MUST BE COMPLETED BY SCREENER	New Jersey Department of Human Services

Office of Community Choice Options

EARC-PAS - ENHANCED AT-RISK CRITERIA SCREENING TOOL
Type of Request

NF Vent SCNF
If on Managed Care Medicaid STOP. No EARC required. Refer to the Medicaid MCO for Authorization.

If individual is on Medicaid not yet enrolled in MCO then EARC is required if criteria is met.
FOR OCCO USE ONLY
AUTHORIZED: NF Vent SCNF
VALID THROUGH:	Valid for this Hospital Admission only.
IMPORTANT: THIS AUTHORIZATION IS NOT A GUARANTEE OF MEDICAID PAYMENT. MEDICAID PAYMENT IS CONTINGENT UPON FULL CLINICAL AND FINANCIAL ELIGIBILITY WITHIN 90 DAYS OF ADMISSION TO THE NF AS PER N.J.A.C. 8:85-1.8(b).
NOT AUTHORIZED NF
Requires on-site PAS in Hospital. OCCO Regional Office will schedule on-site PAS assessment.
OCCO Reviewer Comments:	OCCO Reviewer Comments:
Name of Reviewer (Print)

Signature of Reviewer

Date of Review

SECTION 1 - IDENTIFYING INFORMATION

Patient Name (Print) - Last First

Social Security Number

Street Address

Date of Birth (Month / Day / Year)

_____ / _____ / _____
City, State, Zip Code

County of Residence

Gender

Male Female
Where did the patient live at time of admission?
Private Home/Apartment (alone) Private Home/Apartment, with care (family or agency)
Facility (Specify):
SECTION 2 - MENTAL ILLNESS, INTELLECTUAL DISABILITY AND/OR DEVELOPMENTAL DISABILITY
1.	Does the patient have any history of mental illness (such as but not limited to Schizophrenia, Bipolar	YES	NO
Disorder, Major Depression, Anxiety Disorder, Psychotic Disorder), intellectual disability, or developmental disability (such as but not limited to Cerebral Palsy, Epilepsy, Autism, Spina Bifida)?
a.	Date of Level I PASRR Screen:
b.	Level I Screen Outcome: Negative Positive
c.	Level II Determination outcome (If applicable): Negative Positive
d.	Did physician certify NF placement as 30-day exempted hospital discharge? ………………………...YES	NO
NOTE: For all PASRR Positive Screens, include a copy of the completed PASRR Level I Screen (Form LTC-26) with this EARC-PAS request. If patient triggers positive and requires specialized services, 1) Hospital patient cannot transfer to NF and 2) NF patient cannot remain in NF. Provider to contact DDD/DMHAS to coordinate specialized services. EARC-PAS referrals will not be authorized until OCCO confirms PASRR Positive Level I Screens as a 30-Day Exempted Hospital Discharge and/or receives results of PASRR Level II Determination from DMHAS and/or DDD that Specialized Services are not required.
SECTION 3 - INSURANCE INFORMATION
1.	Medicare Number:
Traditional Medicare Coverage: Part A Part B
Medicare HMO
Number of Days Authorized:
2.	Does the patient have other insurance that will cover 100% of the skilled nursing facility stay, including co-insurance payment at 100% if they exceed the first 20 days of Medicare? …...………………………………………YES ……NO
a.	Name of Carrier:
b,	Number of Days Authorized:
c.	Type: Primary Secondary Supplemental
SECTION 3 - INSURANCE INFORMATION, Continued
1.	Did patient apply for Medicaid and is application pending?...........................................................................Yes ………..No
2.	Is Medicaid expected to pay for any of the cost of the nursing facility stay?	…Yes	………..No
3. Will the patient’s funds last less than six (6) months in a nursing facility?...	…Yes	………..No
SECTION 4 - COGNITIVE STATUS AND ADL SELF PERFORMANCE

1.	How well does patient make decisions about organizing the day (e.g. when to eat, choose clothes, when to go out)?

Independent	Modified	Minimally	Moderately	Severely

Independence	Impaired	Impaired	Impaired

2. Can patient recall 3 items from memory after 5 minutes?	Yes ………No

3.	How well does patient express or make self-understood (expressing information content, however able)?

Understood	Usually	Often	Sometimes	Rarely/Never

Understood	Understood	Understood	Understood

4.	ADL Self Performance (score over past 3 days)

Limited	Extensive	Maximal	Total	Did Not

Independent	Set Up	Supervision	Assistance	Assistance	Assistance	Dependence	Occur

Bed Mobility

Transfer

Locomotion (indoor/outdoor)

Dressing (Upper and/or

Lower body)

Eating

Toileting (toilet use and/or

toilet transfer)

Bathing (over last 7 days

excluding washing of back

and hair).
SECTION 5 - MEDICAL
1.	Diagnosis (es):
YES	NO
2.	Does the patient have catastrophic illness, a debilitating and/or a chronic illness affecting functional status that may require long term care services?
Specify Major Health Needs: _______________________________________________________________

__________________________________________________________________
3. Is this patient ventilator dependent?……………………………………………………………………………….….…………
SECTION 6 - FINANCIAL
INCOME
YES	NO
1.	Patient’s monthly income is at, or below, the current NJ Care Special Medicaid Program’s maximum monthly income limit of $1,041 or
2.	Patient’s monthly income is at, or below, the current Medicaid institutional cap of $2,313.
NOTE: If patient's income is >$2,313 and assets are minimal, patient may still qualify for NF Medicaid Reimbursement.
SECTION 6 – FINANCIAL, Continued
ASSETS
Check one: This is an indication that the patient may become Medicaid Eligible within the next (6) months by spending down assets in a nursing facility as private pay

Patient has no spouse in the community and resources no greater than $4,000 (plus $1,500 burial fund), or
Patient has no spouse in the community and resources at or below $53,000 (plus $1,500 burial fund), or
Patient has a spouse in the community with combined countable resources at or below $128,420 (plus $1,500 burial fund).
SECTION 7 - INITIAL PLAN OF CARE
Provide information and counsel patient and/or patient’s family or authorized representative(s) about:

1. Long-term care supportive services including discharge to community with supportive services, referral to ADRC/AAA and placement in Nursing Facility/Sub-Acute,

2. How to submit an application to determine financial eligibility for Medicaid benefits, and

3. Medicaid eligibility dependent upon both clinical and financial eligibility. NF Preadmission Screening (PAS) utilized to determine clinical eligibility following NF admission.
Patient Choice of Setting - Check all that apply:
Nursing Facility – Long Term
Sub-Acute Nursing Facility Placement – Short Term
Provider feels there is a potential for discharge of the patient to the Community in the future? ………. Yes No

Patient/family expresses an interest in returning to Community? ………………………………………… Yes No

Was a referral made to County ADRC/AAA? ……………………………………………………………… Yes No
Other:
I acknowledge that I was prescreened and received counseling. I also consent to the Plan of Care proposed above.
Name of Patient/Authorized Representative (Print)

Check One:

Patient Authorized Representative
Signature of Patient/Authorized Representative	Date

SECTION 8 - ATTESTATION
I screened the above named patient and counseled the patient on Discharge Options.

I attest to the information that appears on this At-Risk Criteria Screening Tool.
Name of Certified EARC-PAS Assessor (Print)

Certified EARC-PAS Assessor Certification No.

Certified EARC-PAS Assessor Telephone

Certified EARC-PAS Assessor Fax

Signature of Certified EARC-PAS Assessor	Date Screen Completed by Certified EARC-PAS Assessor

Name of Hospital

County

Date of Admission to Hospital

Fax to: OCCO Regional Office

NRO Fax	SRO Fax

(732) 777-3600	(609) 704-6055	Date/Time Faxed

FAX all three pages of the completed EARC-PAS Screening Tool to OCCO Regional Field Office.

2.	Transfer of Hospital Patient to Medicaid Certified NF cannot occur until OCCO issues EARC-PAS authorization.

New Jersey Department of Human Services

EARC-PAS - ENHANCED AT-RISK CRITERIA SCREENING TOOL

(Continued)

LTC-34

MAR 19	Page 2 of 3 Pages.

MAR 19	Page 1 of 3 Pages.

LTC-34, Enhanced At-Risk Criteria Screening Tool

ltc-34, EARC-PAS, LTC, enhanced at risk, criteria, screening tool, hospital preadmission screening process, aging and community services, long term care,

Deanna Freundlich

2019-03-01

Windows User

human services