Instructions for Form CP-2 "Long Term Services and Supports Referral" - New Jersey

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This document contains official instructions for Form CP-2, Long Term Services and Supports Referral - a form released and collected by the New Jersey Department of Human Services. An up-to-date fillable Form CP-2 is available for download through this link.

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Download Instructions for Form CP-2 "Long Term Services and Supports Referral" - New Jersey

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INSTRUCTIONS FOR THE
LONG TERM SERVICES AND SUPPORTS REFERRAL FORM (CP-2)
Referral Process for CWA
The County Welfare Agency (CWA) utilizes this form to refer individuals residing in the community
who are seeking nursing facility (NF) placement, assisted living (AL) residences or Waiver programs
and are potentially or currently Medicaid eligible or who are converting from private pay to Medicaid
to the County Area Agency on Aging/Aging & Disability Resource Connection (AAA/ADRC). The
CP-2 is also used by the CWA to verify Medicaid eligibility when referring NF residents who are
requesting Waiver services to the Office of Community Choice Options (OCCO) Regional Office.
The referral form will serve as verification of financial eligibility and should include a physician-
completed PA-4 form.
Referrals need to be made if one of the following scenarios occurs:
(a)
Consumers seeking long term services and supports (LTSS) who, upon initial intake, appear to
be eligible for Medicaid Waiver services and may be eligible for an expedited process. In such
cases, the CP-2 referral to the AAA/ADRC will be accomplished prior to and/or while the
verification and validation process of financial eligibility is being determined.
(b)
Consumers seeking LTSS who do not meet the above requirement but can benefit from home
and community-based services (HCBS) that can potentially be provided by other federal, state
or locally-funded programs.
FORM INSTRUCTIONS:
AAA/ADRC REFERRALS (for individuals in the community):
1.
The CWA worker must complete the entire top part of the form including the location of the
AAA/ADRC as well as the referral source (CWA) and name of the person making the referral.
2.
A Medicaid number must be on the form. A PA-4 is necessary for all NF and Waiver referrals,
including AL.
3.
The CP-2 referral form can be faxed or emailed to the AAA/ADRC designated staff, where it
will be processed for screening, initial options counseling and assessment.
OCCO REFERRALS (for individuals in a NF or AL):
4.
The CWA worker must complete the entire top part of the form including the location of the
OCCO Regional Office (Northern or Southern) as well as the referral source (CWA) and name
of the person making the referral.
A Medicaid number must be on the form. The resident’s date of financial eligibility and income
5.
must be recorded in the financial section of the CP-2.
6.
The CWA worker must also check the appropriate box in the participant information section
indicating interest in either a community-based Waiver or NF placement.
7.
If an individual is currently in a NF, include the admission date.
8.
A PA-4 is necessary for all NF and Waiver referrals, including AL.
9.
The CP-2 referral form can be faxed or emailed to the OCCO Regional Office designated staff,
where it will be processed for level of care assessment.
CP-2 (Instructions)
MAR 15
INSTRUCTIONS FOR THE
LONG TERM SERVICES AND SUPPORTS REFERRAL FORM (CP-2)
Referral Process for CWA
The County Welfare Agency (CWA) utilizes this form to refer individuals residing in the community
who are seeking nursing facility (NF) placement, assisted living (AL) residences or Waiver programs
and are potentially or currently Medicaid eligible or who are converting from private pay to Medicaid
to the County Area Agency on Aging/Aging & Disability Resource Connection (AAA/ADRC). The
CP-2 is also used by the CWA to verify Medicaid eligibility when referring NF residents who are
requesting Waiver services to the Office of Community Choice Options (OCCO) Regional Office.
The referral form will serve as verification of financial eligibility and should include a physician-
completed PA-4 form.
Referrals need to be made if one of the following scenarios occurs:
(a)
Consumers seeking long term services and supports (LTSS) who, upon initial intake, appear to
be eligible for Medicaid Waiver services and may be eligible for an expedited process. In such
cases, the CP-2 referral to the AAA/ADRC will be accomplished prior to and/or while the
verification and validation process of financial eligibility is being determined.
(b)
Consumers seeking LTSS who do not meet the above requirement but can benefit from home
and community-based services (HCBS) that can potentially be provided by other federal, state
or locally-funded programs.
FORM INSTRUCTIONS:
AAA/ADRC REFERRALS (for individuals in the community):
1.
The CWA worker must complete the entire top part of the form including the location of the
AAA/ADRC as well as the referral source (CWA) and name of the person making the referral.
2.
A Medicaid number must be on the form. A PA-4 is necessary for all NF and Waiver referrals,
including AL.
3.
The CP-2 referral form can be faxed or emailed to the AAA/ADRC designated staff, where it
will be processed for screening, initial options counseling and assessment.
OCCO REFERRALS (for individuals in a NF or AL):
4.
The CWA worker must complete the entire top part of the form including the location of the
OCCO Regional Office (Northern or Southern) as well as the referral source (CWA) and name
of the person making the referral.
A Medicaid number must be on the form. The resident’s date of financial eligibility and income
5.
must be recorded in the financial section of the CP-2.
6.
The CWA worker must also check the appropriate box in the participant information section
indicating interest in either a community-based Waiver or NF placement.
7.
If an individual is currently in a NF, include the admission date.
8.
A PA-4 is necessary for all NF and Waiver referrals, including AL.
9.
The CP-2 referral form can be faxed or emailed to the OCCO Regional Office designated staff,
where it will be processed for level of care assessment.
CP-2 (Instructions)
MAR 15
INSTRUCTIONS FOR THE
LONG TERM SERVICES AND SUPPORTS REFERRAL (CP-2) FORM
(Continued)
For NF Transitions Only
Persons being discharged to community on Waiver or community programs
A. OCCO will forward a completed CP-2 form, minus the financial information, to the
CWA to verify that an individual who is being discharged to the community from a
NF on a Medicaid Waiver is financially eligible.
B. The CWA completes the financial section of the CP-2 from and returns it to OCCO
within three (3) business days.
Fast Track Referral from CWA
When a CWA worker wants to refer a consumer for Fast Track, the CP-2 will serve as a referral
form.
The CWA worker will check the appropriate Fast Track box selection in the participant
information section and must then follow these steps:
1.
The CWA worker will complete and forward to the ADRC Support System Designee an
INITIAL CP-2 to refer a consumer that appears to be eligible for Fast Track while his/her
financial application is being processed.
2.
The CWA worker will complete a clearly marked FINAL CP-2 and forward to the respective
OCCO Regional Office with the completed information section to confirm the financial
eligibility/ineligibility determination.
CP-2 (Instructions)
- 2 -
MAR 15
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