Instructions for Form LTC-2 "Notification From Long-Term Care Facility Admission or Termination of a Medicaid Beneficiary" - New Jersey

This document contains official instructions for Form LTC-2, Notification From Long-Term Care Facility Admission or Termination of a Medicaid Beneficiary - a form released and collected by the New Jersey Department of Human Services. An up-to-date fillable Form LTC-2 is available for download through this link.

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Download Instructions for Form LTC-2 "Notification From Long-Term Care Facility Admission or Termination of a Medicaid Beneficiary" - New Jersey

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INSTRUCTIONS FOR COMPLETION OF THE
New Jersey Department of Human Services
Division of Aging Services
NOTIFICATION FROM LONG-TERM CARE FACILITY FOR ADMISSION AND TERMINATION
Complete each section and submit to the Office of Community Choice Options Regional Office for notice of
PAS request, admission, termination, and transfer.
Notification -Type of Notification: Check the appropriate box.
Request PAS
Notice of Admission
Notice of Termination
Notice of Transfer
SECTION I - PATIENT INFORMATION
1. Name - self explanatory
2. Social Security Number - patient’s number
(Note: the Medicare number is NOT ALWAYS the patient’s SSN)
3. Sex - self-explanatory.
4. Date of Birth-self – explanatory
5. HSP#-12digit Medicaid Number, if available (Confirmed By: Give name of CWA approving financial
eligibility) NJ Family Care, MLTSS, FFS, MCO write in name of MCO if know.
SECTION II - PROVIDER INFORMATION
1. Provider Number-7 digit Molina provider number
2- 4 Facility name and address
5. Facility Phone number
6. SCNF
SECTION Ill - Status PASRR
1. Enter date of PASRR level1 screen.
2. Check the appropriate box, negative or Positive. If positive, continue to check the appropriate box for the
positive screen.
3. Date of the Positive Level ll evaluation. (unless PASRR 30 Day Exempted Hospital Discharge)
4. Outcome of PASR Level ll evaluation- check the applicable box for yes or no for specialized services.
SECTION IV – REQUEST FOR PAS:
Check off box indicating type of PAS Request:
a. Private to Medicaid
b. PAS Exempt >20days (Physician 20 day note must accompany request or PAS will not be
completed).
c. Medicare to Medicaid
d. Out of State Approval Admission,
e. SCNF to NF
f. NF to SCNF
g. Transfer
h. EARC PAS
i.
Other
LTC-2 Instructions
FEB 15
| 1
INSTRUCTIONS FOR COMPLETION OF THE
New Jersey Department of Human Services
Division of Aging Services
NOTIFICATION FROM LONG-TERM CARE FACILITY FOR ADMISSION AND TERMINATION
Complete each section and submit to the Office of Community Choice Options Regional Office for notice of
PAS request, admission, termination, and transfer.
Notification -Type of Notification: Check the appropriate box.
Request PAS
Notice of Admission
Notice of Termination
Notice of Transfer
SECTION I - PATIENT INFORMATION
1. Name - self explanatory
2. Social Security Number - patient’s number
(Note: the Medicare number is NOT ALWAYS the patient’s SSN)
3. Sex - self-explanatory.
4. Date of Birth-self – explanatory
5. HSP#-12digit Medicaid Number, if available (Confirmed By: Give name of CWA approving financial
eligibility) NJ Family Care, MLTSS, FFS, MCO write in name of MCO if know.
SECTION II - PROVIDER INFORMATION
1. Provider Number-7 digit Molina provider number
2- 4 Facility name and address
5. Facility Phone number
6. SCNF
SECTION Ill - Status PASRR
1. Enter date of PASRR level1 screen.
2. Check the appropriate box, negative or Positive. If positive, continue to check the appropriate box for the
positive screen.
3. Date of the Positive Level ll evaluation. (unless PASRR 30 Day Exempted Hospital Discharge)
4. Outcome of PASR Level ll evaluation- check the applicable box for yes or no for specialized services.
SECTION IV – REQUEST FOR PAS:
Check off box indicating type of PAS Request:
a. Private to Medicaid
b. PAS Exempt >20days (Physician 20 day note must accompany request or PAS will not be
completed).
c. Medicare to Medicaid
d. Out of State Approval Admission,
e. SCNF to NF
f. NF to SCNF
g. Transfer
h. EARC PAS
i.
Other
LTC-2 Instructions
FEB 15
| 1
SECTION V - ADMISSION INFORMATION
(IF THIS IS A TERMINATION, SKIP TO SECTION V)
1. Admission Date-
This is the date resident was admitted to the facility. For Private to Medicaid cases this date
should reflect the date the patient was originally admitted to the facility. This type of case
should be sent to the field office 6 months prior to the anticipated date of conversion to
Medicaid.
Transfer- Check the box yes or no.
2. Date of PAS –if applicable
3. Admitted from-check appropriate location:
Community/Boarding Home
Medicare to Medicaid
Psychiatric Hospital
Private to Medicaid-complete “anticipated Medicaid Effective Date”
(Note: It is no longer necessary to attach PA-4)
Hospital - Acute Care Hospital or Rehab Hospital-also complete #5
Other Long Term Care Facility (LTCF)-also complete #5
Other (specify)-use this category if above categories do not apply.
4. Name and Address of Hospital/LTCF Admission Date-self explanatory
5. If admitted from Hosp/LTCF, give the name/address of previous residence-self explanatory
SECTION V1 - TERMINATION INFORMATION
(IF THIS IS AN ADMISSION, SKIP TO SECTION V)
1. Discharge Date-date patient was discharged from the facility
2. Discharged to: (check one)
Home – Community (including relative’s home)/County of residence
Facility (includes NF and AL)/ County of Residence
Other (use this category if above categories do not apply. Include name and address of
“other”/County of residence
Death (Date)-self explanatory
Check “In LTCF” or “In Hospital”
SECTION V11 - CERTIFICATION
1. By signing this certification, Provider is attesting that the facility has a “valid PAS on file”. Complete Name, Title,
Phone Number, and Date
SECTION VI11 - CWA USE ONLY (TO BE COMPLETED BY CWA ONLY)
Section IX - GENERAL INFORMATION FOR NURSING FACILITIES:
Send an LTC-2 for all new admissions that have been prescreened, private to Medicaid, out of state and EARC,
and PAS Exempt cases. LTC-2 is now required to be sent for PASRR notification regardless of payor source and
for notice of termination.
N.J.A.C. 10:63-1.8 (k) mandates the nursing facility (NF) to submit the LTC-2 (formerly MCNH-33) form to the
Office of Community Choice Options Regional Field
Office,
serving the county where the NF is located within
two working days of status of admission, termination, request for PAS for all persons who are currently Medicaid
eligible, or will be eligible within 180 day and for PASRR notification regardless of payor source.
LTC-2 Instructions
FEB 15
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