Level-of-Care Prep Sheet (For Your Physician)

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Level-of-Care Prep Sheet (For Your Physician)

From caidee.org · Tennessee TennCare resource

Bring this to your next appointment with your child's treating physician. It will help them write a strong letter that addresses what TennCare reviewers actually want to see.

What to Ask Your Physician to Address

1. Specific medical diagnoses (with ICD-10 codes): List ALL active diagnoses, not just the primary. Co-occurring conditions strengthen the case.

2. Daily/hourly skilled care requirements: Be specific. Example: "Requires suctioning every 3 hours; G-tube feeds every 4 hours via pump; ventilator settings monitored every 2 hours."

3. Hours of supervision required daily: Quantify it. "Requires constant adult supervision due to seizure risk and elopement behavior — minimum 16 hours/day direct supervision."

4. Activities of daily living (ADL) limitations: Which of these does the child need help with? Bathing, dressing, eating, toileting, transferring, continence. Be honest — "needs help with all 6 ADLs" carries weight.

5. Medications + administration complexity: Number of meds, schedule, route (PO, IV, GT, inhaled), and whether the child can self-administer.

6. Equipment dependence: Ventilator, BiPAP, oxygen, feeding pump, suction, monitors, wheelchair, communication device, etc.

7. THE KEY STATEMENT: "Without home-based care of this intensity, [child name] would require institutional placement — specifically [hospital / skilled nursing facility / residential treatment facility]."

Template Phrases That Win Approvals

"Requires 24-hour skilled care due to..."
"Would otherwise require placement in a [pediatric SNF / hospital / residential treatment facility]"
"Daily care needs are equivalent to those provided in an inpatient setting"
"Medical needs cannot be safely managed without continuous adult presence"
"Behavioral/cognitive limitations create safety risk requiring constant supervision"
"Skilled nursing services normally provided in a hospital are required at home including..."

What Reviewers Don't Care About (Don't Lead With These)

— "The child has [diagnosis]" — diagnosis alone doesn't establish LOC
— "The family loves the child" — sympathy is not a criterion
— "Insurance won't cover [X]" — irrelevant to TennCare LOC determination
— Generalities like "complex needs" or "serious condition" without specifics

Ask for the Letter to Include These Sections

  1. Provider credentials + years of treating this patient
  2. Active diagnoses with ICD-10 codes
  3. Specific daily care requirements (the meat)
  4. Equipment + medication summary
  5. Behavioral/cognitive functional limitations
  6. The "without this care, institutional placement would be required" statement
  7. Provider signature, date, NPI number

caidee.org/downloads/loc-prep-sheet · Updated for 2026 TennCare rules · Not legal advice — for navigation guidance only