Clarification on Long Term Care Prior Approval Requests

Long Term Care (LTC) Prior Approval (PA) requests require a valid Physician (MD) signature that is dated within 30 calendar days prior to the date of submission. Providers must use one of the following forms to submit the MD signature:

- Long Term Care FL2 Form (DMA372-124)
- Physician’s Signature for Authorization of Level of Care (DMA-0100)

Both forms are NOT required. These forms are located on the Prior Approval page of the NCTracks Provider Portal. (See link below) The NCTracks LTC team recommends that you use the Long Term Care FL2 form with all your LTC PA requests. This form provides the most information possible so your request can be processed more quickly.