL nr User Enrollment Confirmation For LOC Determination Please review the following information Click Submit or Back Username Sic i edit the information If the data EM SAM j ida fom entered are correct select u ame E DENR Submit Phone Number 123 453 7890 Departmental TE eommunity Health ss S 34 Selecting Submit will open a Your subscription request has been submitted successfully You will be notified upon approval Confirmation screen This screen will inform you that your subscription request has been submitted successfully Close this screen You will receive an email notification informing you of whether or not your application has been approved or rejected Upon approval you may log into Michigan s Single Sign on system with access rights to the Michigan Medicaid Nursing Facility Level of Care Determination Upon your first log in to the LOCD the User Permission screen will open This will occur only once e Enter your First Name Last Name e Enter your Provider ID review before submitting User Permission i All field d e Enter your Provider Type from the plone TT
3. Choice form is completed by the program it auto fills in the beneficiary s name beneficiary s date of birth beneficiary s Medicaid ID if entered in the LOCD Provider ID the date the LOCD was created online marks the appropriate Does or Does Not meet eligibility box and if eligible enters the Door number through which the beneficiary qualified Section Il Eligible Beneficiary After printing a copy of the Freedom of Choice form complete Section II obtain appropriate signatures provide a copy to the beneficiary and file a copy in the beneficiary s medical record A copy of the Freedom of Choice form must be maintained in the beneficiary s medical file for no less than three years even if the beneficiary was determined ineligible Section Ill Ineligible Beneficiary If the beneficiary did not qualify through any of the seven Doors an Eligibility Option button will be generated on the Freedom of Choice form If the Eligibility Option button is selected please see page 17 of this manual and follow the Eligibility Option button procedures If the Eligibility Option button is not selected complete Section IIl of the Freedom of Choice form for the ineligible beneficiary Provide a copy of the form to the beneficiary and maintain a copy in the beneficiary s medical record for no less than three years Eligibility Option If a beneficiary is determined ineligible Section on the Freedom of Choice form will checkmark the
4. Internet Explorer or Netscape may be updated through your current Internet Explorer or Netscape browser Please note that access to the LOCD via the Mozella browser is not compatible Internet Explorer http www internetexplorer com Netscape http channels netscape com ns browsers default sp Registering in Single Sign On Registering for Single Sign on SSO is a two step process that needs to be completed only once Please note that the SSO system is a secure website this is noted by the s that is located after http Also the SSO website contains no www in its address https sso state mi us Step 1 amp Access Michigan s Single Sign on Web Portal amp Register Personal Information amp Create Unique User ID Access Michigan s Single Sign On Web Portal Direct your Internet browser to the State of Michigan Portal Page https sso state mi us mem it Tot have a username please click Register to apply Password Select Register I forgot my Password Register Personal Information Enter your first name last name and email address These fields are mandatory Entering your middle initial is optional REGISTRATION Step 1 Indicates required field Before continuing carefully review the TRE information you ve entered especially your email weem 1 P 7 ast Name iene enn address since this will be used to contact you p Email amp ddress NOTE Us
5. MDCH Administrative Tribunal The beneficiary may not request an Immediate Review based on an Exception Review determination of ineligibility the Immediate and Exception Reviews utilize the same criteria The difference between these two reviews is that the Immediate Review is requested by the beneficiary and the Exception review is requested by the Provider The Exception Review is telephonic and the Immediate Review is conducted after medical records are sent to the vendor by the Provider for a hands on review The Exception Review is determined within 24 hours The Immediate Review is determined within three business days Again Immediate and Exception Reviews are not appeals They are an additional review of medical functional eligibility available to beneficiaries who were determined ineligible based on the LOCD To request an Administrative Tribunal Hearing the ineligible beneficiary must contact the Michigan Department of Community Health Administrative Tribunal toll free at 877 833 0870 or 517 334 9500 The fax number is 517 334 9505 If the beneficiary prefers to request an appeal form in writing the address is as follows Michigan Department of Community Health Administrative Tribunal amp Appeals Division P O Box 30763 Lansing MI 48909 The MDCH Administrative Tribunal s web address is http Wwww michigan gov mdch 0 1607 7 132 2946 5093 16825 00 html
6. Nursing Facility Level of Care Determination Emergency and involuntary Transfers The Emergency Involuntary Transfer LOCD is a shortened version of the original LOCD It does not Previdor ID Provider Type 60 Beneiciary D question the medical functional eligibility of the focis CENTS e e beneficiary What it does do is connect the beneficiary n via their Medicaid Beneficiary ID with the new Provider e in the MMIS system However once the beneficiary is admitted under the new Provider the beneficiary must continue to meet the LOCD criteria on an ongoing basis Enter the beneficiary s ID name date of birth Provider contact name and Provider contact number You must also select if this is shorted LOCD was completed based on Emergency Transfer or Involuntary Transfer Select Submit LOCD Search Button Participant Inquiry The Participant Inquiry button is selected to search the LOCD database for a beneficiary s LOCD Only those LOCDs created under a specific Provider ID may be viewable by that Provider To search the database for a beneficiary s LOCD select Participant Inquiry This will open the Participant Inquiry Search screen Enter your Provider ID and Provider Type To receive an individual LOCD enter the beneficiary s name or their Beneficiary ID and select Submit To receive all of the beneficiary s LOCDs created under your Provider ID enter only your Provider ID and Provider Type and selec
7. box that reads Does not meet eligibility Section will also contain an ELIGIBILITY OPTION button that s viewable only when a beneficiary is determined ineligible Providers have the option of selecting this button When the Eligibility Option button is selected the Option screen will open There are two choices on this screen One must be selected After making your selection select the Backspace button on your keyboard to return to the Freedom of Choice form print it 1 The Provider will contact the vendor the Michigan Peer Review Organization 1 800 727 7223 to request a telephonic Nursing Facility Level of Care Exception Review on behalf of the ineligible beneficiary Exception Review is defined on page 18 of this manual 2 The Provider will issue an Adverse Action Notice to the ineligible beneficiary Adverse Action Notices are located on the MDCH website at http www michigan gov mdch 0 1607 7 132 2945 5100 103102 00 html REEM 3 mdiss 2 w 3 Help Exit Application Michigan Medicaid Nursing Facility Level of Care Determination Provider ID 123456 Provider Type 23 Beneficiary ID 0 Applicant s First Name JANE Middle Name MARY Last Name DOR Date of Birth 03 24 1923 Exception Please hold this review for 30 days The provider will contact the vendor for an exception request Adverse Action A formal adverse action notice has been provided The person has been referred for other community program options to
8. drop down arrow review before CE NINE submitting ibd Last Name e Select Submit Provider ID Provider Type wj To clear all fields and start again select Reset If you submit the User Permission screen and realize you ve entered incorrect data upon your next log in select Account Maintenance and select Change My Personal Information Michigan Medicaid Nursing Facility Level of Care Determination Page 01 01 2007 User Manual OVERVIEW THE MICHIGAN MEDICAID NURSING FACILITY LEVEL OF CARE DETERMINATION Michigan s Medical Services Administration implemented the Michigan Medicaid Nursing Facility Level of Care Determination LOCD in policy bulletin MSA 04 15 as statewide policy on November 1 2004 The most recent update to the LOCD was issued March 1 2005 in bulletin MSA 05 09 Both bulletins are available for review on the Michigan Department of Community Health s website at http www michigan gov mdch As mentioned previously in this User Manual the LOCD is an online medical functional assessment that determines a Medicaid or Medicaid pending beneficiary s nursing facility level of care medical eligibility It is applied to beneficiaries prior to enrollment in the MI Choice Program or the Program of All Inclusive Care for the Elderly PACE and prior to admission into a Medicaid reimbursed nursing facility The LOCD is also applied to current nursing facility residents that have applied for Medicaid status is pending as the
9. located in the Field Guidelines If the beneficiary has been in a program or combination of the above programs for at least one year AND the beneficiary requires ongoing services to maintain current functional status AND those services can not be met elsewhere in the community select Program participant for at least one year AND requires ongoing services ee o eee eee eee O M Help Exit Application Michigan Medicaid Nursing Facility Level of Care Determination Provider ID 2t Provider Type 63 Beneficiary ID 0 Applicant s First Name GHKJ Middle Name GHK Last Name GHKJ Date of Birth 12 12 1926 iC Door 7 Service Dependency If the beneficiary has not been a prog ram The applicant is currently being served by either MI Choice Program PACE or Medicaid reibursed nursing Ini facility M bine ti i gt ferred fi ing facility to MI Choice MI participant for at least one year select the EE ERTS E accros service programs e g transferred from nursing facility to Dice 1 1 Ww IAI Program participant for at least one year and requires ongoing services to maintain current functional status No radial dial NOT Program participant for at other community residential or informal services are available to meet the applicant s needs least one year NOT Program participant for at least one year Submit Reset Select Submit If the beneficiary qualifies through Door 7 the Freedom of Choice form will open and checkm
10. of the Michigan Single Sign on System Michigan s Single Sign on system SSO is a secure Internet website located on the State of Michigan s Portal Page https sso state mi us SSO is utilized by health professionals throughout the state to gain access to numerous applications involving the submission of confidential data to the state i e the Michigan Disease Surveillance System and the Michigan Childhood Immunization Registry Access to Online applications requires registering with SSO The registration process ensures that only authorized individuals may enter view and submit data through SSO The secure nature of the system stipulates that e Each SSO user must create his or her unique User ID and password when registering even if an email account is shared If a registered user is using the system incorrectly identification of that user is made via his or her User ID e f a SSO registered user will no longer access the LOCD no longer employed change in job position he or she must be removed from the registry The facility or agency is required to call the client service center at 517 241 9700 or email ditservice michigan gov to request the removal of the user from the Single Sign on system Software Requirements On line access to LOCD requires access to the Internet through either of the two following Internet Browsers e Internet Explorer version 5 5 or greater e Netscape version 6 or greater Earlier versions of
11. signatures give the original to the applicant and file a copy in the applicant s medical record Door 2 Cognitive Performance Door 2 contains three topics related to cognitive performance A Short term memory B Cognitive skills for daily decision making C Making self understood Cognitive Performance has a 7 day look back period Definitions for Levels of Performance for each cognitive topic are located in the Field Guidelines A Short term Memory Kahn Es Application Select one of the two options Michigan Medicaid Nursing Facility Level of Care Determination Memory Okay or Memory Provider iD 6 Provider Type Bonoficiery I 0 Applicant s Firat Name TEST Medda Harms TEST Last Narre TEST Problem Select Submit pee GRU Door 2 Cognitive Performance Dons ihe applicant have ony problems with momory or making decisions A Shorttenm memory okay Seoms appears 16 recall aur 5 minutes E TREAT D Miamiory Okay CO Nhamory Fri s x Halp Exit Apade ation B Cosqnithes skills for dalby decisionmn am eree B Cognitive skills for daily decision The applicant s E Pax E Aichi pos Medlcald Nursing Facility Level af Cure Determination m aki Ng daily tige wr and mac fe decskionik m E Modified depen adani Avera E E E Fran deter tae eet A Select one of the four options The applica organiza day mui epp PEEL eae ong al ee decile ion Saison in fscad lle ne rate es Hint Ms m pn CO Moderately Inq
12. tne ronowlng applications LOC Determination Subscibe bo Appleman aid new Holes Le Existing subiscnplian amp rccoun Maimbenanee ger Ut THE ONLINE THE MICHIGAN MEDICAID NURSING FACILITY LEVEL OF CARE DETERMINATION Welcome Screen After selecting the LOC Determination the LOCD Welcome screen will open At the top of this screen is a News Box This News Box is periodically updated with reminders on LOCD policy LOCD tips and notices of when the LOCD will be unavailable due to state holidays The Welcome screen also lists contact information for LOCD users For LOCD technical support or questions contact Michigan s Provider Support Hotline at 1 800 292 2550 M F between 8 00 A M and 5 00 P M The Provider Hotline also accepts faxed inquiries at 517 241 8968 as well as email inquiries at ProviderSupport michigan gov In the upper right hand corner of the Welcome screen is a link Help Forms FAQ to the MDCH website that contains documents related to the use of the LOCD as well as the policy that supports LOCD application requirements m At the bottom of the Welcome screen are six oq buttons that link the user to different functions of eee S noel the LOCD Three of the six buttons are data sptmst entry buttons Welcome to Michigan s Medicaid Nursing Facility Level of Care Determination Two of these three buttons are used to create a LOCD TIPS LOCD TIPS LOCD TIPS LOCD TIPS LoCD TI
13. Lana Wane aa Services DHS the ID must be entered once it is un PEN LN NES AE received by selecting Add Beneficiary ID Y FLA I FRZLOYNEIEYRC 01 11 1913 Use TUE LCS CLARA niall 5 FRELS ee Ree OLAS Enter your Provider ID and Provider type and the beneficiary s name in the Participant Inquiry screen Add Beneficiary ID to retrieve only this LOCD or enter your Provider ID eee and Provider type only this will pull all online LOCDs im that you entered that do not have a beneficiary ID irs entered on them Select Submit Bo Lxx 000 Select Update next to the name of the beneficiary for whom you wish to add their Medicaid beneficiary ID Enter the beneficiary s ID in the blank box next to Beneficiary ID Select Submit Please note that an LOCD is considered incomplete until the Beneficiary ID is added to the existing online LOCD Further a Provider may not bill for services rendered until the Medicaid Beneficiary ID is added to the online LOCD Emergency Invaluntary Transfer The Emergency Involuntary Transfer button is selected when the State Survey Agency has closed a facility involuntarily or has closed the facility due You are about to do an Emergency Involuntary Transfer are you to an emergency When this button is selected a sure screen will open asking if this is the appropriate LOCD emergency involuntary that you wish to perform a Beneficiary Error Microsoft Internet Explorer Michigan Medicaid
14. Limited Se eee en Ovenaght encouragement oi roe 3 x Bey tures deg das F days OF sopemiinn J or mone times plus Assistance Extensive Assistance Te AM iram e Total Dependence or Activity did not MIU etn ay sti MM t sme pidas a TE am fj via ad an ol iude sd MS red hp al birena typea u prided 3 ar mo i amii occur Definitions of the six ADL levels Fal parrmane by ane aig pb et weet Faye Te dus n re he Ful ts MIS ws Aut ed enia insulin al scum dang regala of ability are located in the Field Guidelines document that is available on the MDCH website After selecting the level of ability for Bed Mobility select Submit Then select the level of ability for Transfers then Submit Do the same for Toileting and Eating selecting Submit after entering each level of ability If the beneficiary qualifies through part s A B C or D of Door 1 the program opens the Freedom of Choice form If the beneficiary does not qualify through Door 1 the screen for Door 2 will open The Freedom of Choice form auto fills the applicant s name beneficiary ID if entered Provider ID the date the online LOCD was created and checkmarks the box stating that the applicant Does meet eligibility criteria It will also provide the Door Number through which the beneficiary qualified Policy requires Providers of long term care services to print a copy of the Freedom of Choice form complete Section Il obtain appropriate
15. Michigan Medicaid Nursing Facility Level of Care Determination User Manual November 2006 Table of Contents Ughd cove 0 cont he q SERPENT RERO MOTO LIMEN 1 Michigan Medicaid Nursing Facility Level of Care Determination User Manual 1 Other LOCD Resources S rcino ienr a a E E A 1 The Michigan Department of Community Health Single Sign on System cccccceescseeeeeeeeeeeeeeeeeeeseeseeees 2 Overview of the Michigan Single Sign on System cccccecccssseeeeeeeeeeeceaeeeeeeeeeeessaeeeeeeeeeessssaeaeeeeeeeeeeas 2 Software Requirements ccccccccsseseeeeceeeecceeesseeeeeeeeeaseeeeseeeeeeesaseeeeeeeeeeeseaseceeeessssaaaseeeeeeeessueaaseeeeeeeessaas 2 FAEOISIS RING in SING IS IC I ON sarees tc Er 2 Access Michigan s Single Sign On Web Portal ccccccseseceeeceeseeceeeeeeeeeeeeeseeeeeeeesseeseeeesseegeeeeessaeees 3 Register Personal Information s sud oai das oun vanced Sedans vad arial oun eats en s lv bab dar ird teats dunt Cora dYad as oseeadetes 3 Sim NMeD M3 a peer rm 3 Contirmation of hegisSira on Email asco osos ion tamc qoa assit or Oe dat caus dese basa Po is dues ice m ase ous 5 Gliande Tempobary Fass Word n nacht cesses Eos anc aate lat een n oec tO Sauder casa melon tuc Senden ceed eee 5 Answer Ghallenge Response Questions aides Cai et e tasa edo nem acide cesa si ne tuta e e medo iSo D dde aee RR CE 6 Forgotten Fass WONG eT m T t T 6 SUIS Cre TO EOC DE
16. N 7 0014 m een eee 9 The Michigan Medicaid Nursing Facility Level of Care Determination ccccceecccceecsseeeeeeeeeeseeeeeeeaaeeeeees 9 Accessing the EOGD Via the Interbiel douce esac ee tet ro NO Eu bie eren ved a at ie veut 9 j2emn me ncc REN 10 The Michigan Medicaid Nursing Facility Level of Care Determination ccccccccccceecesseeeeeeesaeeeeeeeesaeeeees 10 WECOME OCEN RO D o om 10 LOCD Data Entry Buttons Continue to LOCD Add Beneficiary ID Emergency Involuntary Transfer 11 egus nredEO SPICE eee 11 Completing the DOOS siur e mt 11 Door 1 Ac vilies of Dally LIVING aud tar er ortu tru Eu T E Rt Cur P RR 11 Door e CognilvePerfolmaliGe cierres enden ecscleteror ito te rd Feed aea e delete teh leve eor eli eite dere ed 12 Door 9 T hnysiciam InvolvermigliDsmreeseten dou ees oe gendbo 3ycetu coin tudo dea Devin Bao vire Peta diede loue apr rte ende opio pre E2d 13 Door 4 Treatments and GondillOnS u eot ocio a torte oleo Pd ad cete eite tore e eed e vore eoa 13 Door 5 Skilled Rehabilitation Services eeeeeesssssseseeseeeseeeeeenn nnne 14 DOOrG BENI VO gt T M 15 Door 7 Service Depetideriey issiuemnss diveptitabetos e a a aea 15 Freedomil G noce FO d SERIEN m Mr M 16 zeli deo MC PU 17 Nursing Facility Level of Care Exception Review c
17. Notice xj If the Provider does not request an Exception Review through the vendor the Provider must immediately issue an Adverse Action Notice to the beneficiary regardless of whether or not the Eligibility Option button was selected Nursing Facility Level of Care Exception Review The Nursing Facility Level of Care Exception Review NF LOC Exception Review is additional criteria developed by the state that addresses frailty The Provider may request the vendor to conduct this review on behalf of an ineligible beneficiary The review is telephonic and the vendor will make a determination within 24 hours NF LOC Exception Criteria are located on the MDCH website at http www michigan gov documents AttachD Exception Criteria pc WEB 107347 7 pdf Continuing to Another Online LOCD If you ve completed one LOCD and wish to complete another one for another beneficiary select Return to Home located at the top of the Freedom of Choice form Select Continue to LOCD Closing the LOCD To Log Off the system select Return to Home located at the top of the Freedom of Choice form Select Exit Application Add Beneficiary ID If the beneficiary has a Medicaid Beneficiary ID at the time the online LOCD is completed it must be entered in the LOCD If an online LOCD is completed for a beneficiary prior to the beneficiary receiving their Medicaid Search Resulte for a Participant Beneficiary ID from the Department of Human Fana Mame ti Hane
18. PS beneficiary s online LOCD one is for new Multiple online LOCDs for the same beneficiary do not affect billing Misspelled names ora admissions or enrollees and one is for emergency name that was entered as last name first and first name as last do not affect billing Incorrect birth dates do not affect billing A Medicaid ID that begins with Zero will not show the Zero in or involuntarily transferred residents the online LOCD Please remember that the LOCD is to be applied to Medicaid AND to Medicaid Pending beneficiaries Don t wait for a confirmation of Medicaid financial eligibility if the individual applied for Medicaid apply the LOCD Please direct all your billing and LOCD technical questions to the Provider Hotline at 800 292 2550 or FAX the Provider Hotline at 517 241 8968 Continue to LOC Determination te ee create an online LOCD for new Michigan s nursing facility level of care determination form is a web based tool that determines an applicant s admission or new enrollee medicalfunctional eligibility for Michigan s Medicaid covered nursing facilities Michigan s Home and Community Based Waiver for Elderly and Disabled MI Choice Program and the Program of All Inclusive Care for the Elderly PACE The form was developed for use by health care professionals representing the m Emergency Involu ntary Transfer pra aTuBIeNIee create an online LOCD for a The system is available Monday through Friday between t
19. an Web Site is being processed You will receive an Email within 24 hours with a web site to get your password Close Michigan Medicaid Nursing Facility Level of Care Determination Page 4 01 01 2007 User Manual Step 2 g g g g g Confirmation of Registration Email Change Temporary Password Answer Challenge Response Questions Subscribe to LOCD Enrollment Confirmation Confirmation of Registration Email The confirmation email will include a link to Single Sign on s Change Password screen Select this link to change the temporary password that was assigned to you in the email You must change your temporary password and you may use this temporary password only ONE time If you do not intend to complete registration at this time do not select this link upon email notification You may log in at another time to https sso state mi us and complete the registration process using your one time temporary password NOTE PASSWORDS ARE CASE SENSITIVE Hemember the upper case and lower case portions of your password or use all upper case or all lower case Department of ICH Gommunity Hea in User johnd2000 s password has expired Input old password Input new password Contirm new password NOTE Passwords must be at least five 5 characters in length Passwords are case sensitive Change Password Change Temporary Password To continue the registration process select the SSO link
20. ark that the beneficiary Does Meet eligibility If the beneficiary does not qualify thorough Door 7 the Freedom of Choice form will open and checkmark that the beneficiary Does Not meet eligibility Michigan Medicaid Nursing Facility Level of Care Determination Freedom of Choice Annbcant s Daie of Birth enresentadwe H anyk Freedom of Choice Form FECTION I FOSCTORALMIBOICAL ELIGELITY Based on an assessment of funcional abliliezs amd needs comducted on applicant Indicated sbor tomie When the LOCD is completed the Freedom of Choice form will open Section of the Freedom of oO Does mesi the funcions keesdical elglblity Esia tor Mecicak LTC programs by scoring in Door L1 Does Hot meet the Ssrcianablmegdicsi eigiblity crisesias Tar Medical HE Leve of Care exse Choice form will checkmark that the beneficiary und duces ELIGIBILITY OPTION either Does or Does Not meet eligbility criteria EA m Wl wc and fill in the beneficiary s and provider s we wa rwweworaker 8 mt PR information Lore aaa ns BI r a CI voor mrene y een h Y J A viet If a beneficiary does not meet eligibility criteria Section will contain an ELIGIBILITY OPTION Hore eee ITE button This button is viewable only when a beneficiary is determined ineligible Provider s have oa rea eae re the option of selecting this button as another a eo ee a possible option of medical review for the beneficiary When the Eligibility O
21. ber Enter the number as it is shown in the box below 4 into the empty box directly above it Select Continue You will immediately receive a User Registration Confirmation screen of your personal data and User ID Michigan Medicaid Nursing Facility Level of Care Determination Page 01 01 2007 User Manual Please review all of your information on the user registration confirmation screen If there are corrections to be made select the Back button If the information is correct select Submit Your data has now been sent to Michigan s Single Sign on system A new screen will open that reads your request to be registered is being processed It also informs you that your temporary password will be emailed to you within 24 hours The temporary password is usually received much sooner sometimes within a few hours Close this screen and your Internet Browser Step 1 of the registration process is complete Step 2 of registration continues after you receive an email from SSO The email will contain your temporary password and a link to SSO to continue with the registration process Se Deal inert oF 1 P Community Health Lo ate ot USER REGISTRATION CONFIRMATION Please review the following information Click Submit First Name John Initial Last Name Doe Email Address dosjyahoo cam Your User Id will be doej2000 Micnigaisey einen sa Your request to be registered to the Michig
22. ccccccccecccsssseeeceeeeeesaeeeseeeeeeesaaeaeeeeeeeeessaeaaeess 18 CIOS iG the EOC D gecesi 18 Ada Beneicay iB CEPERUNT 18 Emergency lnvoluntary HatlSIer scisiscicnendeheciivattinsmirtvssacnieidanntioneraebncamiteatudiueticemieaecincaseds 19 LOC BD Search BPUPDOE S isa atccodseud ciao did dceo nci sie inposita uti a nmi coasneadido ied a a 19 FAL LICH AE MINE EE 19 sz lt 1 BM 210 1 0 prem Lm 20 PANE BIAnK ADDICTION et PER 20 Exiting LOC DO Button T T MT 20 EXIL ADDING AU OM E 20 ADDOSL GINS 2oiuiststarsiidesim ad esae a seats dancubusaheaidsisssnatbagnababsncnadanuies 21 INTRODUCTION Michigan Medicaid Nursing Facility Level of Care Determination User Manual The Michigan Medicaid Nursing Facility Level of Care Determination LOCD is the state s Medicaid functional medical assessment that determines nursing facility level of care eligibility for Medicaid or Medicaid Pending beneficiaries The LOCD is accessible through the Michigan Department of Information Technology s secure on line Single Sign on system To gain access to the LOCD you must first register with Michigan s Single Sign on system The first section of this manual provides step by step instructions on how to register with Single Sign On Once the registration process is completed and authorized by the state the second section of this manual provides detailed instruction on how to complete the onli
23. e LOCD criteria therefore it is expected that appropriate medical intervention and discharge planning will take place as needed If the beneficiary qualifies through Door 3 the Freedom of Choice form will open If the beneficiary does not qualify through Door 3 the screen for Door 4 will open Door 4 Treatments and Conditions Door 4 has nine topics related to physician documented treatments and conditions If the treatment or condition is a physician documented diagnosis within the beneficiary s medical record and the treatment or condition continues to affect functioning or the need for care select Yes for that treatment condition If the beneficiary does not have the condition or is not under treatment or there is no physician documented diagnosis within their medical record select No for that treatment condition A Stage 3 4 pressure sores Intravenous or parenteral feedings Intravenous medications End stage care Daily tracheostomy care daily respiratory care daily suctioning Pneumonia within the last 14 days Daily oxygen therapy Daily insulin with two order changes in last 14 days Peritoneal or hemodialysis rommoomp Qualifications for each treatment and condition are located in the Field Guidelines Treatments and Conditions have a 14 day look back period You must select Yes or No for each treatment or condition Help Exit Application Michigan Medicaid Nursing Facility Level of Care Determination Pr
24. ealrosl Doaar 2 Cognitive Performance Dass the apphcant have any problems wh omerary ar mrsalkong detrei Independent Modified d t bes ien rm poor Tc C imi sell i rcr apressing information contend however alle ndman os aly ti ired er Aft nias um ndependent Moderately Tha as outa are deci iS iro rri ru went i in ally I sdare mad i saei ltr I r I E j The rides a hos Afii epu Bnafersg 1hon n gn wenns hong Ihgughts resgulling in delayed responses mpaired Severely Impaired HUN REIN J t m m Understood abild y but i amp able j express concha roguata regarding ad lead barit needs select Submit C Rete prepa seat ze At bati understanding is limited to interpretation of he ot ri dual applicant specsic sounds or body langu wage e g indecated presence of pain or ered fo to C Making self understood Select one of the four options Understood Usually Understood Sometimes Understood Rarely Never Understood Select Submit If the beneficiary qualifies through Door 2 the Freedom of Choice form will open If the beneficiary does not qualify through Door 2 the screen for Door 3 will open Exit Application Help Door 3 _Physician Involvement Michigan Medicaid Nursing Facility Level of Care Determination Provider ID 0 Provider Type Beneficiary ID 0 Applicant s First Name TEST Middle Name TEST Last Name TEST Date of Birth 11 11 1911 Door 3 has two topics related to physician involve
25. elect Continue to LOC Determination to conduct an LOCD assessment The beneficiary s Information screen located above Door One of the LOCD will open The program will automatically enter the Provider ID and Provider Type that you are registered under Enter the following information Enter the Beneficiary s First Name Middle Name and Last Name Enter the Beneficiary s Date of Birth mm dd yyyy no hyphens Enter the Provider Contact s First and Last Name Enter the Provider s Day Time Phone number no hyphen RRRR If the Medicaid ID is not available when you create the online LOCD enter it as soon as you receive it You may submit a claim only when the Medicaid ID is added to the online LOCD LTC Screening Microsoft Internet Explorer Exit Application Michigan Medicaid Nursing Facility Level of Care Determination fields are mandatory Provider ID D Provider Type 77 Beneficiary ID Applicant s First Name Middle Name Last Name Date of Birth mm dd y y y y Provider Contact First Mame a as ta m un Last Name Day Time Phone Completing the Doors There are seven 7 possible Doors of eligibility in the LOCD They must be addressed in sequential order If the applicant qualifies through any one of the seven Doors the program will open the screen to the Freedom of Choice form bypassing any remaining Doors The Freedom of Choice form is described o
26. ers who have been assigned a State of Michigan email address must use this address to register State of Michigan employees must use their michigan gov email address when registering regarding your temporary password If you would like to clear all fields on this screen and begin again select Clear then re enter your information When you have completed all fields select Continue Create Unique User ID 4 A portion of your User ID is created for ws 3 you through the registration process this portion is your last name first initial The remainder of your User ID Department of u Gommunity Health Michigan gov 3 REGISTRATION Step 2 must be unique This unique portion Please Enter a four digit number to create a unique UserID OR Please generate a random four digit number for me O Yes Enter the number as it is shown in the box below wi is created by you It must be a series rl A l of four numbers following your last name first initial State of Michigan employees will not see this portion of Single Sign on Enter a four digit number that you remember in the white box following your User ID your last name first initial Select No next to Please generate a random four digit number for me If you select Yes the system will generate a random four digit number for you Example doej1234 At the bottom of the screen is a five digit number located inside a blue box Enter this num
27. he hours of 7 00 A M and 7 00 P M and the second resident that was transferred sala EM eae ND cn involuntarily or due to an emergency The third data entry button is used to update an The Social Security Act Sections 1919a 1915c and 1934 forms the legal authority for states to develop an existing online LOCD with the beneficiary S individual definition for Medicaid nursing facility level of care This electronic tool identifies Michigan s eligibility Medicaid Beneficiary ID criteria For technical support and utilization of the LOC Determination please contact the Provider Support Hotline at mew Add Beneficiary ID add the 1 800 292 2550 Monday through Friday 8 00 A M till 5 00 P M You may also fax the hotline at 1 517 241 i JO 8968 or contact them by email at ProviderSupport michiqan qov beneficiary S Medicaid ID to the existing online LOCD Continue to LOC Er a Emergency Involuntary Determination FILE des Transfer Exit Application Add Beneficiary ID Print Blank Application Version 2 1 20 Michigan s Medicaid Nursing Facility Level of Care Determination meets HIPAA compliance The remaining three of the six buttons are used to exit the LOCD Exit Application to print a hard copy of the LOCD Print Blank Application and to look up existing LOCDs Participant Inquiry LOCD Data Entry Buttons Continue to LOCD Add Beneficiary ID Emergency Involuntary Transfer Continue to LOC Determination S
28. in your confirmation email https sso state mi us Enter your User ID and temporary password to open the Change Password screen Again please note that your temporary password may be used only one time After it s used once it will expire Change your password as follows 1 2 3 4 Enter Old Password passwords are case sensitive Enter New Password that is at least five 5 characters in length passwords are case sensitive Confirm New Password by re entering passwords are case sensitive Select Change Password Michigan Medicaid Nursing Facility Level of Care Determination Page 01 01 2007 User Manual Answer Challenge Response Questions Selecting Change Password will generate a screen containing password reminder questions Challenge Response Should you forget your password these challenge responses are developed to ask questions that only you would know the answers to thus Change Challenge Response Answers maintaining the confidentiality of Change your answers and click OK You must provide an answer to each challenge your password and the security of l l lat is your mothers maiden name the SSO system You may not ip cia cia ystem ou may no Answer eeeeeeee O Confirm Answer eeeeeeee bypass these Challenge Response questions What are the last four 4 digits of your social security number Answer jeeccccee Confirm Answer eeeeeeee Answers to Challenge Response questions are case sensit
29. ive What is the name of the city in which you were born Answer leceecece Confirm Answer eeeeeeee Enter your answer to each question What is your fathers middle name in the blank Answer field located f Answer jeecceece Confirm Answer eeeeeeee below each question Please remember that answers are case Cancel sensitive To the right of each answer field is a Confirm Answer field Re enter your answer to each question If you want to change your responses to the questions select Cancel and re enter your answers To submit your Challenge Responses select OK You will receive an email notification that your answers and confirmed answers match or don t match If your answers do not match you will be asked to re enter your answers Selecting OK will open an Account Maintenance screen Select Done Department of T i ATIS 4 B vy MOCH onse 5 michigango ew L AnA A 78 n s vo N T o e User ID brooksj3619 Sign Off Account Maintenance e Change My Personal Information e Change My Password e Change My Challenge Response Answers Done Forgotten Password Should you forget your password select forgot my Password from the Single Sign on Log In screen Enter your User ID You will be asked to respond to two of your challenge response questions Remember that challenge responses are case sensitive Correct responses will generate a Single Sign on email response to your email addres
30. ment Door 3 Physician Involvement Is the applicant under the care of a physician for treatment of an unstable medical m m condition A Physician Visits A Physician Visits In the last 14 days how many days has the physician or authorized assistant or practitioner examined sos the applicant Do not count emergency room exams Enter zero if none B Physician Orders B Physician Orders In the last 14 days how many days has the physician or authorized assistant or practitioner changed the applicant s orders Do include physician order changes in the emergency room Do not include drug or treatment Physician Visits and Physician Orders order renewals without change Enter zero if none are defined in the Field Guidelines Physician Visits and Physician Orders have a 14 day look back period A Physician Visits Enter the number of days the physician examined the beneficiary DO NOT count emergency room visits C Physician Orders Enter the number of days the physician changed the beneficiary s orders DO count emergency room physician order changes DO NOT count drug or treatment order renewals without change Select Submit If the beneficiary qualifies through Door 3 a Discharge Planning Retrospective Review screen will open Qualifying through Door 3 is an indicator that the beneficiary may be clinically complex Once the beneficiary s condition becomes more stable he or she may no longer be eligible based on th
31. n page 19 Door 1 Activities of Daily Living Dum Michigan Medicaid Nursing Facility Level of Care Determination oe Pime n n deta Tree TT Berehciary ID E Door 1 includes four Activities of Daily SS acne ee Livi n AD Ls don ers se eal Et dustkces Inm bel chan sabitha inde Pode othe tom baih isat Mpa adem nee rar 7IX ETT GMBDIC IIIJ A Bed Mobility Cite Serer an MUN Hep Ext Application d d E rale MEA irs F B S Transfe rs Limites Aitne Michigan Medicail Haring Facilitv Level of Care Determination ant eh rohe rude IO Provider Tre jerii ID C Toileting rere DERA inte 5 Pup ame TEST is deus Hi Te MERE TENE Whde appliicand periceemed pa Date of H wih 11 n 114 D Eating aeaea by ana Door 1 Activities of Dally Living Tatal Bependenca t CM minae oie adus doro BE reta n e iui grind iraredfars origi the tilet cleanses charger Activities of Daily Living have a 7 day No Pi or gmn i sight DA help caught provided osiy or 2 bimes daneg lari 7 days Overnight enceurs Hen Ext Apoic ution look back period ied Asa Michigan Medicaid Nursing Facility Level of Care Determination PEC ant gy i rendo Ai faded Eo ham TEST dx dila a hl TT prone age ip a late For each ADL select the beneficiary s Rett bear T Aalvles of Bally Living a level of ability from one of the six levels penc ode a mb eques ha lute miaka none ter een fb fn Independent Supervision
32. ndering Moved with no rational purpose seemingly oblivious to needs and safety Verbally Abusive Others were threatened screamed at cursed at Physically Abusive Others were hit shoved scratched sexually abused Select 0 1 5 2 Or 9 depending on how frequently the Socially Inappropriate Disruptive Made disruptive sounds noisiness screaming self abusive acts beneficiary displayed a behavioral symptom Vos e me eap o TUE UPC IR PUR Resists Care Resisted taking medication or injections ADL assistance or eating Problem Conditions 0 Did not occur in the last 7days PME ea oat a cea een re MUS 1 Occurred 1 3 days in the last 7 days Hallucinations C Yes C No 2 Occurred 4 6 days in the last 7 days Submit Reset 3 Occurred daily For problem conditions select Yes or No if it occurred within the last seven days When this screen is completed select Submit If the beneficiary qualifies through Door 6 the Freedom of Choice form will open If the beneficiary does not qualify through Door 6 the screen for Door 7 will open Door 7 Service Dependency Door 7 refers to individuals who have been enrolled in a Medicaid reimbursed nursing facility the MI Choice Program or the PACE program for one year or more AND who remain service dependent You may combine the length of time the beneficiary has continuously been in the MI Choice Program PACE or other nursing facilities Qualifications for service dependency are
33. ne LOCD Other LOCD Resources Below is a list of additional resource documents related to the LOCD such as LOCD policy definitions of level of ability Nursing Facility Level of Care Exception Reviews for ineligible beneficiaries beneficiary appeals and guidelines to state services for persons needing long term care These documents including this User Manual are located on the Michigan Department of Community Health s website at http Awww michigan gov mdch gt gt Providers gt gt Information for Medicaid Providers gt gt Michigan Medicaid Nursing Facility Level of Care Determination e Nursing Facility Level of Care Determination Policy e Freedom of Choice form e Michigan Medicaid Nursing Facility Level of Care Determination Field Definitions e Michigan Medicaid Nursing Facility Level of Care Determination User Manual e Nursing Facility Level of Care Exception Process e Michigan Medicaid Nursing Facility Level of Care Determination Process Guidelines e Access Guidelines to State Services for Persons with Long Term Care Needs e Telephone Intake Guidelines e Appeal Notices You do not need to be registered with Michigan s Single Sign on system to access the MDCH website documents You must however be registered with the Single Sign on system to complete the LOCD on line The web address for the MDCH documents is http www michigan gov mdch THE MICHIGAN DEPARTMENT OF COMMUNITY HEALTH SINGLE SIGN ON SYSTEM Overview
34. orm will open If the beneficiary does not qualify through Door 5 the screen for Door 6 will open If the beneficiary qualifies through Door 5 a Discharge Planning Retrospective Review screen is generated Qualifying through Door 5 is an indicator that the beneficiary may be clinically complex Once the beneficiary s condition becomes more stable he or she may no longer be eligible therefore it is expected that appropriate medical intervention and discharge planning will take place as needed Door 6 Behavior Door 6 relates to behavioral symptoms and problem conditions Qualifications for behavioral symptoms and problem conditions are located in the Field Guidelines Behavioral Symptoms include Problem conditions include A Wandering A Delusions B Verbally Abusive B Hallucinations C Physically Abusive D Socially Inappropriate Disruptive E Resists Care E Michigan Medicaid Nursing Facility Level of Care Determination ET Provider ID Provider Type 63 Beneficiary ID 0 Behavioral symptoms and problem conditions E e nh a RN eS have a 7 day look back period Door 6 Behavioral Has the applicant displayed any challenging behaviors in the last 7 days ehavior Code D Behavior not exhibited in last 7 days 1 Behavior of this type occured 1 to 3 days in last 7 days 2 Behavior of this type occured 4 to 6 days but less than daily 3 Behavior of this type occurred daily Behavioral Symptoms Behavior Symptoms Wa
35. ovider ID 77 7 77 Provider Type 63 Beneficiary ID 0 Applicant s First Name GHKJ Middle Name GHK Last Name GHKJ Date of Birth 12 12 1926 Door 4 Treatments and Conditions Has the applicant in the last 14 days received any of the following health treatments or demonstrate any of the following health conditions Complete each item below either Yes or No Stage 3 4 pressure sores C Yes C No Intravenous or parenteral feeding C Yes C No Intravenous medications C Yes C No End stage care C Yes C No Daily tracheostomy care daily respiratory care daily suctioning C Yes C No Pneumonia within the last 14 days C Yes C No Daily oxygen therapy C Yes C No A B C D E F G H Daily insulin with two order changes in the past 14 days C Yes C No Peritoneal or hemodialysis C Yes C No Submit Reset After answering Yes or No for each treatment condition select Submit If the beneficiary qualifies through Door 4 the Freedom of Choice form will open If the beneficiary does not qualify through Door 4 the screen for Door 5 will open If the beneficiary qualifies through Door 4 a Discharge Planning Retrospective Review screen will open Qualifying through Door 4 is an indicator that the beneficiary may be clinically complex Once the beneficiary s condition becomes more stable he or she may no longer be eligible therefore it is expected that appropriate medical intervention and discharge planning will take place as needed
36. payer for nursing facility services and to new admissions who are Medicaid eligible regardless of primary payer source if Medicaid beyond Medicare co insurance and deductible amounts will be requested for Medicaid reimbursable nursing facility services Although the LOCD is to be completed prior to the start of Medicaid reimbursable services policy allows a fourteen 14 day grace period after admission or enrollment for the LOCD to be applied online For example a hard copy of the LOCD may be completed upon admission or enrollment however an online LOCD must be completed within fourteen 14 days of that beneficiary s admission or enrollment The online LOCD is available Monday through Friday between the hours of 7 00 A M and 7 00 P M as well as the second Saturday of the month The online LOCD is not available on State of Michigan holidays Holidays are posted in advance at the tope of the LOCD s Welcome screen Accessing the LOCD via the Internet The LOCD is accessible only through Michigan s Single Sign on system an Internet based website described on page one 1 of this manual 1 Direct your web browser to https sso state mi us 2 Enter your User ID and password If you are not registered with Single Sign on you must first register Instructions for registration are located on page 2 3 Select LOC Determination a SOM DCH Application Portal WELCOME Your Name You are curreniy supscrined ro
37. ption button is selected the LL ae Option screen will open There are two choices on this screen One must be selected Further instruction on the Option screen is on page 17 of this manual If the Eligibility Option button is not selected print a copy of the Freedom of Choice form and complete Section Ill Appeals Give the completed form to the beneficiary and place a copy in the beneficiary s medical record If a beneficiary qualfies for services under the LOCD cirteria then they must be informed of their benefit options Section Il of the Freedom of Choice form lists those options MI Choice Program PACE and nursing facility services The beneficiary must select in writing which of those options they are interested in receiving program servcies from The provider must provide local contact information on the program the beneficiary is interested in Give the completed form to the beneficiary and place a copy in the beneficiary s medical record Please note that the Freedom of Choice form is designed to print on one page If it s printing to a second page or printing beyond the margins the margin settings or font size of your Internet browser need to be adjusted To adjust font size select View from your internet browser select Text size and select Medium or Smaller To adjust the margins select File then Page Setup and specify the margins accordingly 0 25 for all margins is recommended Section Section of the Freedom of
38. rmination must be completed as indicated in the policy in order for reimbursement to be made Click Here Exiting LOCD Button ae SR Hh Fh ER P x Nh Exit Application Selecting Exit Application displays the MDCH Portal screen From here users may Sign Off to close out of the LOC Determination This screen also allows Providers to access Account Maintenance Account Maintenance allows users to change their personal information such as their name SOM DCH Application Portal and email address or change their WELCOME Your Name Password and Challenge Response You are currenuy supscripea to uie ronowing applications Answers which are questions designed to remind a user of their existing password LOC Determination Subscribe to Applications sima Roles to Existing Subscription Account Maintenance APPEAL RIGHTS If an ineligible beneficiary is issued an Adverse Action notice from the Provider based on an LOC Determination of ineligibility the beneficiary has the right to appeal through the MDCH Administrative Tribunal The beneficiary also has the right to request an Immediate Review through the vendor An Immediate Review is not an appeal it s another medical functional review If the ineligible beneficiary is issued an Adverse Action notice from the vendor based on an Exception Review requested by the Provider or an Immediate Review requested by the beneficiary the beneficiary has the right to appeal through the
39. s The email will contain a new temporary password Log in using your temporary password then go through the Change Password process Subscribe to LOCD Once you ve completed your Challenge Responses and Password Update you will be directed to the Michigan Department of Community Health SOM DCH Application Portal screen Select Subscribe to Applications A Subscription screen will open From the drop down arrow select LOC Determination Select Next The Subscription For LOCD Determination screen will open Enter your work telephone number including your area code Your email address will appear automatically State of Michigan employees will be asked for their Supervisor Security Administration email address Non State employees do not enter this information Department of Gommunity Health SOM DCH Application Portal WELCOME Your Name You are NOT currently subscribed for any applications If you wish to subscribe for application access please click on the Subscribe to Applications link below Department of Community Health te As DI c ditis S SUBSCRIPTION Please Select from the list Department of Subscription For LOC Determination Indicates required field Work Phone Include area code eg 517 123 3456 Your F mail Your Email Address Select Continue or select Reset to re enter your telephone number Michigan Medicaid Nursing Facility Level of
40. t Submit This will open the Participant Inquiry Results screen Select Inquire next to the beneficiary s name and their LOCD will appear on the screen If you want to print the LOCD select Print This Page from the top of the screen Blank LOCD Button ank Application The Print Blank Application button will link you to the MDCH website From this website you may print a blank LOCD from by selecting click here from the LOC Determination Form section F iria Finest Facit Vaio e ped rM f j H onsired Sies Michigan Medicaid Nursing Facility Level of iituirwids Online anian Care Determination aiiu Mirri Related Content eliyir Perens Jur ung Agency Community Heath ssa MM Infanmailon fer Medicaid Provider STS Michigan Medicaid Hursimi Facility Level af Care Esetermlnatien Maral Tha MI Eligibility The Michigan Department of Commurely Health implerrinted reased Verificalian System hnchonalredcal eligible crberea for Madiin r eimbursed long beem Eve cate Breicas afaclive November 1 300M To review policy bulletin MSA piedica Policy H 15 whith describes the mquined changes Click Hara Fite aate or Bulletins ute inks have been created tothe exiredyal atachmems of MBA 04 15 Progesqoad Medicaid sgg below Changes Mursing Facility Coil tanhia reai LOC Determination Form Providers may utilize a copy of the LOC Determination to gather information However the online LOC Dete
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