Provider Information

Section 1919(e)(7) of the Social Security Act and Chapter 42 of the Code of Federal Regulations, Sections 483.100 through 483.138 specify the requirements for preadmission screening of all individuals with intellectual and developmental disabilities before they enter a Medicaid certified nursing facility (NF), regardless of payment source.

Federal regulations require the PASRR Level I screenings take place prior to admission in order for a state to receive federal financial participation for Medicaid reimbursement of nursing home care.  Individual determined to require Specialized Services through the PASRR Level II process are prohibited from being admitted to a NF, or remaining in a NF.>

For further information about the Level I process, and forms that are used for that process, please visit the Division of Aging Services / PASSR.

If an individual who is currently living in a NF and who has an intellectual or developmental disability has been identified through the Minimum Data Set 3.0 (MDS 3.0)as having a significant change in condition, then the Division of Developmental Disabilities must be notified via completion and submission of the PASRR Resident Review Referral Form.

Below are documents for preparation of a Division of Developmental Disabilities (DDD) contract application as well as annual contract reporting. Third-party contract providers should familiarize themselves with the NJ Department of Human Services Contract Policy and Information Manual.  

Questions about contracting with DDD may be forwarded to: DDD.CAInquiries@dhs.nj.gov 

Items 1-14 are for annual reporting:

  1. Required Documents Checklist
    1. Condensed Annex A
  2. Standard Language Document
    1. Non State Agency (used by Provider Agencies)
    2. State Agency (used by State Agencies, i.e. state universities, counties, municipalities)
  3. Annex B (Budget Template)
  4. Business Associate Agreement (revised 2013)
  5. Source Disclosure Certification/(N.J.S.A. 52:34-13.2) (formerly Ex Order 129)
  6. Standardized Board Resolution
  7. AA-302/Affirmative Action Employee Information Repor
    1. AA-302 Instructions A
    2. A-302 Form
  8. Annual Report to the Secretary of State
  9. Notification of Licensed Public Accountant
  10. Equipment Inventory List
  11. Public Law 205, Chapter 51 (only applicable to For-Profit Organizations)
    1. Chapter 51 For
    2. Certification and Disclosure Form
  12. NJ Charitable Registration (only applicable to Charitable Organizations)
  13. Agency Contact For
  14. Cluster Designation
    1. Cluster Designation Form
    2. DDD Cluster Policy
  15. P1.10/Contract Modification
    1. P1.10 Policy   
    2. P1.10 Form
  16. ACH/Electronic Payment Authorization ACH Instructions   ACH Form
  17. W-9/Vendor Questionnaire
  18. Payment Voucher
    1. Instructions
    2. Payment Voucher Form (Word)
    3. Payment Voucher (Excel)