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Safety Determination Request Form - State of Tennessee - tn 2025

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The document is a Safety Determination Request Form used by entities submitting a Prior Authorization Evaluation (PAE) for nursing facility level of care (NF LOC) under TennCare. It requires detailed information about the applicant's living arrangements, safety concerns, and justifications for requesting a safety determination. The form outlines various criteria related to the applicant's acuity scores, mobility, toileting needs, orientation deficits, behavioral issues, recent falls, hospital admissions, and caregiver status. It emphasizes the necessity of comprehensive documentation to support claims of safety concerns that may prevent the applicant from being safely served in community settings.

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