Montana's Senior and Long Term Care Division uses this screen to decide whether an applicant meets nursing facility level of care, for nursing facility admission or for home and community based services (HCBS). The referring hospital, facility or case manager records diagnoses, treatments and a coded functional assessment. Mountain-Pacific Quality Health reviews it and records the determination in its own section.
The referring facility, hospital clinician or case manager completes the identifying, diagnosis and functional assessment portions and names the applicant's health care professional. The Mountain-Pacific Quality Health sections are completed only by the reviewer.
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Level-of-Care Determination
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Mountain-Pacific Quality Health reviews DPHHS-SLTC-86 for the Department of Public Health and Human Services. Its reviewer records whether nursing facility level of care is met, the criteria met, any HCBS referral, placement and effective date, then copies the outcome to the case management team, nursing facility and referral source.
For the functional assessment, 0 means independent, 1 means the person needs mechanical aids or undue effort, 2 means consistent human help, and 3 means unable to meaningfully contribute. For functional capabilities, 0 is good, 1 mild impairment, 2 significant impairment and 3 total loss.