Participant Name:
SAR #:
Submit Date:
NC INNOVATIONS WAIVER AND ICF-IID
LEVEL OF CARE CRITERIA
Innovations
Met
Not
Met
ICF-IID
N/A
Record Number:
Required Attachments
Psychological evaluation is attached and meets all of the following:
 Test was administered by a Licensed Psychologist or Licensed Psychological Associate.
 Psychological evaluation was performed within five (5) years for adults and three (3) years
for children OR
 A psychological evaluation is included but not within the above timeframes and the
Licensed Psychologist or Licensed Psychological Associate has updated the evaluation to
assure accuracy and timeliness of LOC determination and the signature of the Licensed
Psychologist or Licensed Psychological Associate on the update is not more than 30 days
old.
 Psychological evaluations include a standardized IQ test and an adaptive behavior
assessment.
*If this section is not met the Initial Level of Care request is NOT Reviewable.
Contact the agency that submitted the information.
If the applicant’s qualifying condition has a medical diagnosis, other than mental retardation, the
NC Innovations Medical Assessment form is attached and must meet all of the following:
 NC Innovations Medical Assessment form was completed by a physician;
 Physician signature is not more than 30 days old;
 Physician’s evaluation or supplemental medical information submitted.
*If this section is not met the Initial Level of Care request is NOT Reviewable.
Contact the agency that submitted the information.
The completed NC Innovations Level of Care Eligibility Determination form is attached and meets
the following:
 Form is signed by Physician, Licensed Psychologist or Psychological Associate as
appropriate based on who completed the assessment;
 Signature and printed name of Physician, Licensed Psychologist or Psychological Associate
is not more than 30 days old;
 Information obtained from the assessment is used to complete the NC Innovations Level of
Care Eligibility Determination tool;
 Level of Care Recommendation is checked Eligible for ICF/IID.
*If this section is not met the Initial Level of Care request is NOT Reviewable.
Contact the agency that submitted the information.
Person requires active treatment necessitating the ICF/IDD level of care. (Active treatment refers
to aggressive, consistent implementation of a program of specialized and generic training,
treatment and health services. Active treatment does not include service to maintain generally
independent clients who are able to function with little supervision or in the absence of a
continuous active treatment program.)
Person has a diagnosis of Intellectual Disability per the DSM-5, characterized by significant
limitations both in general intellectual function resulting in, or associated with, deficits or
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Innovations/ICF-IID Level of Care Criteria
Page 1
impairments in adaptive behavior and
 The disability manifests before age 18 OR
Person has a closely related condition that meets ALL of the following conditions:
 is attributable to:
o Cerebral palsy, epilepsy; or
o Any other condition, other than mental illness, found to be closely related to
Intellectual Disability because this condition results in impairment of general
intellectual functioning or adaptive behavior similar to that of Intellectually
Disabled persons and
 The related condition manifested before age 22 and
 Is likely to continue indefinitely; and
The related condition results in substantial functional limitations in three (3) or more of the
following major life activity areas as determined by reports from physicians, psychologists and
other appropriate disciplines. (Please complete the applicable sections):
 Self-Care (ability to take care of basic life needs for food, hygiene, and appearance) as
evidenced by:

II. Understanding and use of language (ability to both understand others and to express
ideas or information to others either verbally or nonverbally) as evidenced by:

III. Learning (ability to acquire new behaviors, perceptions and information, and to apply
experiences to new situations) as evidenced by:

IV. Mobility (ambulatory, semi-ambulatory, non-ambulatory) as evidenced by:

V. Self-direction (managing one’s social and personal life and have ability to make decisions
necessary to protect one’s life) as evidenced by:

VI. Capacity for independent living (age-appropriate ability to live without extraordinary
assistance) as evidenced by:
Initial Review:
All Criteria Met:
YES
NO (send to Clinical Reviewer)
NOTE: All Initial Level of Care requests must be reviewed by Clinical Reviewer.
Reviewer Name, Credentials:
Date:
Comments:
Clinical Review:
Approved
Send to Peer Review
Reviewer Name, Credentials:
Date:
Comments:
Partners only: All Level of Care requests must be reviewed by MD.
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Innovations/ICF-IID Level of Care Criteria
Page 2