Every state has a level-of-care form, and no two states mean the same thing by it. In Florida and Pennsylvania the form is a physician’s certification and the application does not move until a doctor signs. In Michigan, Wisconsin and Indiana there is no physician’s signature at all; a licensed assessor completes an instrument in person and the state’s system scores it. In Texas both happen, in sequence. For a case management agency working across state lines, or a physician practice asked to sign for patients in one, the difference decides who the agency is waiting on and what records that person needs. This is the set, read from the states’ own forms, manuals and rules.
Twelve states, side by side
| State | Instrument | Who completes or signs | Who validates | Clock or validity |
|---|---|---|---|---|
| Georgia | CCSP Level of Care and Placement Instrument, the DMA-6 family; the provider portal lists a Level of Care Placement Form (5588) | “The physician and RN care coordinator complete the LOC form”; the RN care coordinator approves it | Alliant Health Solutions “or other DMA approved entities determine the LOC” | RN approval “for a CCSP stay of up to one year”; caseworker follow-up if the form has not reached DFCS “within 30 days of the application date” |
| Florida | AHCA Form 5000-3008, Medical Certification for Medicaid Long-Term Care Services | A Florida-licensed MD or DO; an ARNP “if within their scope of practice”; a PA “if delegated by the supervising physician” | CARES, with an in-person visit | “Good for one year from the date of the health care professional’s signature” absent a significant change |
| Pennsylvania | MA 570 Physician Certification, plus the Functional Eligibility Determination | “A Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)” licensed in Pennsylvania or a bordering state; “Physician Assistants, Certified Registered Nurse Practitioners, or doctors in training will not be accepted” | The Independent Enrollment Broker; the Area Agency on Aging does the functional determination; the OLTL Medical Director decides when the two disagree | The doctor “should return the form within five (5) business days”; the process “should not take more than 90 days” |
| Texas | Medical Necessity and Level of Care (MN/LOC) assessment, with Form 2601 Physician Certification | An MD, DO or military physician who “has personally examined the applicant/member in the last 12 months” and reviewed the record; signature required at the initial request only | Texas Medicaid & Healthcare Partnership (TMHP) | The MCO “has 45 days to complete the entire process”; five business days to obtain the physician’s signature before further attempts |
| Michigan | Level of Care Determination (LOCD), in CHAMPS | “A qualified and licensed health professional”, face to face: physician, RN, LPN, clinical social worker, PA, NP, psychologist, PT, OT, RT or speech therapist | MDHHS, through CHAMPS; “only the LOCD application in CHAMPS can determine functional eligibility” | Entered “within 14 calendar days from the date it was conducted”; “valid for 365 days from the conducted date” |
| North Carolina | For CAP/DA, the HCBS Service Request Form with a Physician Attestation; “a service request form replaces the FL-2 form”. The FL-2 remains the nursing facility instrument | The physician attests; the FL-2 carries a physician’s signature | The independent assessment entity or care management entity “in combination with NC Medicaid” | The SRF “must be completed within 14 business days” by the IAE “and 45 calendar days by the CME”; an incomplete one “is voided” |
| Indiana | The interRAI assessment, by the state’s Level of Care Assessment Representative (Maximus) since July 1, 2025 | The contractor’s assessor; no physician signature | FSSA performs “a final review of all NF LOC determination recommendations” | Assess “within 7 calendar days”, determination “within 11 calendar days” |
| Illinois | Determination of Need (DON), two parts including the Mini-Mental State Examination | The Care Coordination Unit; a physician appears where “a physician or psychiatrist licensed by the State of Illinois has certified” a cognitive need | The CCU; eligibility at “a minimum score of 29 points on the DON, 15 of which must be scored on Total Impairment” | Decision within 30 days, notice within 15, services within 15 |
| Wisconsin | Long-Term Care Functional Screen (LTCFS) | A DHS-certified screener: a bachelor’s degree or an RN license, a year’s experience with the population, and the certification course | The screen itself determines functional eligibility; annual rescreens by the MCO or the IRIS consultant agency | “Within 30 days of the customer’s agreement to proceed with the LTCFS” |
| New York | UAS-NY Community Assessment for community applicants; the PRI and SCREEN only for people in a facility | “Conducted, signed and finalized by an RN who has completed the UAS-NY required training” | The Department of Health | Within 90 calendar days of waiver authorization; reassessed annually |
| Louisiana (OAAS) | The interRAI Home Care assessment; the LOCET telephone screen for presumptive eligibility at intake | The long-term care access contractor’s trained staff; no physician-signed instrument. A physician pathway is scored from visits and order changes in a 14-day look-back | OAAS or its designee | LOCET approvals “are valid for 30 days” |
| Virginia | DMAS-96, Medicaid LTSS Authorization | Two screeners, from the local DSS and the local health department, and a physician: “the physician’s signature certifies expected length of stay as well as Level of Care” | DMAS | Authorizations “for NF, PACE, or CCC Plus Waiver are interchangeable” |
Two corrections to things that circulate, including in earlier copy on this site. Louisiana’s Form 90-L is the Office for Citizens with Developmental Disabilities’ instrument, used “to determine if someone meets level of care for an Intermediate Care Facility for Individuals with Intellectual Disabilities”; it is not the nursing facility instrument, which OAAS runs on the interRAI with no physician’s signature. And New York’s PRI and SCREEN have not been the community instrument for over a decade: “effective April 1, 2014, the UAS-NY is the LOC tool to be used for NHTD”, and from September 1, 2017 “all Level of Care (LOC) assessments for community based individuals will be conducted using the Uniform Assessment System”.
Three models, not one
Read the table down and the states sort into three.
The physician certifies. Florida, Pennsylvania, Texas, Georgia and Virginia all put a doctor’s signature on the instrument, and the signature carries a legal statement. Florida’s reads “I certify the individual requires nursing facility (NF) services” and “I certify the individual is in need of Medicaid Waiver Services in lieu of nursing facility placement”. Georgia’s pediatric form, the DMA-6A, reads “I certify that this patient requires the level of care provided by a nursing facility, or ICF/ID”. Texas’s physician certifies the member “requires ongoing nursing services under the direction of a physician”. Pennsylvania is the strictest about who may sign: MD or DO only, and the Pennsylvania Health Law Project’s note on the 2020 form update says in terms that forms signed by physician assistants, nurse practitioners “or doctors in training will not be accepted”. Florida and Louisiana’s developmental disability form go the other way and accept a nurse practitioner or physician assistant under supervision.
In these states the application waits on the physician, and the states say so. Chester County’s guidance to Pennsylvania applicants: “your doctor must fill out and submit the form to the IEB as soon as possible. If they do not submit the form on time, your application may be delayed”, and “if your doctor has not sent the Physician Certification Form, the PA IEB will send you a letter and call your doctor and you.” Texas’s managed care plans are given five business days to get the signature before a second attempt, and if the physician never responds, the plan writes to the member and notifies the state. The only published estimate of how long the step takes is a Pennsylvania home care agency’s enrollment guide, which tells families “normally, between two weeks and two months”, with “how long it takes for your doctor to respond” as the biggest factor; a state figure does not exist.
A licensed assessor determines, in person. Michigan, Wisconsin, Indiana and New York take the physician out of the instrument entirely. Michigan’s LOCD “must be conducted face-to-face by a qualified and licensed health professional”; Wisconsin’s screener needs a degree or an RN license plus certification; New York’s UAS-NY is signed by a trained RN; Indiana’s single contractor assesses on the interRAI. The medical facts still come from records, as the NFLOC documentation article sets out, but the signature on the determination is the assessor’s and the clock is the assessor’s: 14 days to enter, 30 days to screen, 11 days to determine.
Both, in sequence. Texas scores the MN/LOC assessment and requires the physician’s Form 2601 behind it, at the initial request only; the annual review is “performed by a nurse”. Pennsylvania runs the physician certification and the functional determination in parallel and sends disagreements to a medical director. North Carolina scores the service request form and attaches a physician attestation. Illinois’s CCU scores the DON and, as an advocate’s guide puts it, “will also ask your doctor to fill out forms and give medical records”.
What the signature is attesting to
A physician asked to sign is being asked to attest to a clinical history. Texas is explicit that the signer must have examined the member and “reviewed the medical record within the last 12 months”. Florida’s form asks for an effective date of the condition and, if the physician leaves it blank, uses the signature date instead, so a blank costs the applicant retroactive months. Florida’s instructions also tell the signer to attach the medication list, which “is not optional”, and whatever else answers a section: “any section that can be addressed through documents should include the documents with the form and marked ‘See Attached’”. North Carolina’s FL-2 asks the physician how many visits in the last 30, 90 and 180 days, and for “X-ray and Laboratory Findings/Date”. Virginia requires the physician to hold the state’s screening training and certification number.
What the physician does not hold is the hospital’s discharge summary, the cardiologist’s consult or the pharmacy’s fill history for a patient seen twice a year. Pennsylvania’s guide notes that the state “does not request additional medical documentation” from the applicant; whatever should be read must go in with the certification. The form’s turnaround is the physician’s wait for other people’s records, and the agency that sends the form with those records attached has removed the wait.
For the agency
The Medicaid waiver case management agency is responsible for the application whichever model its state runs. In a physician-certification state the work is getting a signable form to the doctor; in an assessor state it is getting verified diagnoses and a current history to the screener, who “must obtain a signed release of information” to collect them, in Wisconsin’s words. In both, the records that matter are the ones listed in the NFLOC documentation article, inside the look-back the state reads, and the clocks are the state’s level-of-care clocks, not the federal 45 days. Vivlio for case management retrieves that documentation under the applicant’s release and organizes it the way the instrument asks.
