The Department of Health Care Finance (DHCF) is notifying DC Medicaid Nursing Facility Providers of two changes. First, we are revising the process and format for the level of care (LOC) requirement for institutionally-placed beneficiaries at the annual recertification period. Second, we are revising the process for seeking approval for an out-of-District nursing facility placement by requiring documentation that five in-District nursing facilities have declined admission before an out-of-District placement is authorized. This transmittal supersedes and replaces Transmittals numbered 15-23 and 17-09 regarding nursing facility placement and review procedures issued on July 15, 2015 and April 20, 2017, respectively.