Preadmission Screening (PAS)
Individuals seeking financial assistance from Medicaid for long-term care services must meet the program’s medical (clinical) and financial eligibility requirements. The steps necessary to attain Medicaid approval are known as the Pre-Admission Screening (PAS) process.
The PAS process is administered statewide by Long Term Care Field Office (LTCFO)counselors. Referrals are received in the LTCFO from a variety of sources, including:
- Hospitals, including rehabilitation, psychiatric, and acute care;
- Nursing Facilities and Special Care Nursing Facilities;
- Assisted Living Residences, Comprehensive Personal Care Homes and agencies offering Adult Family Care and Assisted Living Programs; and
- The community, for individuals in need of long-term care services or their caregivers, through community agencies including County Welfare Agencies and the County Offices on Aging/Area Agencies on Aging.
Agencies making referrals for PAS are required to submit the following forms to the LTCFO:
- Hospitals use Form LTC-34 (Word, PDF) or Form LTC-4 (Word, PDF), the Hospital Pre-Admission Screening Referral.
- Nursing homes use Form LTC-2 (Word, PDF), the Notification from Long Term Care Facility of Admission or Termination of a Medicaid Client.
- County Welfare Agencies use Form CP-2 (formerly Form JCN-417) (Word, PDF).
- Physicians referring adults in the community through County Welfare Agencies use Form PA-4 (Word, PDF), the Certification of Need for Patient Care in a Facility other than Public or Private General Hospital. Physicians referring children in the community shall contact the Division of Disability Services for screening and physician Certification for Children form.
- Assisted Living waiver providers use Form AL-6 (Word, PDF), the Assisted Living/Adult Family Care (AF/AFC) Referral Form.
- Individuals residing out-of-state who are seeking long-term care services in New Jersey use the Out-of-State referral packet available through the LTCFOs. Please contact the LTCFO for a referral packet.
Note: Approval for Medicaid Long Term Care Services is a two-fold process. Waiver eligibility is contingent upon the financial eligibility determination for Medicaid by the County Welfare Agency or Board of Social Services.
Below is a table with the referral source, required referral documents and the critical information that needs to be completed to initiate the PAS.
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Referral Source
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Referral
Documents Required
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Critical Information
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All Hospitals
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LTC-4 or LTC-34
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Name of hospital, client’s name, date of birth, Social Security number (SSN), eligibility status, name of the social worker or discharge planner.
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Nursing Facility
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LTC-2
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Client’s name, SSN, provider’s name, date of admission, client’s previous location and status:
- Private to Medicaid
- PAS Exempt
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AL Waiver Providers
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AL-6
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Client’s name and contact information, SSN, diagnosis, name of facility.
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Community
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County Welfare Agency
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CP-2
PA-4 (or its equivalent).
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Client’s name, SSN, Medicaid number if available, address including county, telephone number, income if client wants a waiver, intake worker.
Client’s name, date of birth, current living situation, diagnosis, ADL needs, #10 must be “yes,” MD signature, date.
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Adult Protective Services (APS)
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PA-4 (or its equivalent)
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Client’s name, date of birth, current living situation, diagnosis, ADL needs, #10 must be “yes,” MD signature, date.
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Out-of-State Referral
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Out-of-State packet
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Client's name, address, SSN, contact person with phone number.
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Physician Referrals
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PA-4 (Adults)
Physician Certification for Children (Pediatric age birth through 20)
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Client's name, SSN, diagnosis.
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