Every Medicaid waiver for older adults and adults with disabilities, and PACE, turns on one finding: the person meets the nursing facility level of care. The finding is made on a state instrument, and the instrument is read against documentation. What that documentation is, how old it may be, who reads it and what happens when it is thin are written down state by state, in criteria manuals, form instructions and process rules, and almost never in one place. This is the one place, for the agency that has to assemble it.
What federal rule requires, and what it leaves to the state
42 CFR 441.302(c) requires the state to evaluate “the need for the level of care provided in a hospital, a NF, or an ICF/IID when there is a reasonable indication that a beneficiary might need the services in the near future (that is, a month or less)”, to reevaluate “at least annually”, and, under 441.303(c), to describe in its waiver “who will make these evaluations and how they will be made”, to file “a copy of the evaluation form to be used”, and to keep “written documentation on all evaluations and reevaluations”. The evaluation “means a review of an individual beneficiary’s condition”.
That is the whole federal shape. Nothing in it requires a physician to perform or sign the evaluation, lists the records that support it, or sets a look-back. Those are state choices, which is why Pennsylvania accepts only an MD or DO on its certification and Florida accepts a nurse practitioner, why Indiana’s contractor assesses with the interRAI and Illinois scores a Determination of Need, and why the same hospital discharge summary is required in one state and merely useful in the next.
Two halves, from two places
Every instrument has a medical half and a functional half, and the states are explicit that they come from different sources.
The functional half is observed. Wisconsin’s Long-Term Care Functional Screen “requires in person, face to face contact with the individual”; “the LTCFS is not an interview tool”; screeners are told to “take a tour of the individual’s home and observe them as they perform everyday activities” and, if possible, “ask the individual to demonstrate tasks”. The screener selects “the level of assistance needed based on the level of help needed from another person”, “based on need and not solely on a diagnosis”. Illinois’s managed care training describes the Determination of Need as “a functional assessment (not a clinical or medical evaluation)” with “emphasis on the ability to do a task, not the diagnosis”, and notes that “assessors are not medical staff”. In New Mexico, “the assessment for Community Benefit ADLs may be done in the home by a Care Coordinator”.
The medical half is read from records, and the states say so in the same documents. Wisconsin: “it is best practice to verify all diagnoses with written documentation from the person’s health care provider(s)”; every psychiatric, behavioral, dementia, brain injury and intellectual disability diagnosis “must be verified directly”; a diagnosis counts as verified when it is “stated to screener by a medical doctor (MD), registered nurse (RN), or other health care provider” or “copied from current health records”; “do not interpret an individual’s complaints or symptoms as verified diagnoses”. The screener “must obtain a signed release of information from the person being screened” to collect the health records. Illinois’s Home Services Program: “medical documentation such as a copy of customer’s treatment reports, history and physical, hospital discharge summary, medical or psychological eval is needed to verify diagnoses and should coincide with functional limitations laid out on the DON.” New Mexico’s reviewer “will determine eligibility and eligible services for Community Benefits by applying the level of care criteria based on the Care Coordinators assessment of the ADLs”, and the criterion itself requires that “the functional limitation must be secondary to a condition for which general treatment plan oversight of a physician is medically necessary”, with determination “based on detailed documentation in interdisciplinary progress notes and care plans”.
An agency can staff the first half. It cannot staff the second. The functional screen is a visit; the medical record is in someone else’s chart.
What the reviewer reads
New Mexico publishes the list. Its nursing facility level of care criteria say “the documentation in the recipient’s medical record must support the rating”, and decisions “are based solely on criteria supported by documentation in the medical record including physician notes, history and physical, physician orders, nursing notes, medication administration record, care plan, interdisciplinary progress notes, and therapy logs”. The threshold for the community benefit is that “two or more Activities of Daily Living cannot be accomplished without consistent, ongoing, daily provision” of service. For PACE, “the MAD 379 abstract together with the history and physical will be used for evaluation.”
Florida’s Form 3008 is the most explicit instrument in the country about attachments, because its instructions tell the signer that “any section that can be addressed through documents should include the documents with the form”. Section E: “attach a medication reconciliation form and/or medication list”; “medication list is not optional, and must be attached”. Section N lists what may be attached: “Physician Orders; Discharge Summary; Medication Reconciliation; Discharge Medication List; PASRR Forms; Social and Behavioral History; Treatment orders; Lab reports; X-rays; EKG; CT Scan; MRI; History & Physical.” The CARES program “cannot accept this form if the items or sections marked by an asterisk are not completed”, and if the physician leaves the onset date blank, “CARES will use the physician/ARNP/PA signature date for medical eligibility purposes”.
Louisiana’s admissions guidance lists what its reviewers find useful: “H&P and any additional updates”, “Physician Progress Notes over past 72 hours, up to most recent”, “Medication List (do NOT need whole MAR)”, “Labs/Scans-on admit and most current for comparison”, “Specialists Consults and Notes”, “PT/OT/ST assessment and notes to show progression and prognosis”, psychiatric and social work evaluations. For the PASRR Level I, “H&P form within the last 365 days and MAR including PRNs must be submitted”. The level-of-care instrument itself, the LOCET, “takes 15-20 minutes on average to complete” and “should be completed by someone familiar with how much and the type of assistance the resident received within the specified look back period”.
Ohio defines a complete request: all elements of the ODM 03697, including “individual’s current diagnoses or diagnoses as of the requested retroactive effective date” and “any preadmission screening results and assessment forms”.
Indiana since July 1, 2025 routes every assessment through one contractor, which “will be conducting LOC assessments and making NF LOC determinations” using “the appropriate full interRAI assessment”. The criteria did not change, and the rule behind them is about the chart: “the need for significant skilled personnel involvement must be documented within the patient’s medical record”, and medical necessity for a higher intensity of nursing “must be noted in physician’s orders”.
Montana’s request to its review contractor “should minimally include” the diagnoses, “Special Treatments, Medications, Therapies and Equipment”, and the applicant’s Medicaid status. Its form, the SLTC-86, has a page for the health care professional’s diagnoses and treatments and a page for the functional assessment, and no attachment list; the contractor scores each item.
Georgia’s instrument is completed by two people: “the physician and RN care coordinator complete the LOC form”, the RN care coordinator can approve a stay “of up to one year”, and “the stay begins on the day the LOC form is signed by the RN care coordinator”. The Form 5588 instructions that say what the physician must attach are behind the state’s provider portal and are not quoted here.
How old the documentation may be
The look-back is the part agencies most often get wrong, because the records they are handed are the ones that exist, not the ones the reviewer wants.
New Mexico’s reviewer certifies when “clinical information for the prior 30 days indicates the recipient meets criteria”; if it does not substantiate the level, “the reviewer is obligated to refer the case to physician review”. The history and physical with a physician order must be “dated within 6 months for initial and 12 months for annual”. Louisiana wants the history and physical “within the last 365 days”, and its level-of-care approvals “are valid for 30 days”. Florida’s signed form “is good for one year from the date of the health care professional’s signature, unless there has been a significant change in the individual’s condition”, and CARES “reserves the right to request new 3008’s” when there has been one. Wisconsin accepts diagnoses “copied from current health records” and gives the example note it wants to see: “all diagnoses were confirmed from medical records received 12/2022 from Dr. Jones at Healthy Clinic.” Illinois does not require updated medical documentation at reassessment “if there have not been any changes in the customer’s condition and the customer is not requesting a change of services”.
The pattern: recent physician contact, a year at most for the history and physical, a month or so of clinical notes for the acute picture, and a date on everything.
When it is incomplete
The states have written down what happens, and in most of them it is a clock followed by a denial that is not about the person’s needs.
Ohio: the department “will notify the submitter and specify the necessary information to be provided” and “allow fourteen calendar days”; otherwise “the request may be denied”. New Mexico’s training on technical denials: “the most common reason for an administrative denial (or technical denial) is when the provider does not respond to a request for information (RFI). NM Medicaid rule sets this at 14 business days. Basically, the contractor cannot make a decision with the paperwork that was submitted because it is incomplete.” Iowa, for four of its waivers since April 2026: “if the QIO does not receive the documentation within the required timeframe, the members’ level of care will be denied due to the lack of supporting documentation of a qualifying diagnosis”, the timeframe being 60 calendar days. Indiana routes a potential denial first “to a Maximus physician, and, if the potential denial is upheld, the Division of Aging will then review”. New Mexico requires that “all denials must be reviewed by a Physician”.
A denial for missing documentation is appealable, and the appeal is won by producing the documentation, which is the same work done later with the clock already run. The clocks themselves are the previous article.
What this means for the agency
The Medicaid waiver case management agency owns the application and the functional screen and holds none of the medical half. The level-of-care form goes to a physician who is asked to attest to hospitalizations, specialist findings and a medication list that sit in other organizations’ records, and the reviewer then reads those records against a look-back the agency did not choose. The list above is what to have in hand before the form goes out: the history and physical inside the window, every discharge summary in the look-back, the specialists’ consults, the medication list reconciled across prescribers, therapy and cognitive evaluations where they exist, and the date and source on each. That is the record Vivlio assembles for case management, under the applicant’s release, organized the way the instrument asks for it.
