Provider Central Search
Use the search function below to search Provider Central
Medicaid B: Intermediate Care Facility (ICF) and Short Term Residential Stabilization (STRS)
About
Coverage
Medicaid B
Diagnosis Group(s)
Mental Health, Substance Use, Developmental Disability
Age Group(s)
All, Adult, Child, 18-20
Authorization
Submission Requirements
ICF/IID State Facility
- Service Authorization Request (SAR)
- Level of Care (LOC) Form
- Meet ICF/IDD criteria
ICF/IID Non-State Facility
- Service Authorization Request (SAR)
- Level of Care (LOC) Form
- Meet ICF/IDD criteria
- Initial requests must include copy of most current psychological testing
Short Term Residential Stabilization (H2016 TF U5)
Initial:
- Service Authorization Request (SAR)
- Person Centered Plan (PCP)
- Comprehensive Clinical Assessment (CCA)
Concurrent:
- Service Authorization Request (SAR)
- Updated Person Centered Plan (PCP)
- If the episode of care exceeds 120 days a new Comprehensive Clinical Assessment (CCA) or addendum to previous assessment is required
Service Definition Authorization Parameters
ICF/IID State and Non-State Facility
- Initial and Concurrent: Maximum 180 days
Short Term Residential Stabilization (H2016 TF U5)
- Initial and Concurrent: Up to 30 days
SNAP
| A | B | C | D |
|---|---|---|---|
|
Service Codes & Descriptions
- RC-100 - ICFMR
- T2016 TF U5 Short Term Residential Stabilization
Full Service Definition
Alliance Statement of Work
Was this page helpful?
