Level of Care [LOC]

Centers for Medicare and Medicaid Services, a federally funded program that provides funding to states for individuals that meet the income and level of care requirements for the Affordable Care Act Health Insurance Program, Medicare, Medicaid, SCHIP (state children’s health insurance) and several other health related programs. ARM Administrative Rules of Montana, the rules which govern the programs authorized by the Montana legislature.

Mountain Pacific Quality Health Foundation, the Developmental Disabilities Program contracts with this nursing organization for the purpose of completing initial level of care medical forms for Waiver recipients.

Pre Admission Screen Resident Review, refers to the Centers for Medicare and Medicaid funded program that is responsible for screening individuals for nursing home level of care. When an individual seeks nursing home care a level one screen must be completed by a state sanctioned entity. If the screening determines that the individual meets the level of care a second screen, or level 2 screening is completed to determine if the individual has a mental health disability or a developmental, intellectual disability and requires specialized services while residing in a nursing facility.

A review of a plan's decision to deny coverage for or payment of a service by an independent third-party not related to the plan. If the plan denies an appeal, an external review can be requested. In urgent situations, an external review may be requested even if the internal appeals process isn't yet completed. External review is available when the plan denies treatment based on medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit, when the plan determines that the care is experimental and/or investigational, or for rescissions of coverage. An external review either upholds the plan's decision or overturns all or some of the plan’s decision. The plan must accept this decision.