Tip for State-specific (e.g., TX 3618/3619)

Timely admission notification is critical for Medicaid payment — late notifications can delay reimbursement

Tip for State-specific (e.g., TX 3618/3619)

Ensure the PASRR Level 1 screening is completed and documented before or at admission

Tip for State-specific (e.g., TX 3618/3619)

If the resident is not yet Medicaid-eligible, begin the Medicaid application process immediately — coverage can be backdated up to 3 months

Long-Term Caremoderate

Medicaid LTC Admission Notification

State-specific (e.g., TX 3618/3619) · State Medicaid agencies

Medicaid long-term care admission notification and billing form. Must be submitted within 72 hours of admission for Medicaid clients. Form numbers and requirements vary by state.

Form Details

Total fields: 35
Auto-fillable: 25 (71%)
Time without BeneFill: 25 minutes
Time with BeneFill: 8 minutes
Time saved: 17 minutes
Filled by: doctor
Frequency: per incident
State-specific: Yes — form may vary by state

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Where to Submit This Form

📠

Fax to the state Medicaid agency and/or managed care plan

Typically submitted by the nursing facility upon admission.

🌐

Submit through the state's Medicaid portal (if electronic notification is available)

Filing Deadline

Must be submitted within the state's required timeframe (typically 5-10 business days after admission). Late notification can affect Medicaid payment.

Required Attachments

📎 Admission notification form (state-specific)
📎 Resident demographic information
📎 Insurance and Medicaid/Medicare information
📎 Admitting diagnosis and physician orders
📎 PASRR Level 1 screening results
📎 Level of care determination (if completed)

Processing Time

Notification is typically processed within 3-5 business days. This triggers the enrollment update in the state's Medicaid system.

What Happens Next

The state updates the resident's Medicaid enrollment record. For managed care enrollees, the notification triggers disenrollment from the managed care plan (if the stay exceeds a specified period). The nursing facility can begin billing Medicaid after the notification is processed.

Tips for This Form

✓ Timely admission notification is critical for Medicaid payment — late notifications can delay reimbursement
✓ Ensure the PASRR Level 1 screening is completed and documented before or at admission
✓ If the resident is not yet Medicaid-eligible, begin the Medicaid application process immediately — coverage can be backdated up to 3 months
✓ For managed care enrollees, the notification process varies by state — confirm your state's requirements

More Long-Term Care Forms

MDS 3.0 (Minimum Data Set)

MDS 3.0 · CMS

Standardized health status screening and assessment tool required for all residents of Medicare/Medicaid-certified nursing facilities. Used for care planning and Medicare payment calculation. Must be completed within 14 days of admission and periodically thereafter.

PASRR Level 1 Screening

State-specific · CMS / State Medicaid agencies

Federally mandated preadmission screening for all individuals entering Medicaid-certified nursing facilities to identify those with mental illness, intellectual disability, or related conditions who may need specialized services.

PASRR Level 2 Evaluation

State-specific · State mental health / developmental disability agencies

Comprehensive evaluation for individuals identified in Level 1 screening. Determines if nursing facility placement is appropriate and what specialized services are needed.

Long-Term Care Medicaid Application

State-specific · State Medicaid agencies

Application for Medicaid coverage of nursing facility care. Includes detailed financial disclosure of income, assets, and transfers. A five-year look-back period for asset transfers applies.

Asset Transfer / Look-Back Documentation

State-specific · State Medicaid agencies

Documentation of all asset transfers in the 60 months (5 years) before Medicaid application. Uncompensated transfers may result in a penalty period of Medicaid ineligibility.

Spousal Impoverishment Protection Forms

State-specific · State Medicaid agencies

Documentation establishing the Community Spouse Resource Allowance (CSRA) and Monthly Maintenance Needs Allowance (MMNA) protecting the non-institutionalized spouse's assets and income.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the State Medicaid agencies or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.