Using the LTC DMA-0100 - Physician’s Signature for authorization of level of care form

A new fact sheet, “Using the LTC DMA-0100 Form,“ has been posted to the Fact Sheet page of the NCTracks Provider Portal. (See link below.) The DMA-0100 - Physician’s Signature for authorization of level of care is a supplementary form intended to be used if there has been a Long Term Care (LTC) Prior Approval (PA) request submitted using the provider portal. The DMA-0100 form can be found on the NCTracks Prior Approval webpage. (See link below.)

The new fact sheet provides important information regarding the use of the DMA-0100 form. The fact sheet explains how to correctly fill out the DMA-0100 form and the process to submit the form to NCTracks. Following these guidelines regarding the use of the DMA-0100 form will help to expedite the review of the LTC prior approval requests.