4-25-02 letterhead - State of New Jersey - nj 2026

1. Click ‘Get Form’ to open the 4-25-02 letterhead in the editor.
2. Begin by entering the Nursing Facility name at the top of the form. This identifies where the PEME request is originating from.
3. Fill in the Resident Name and Medicaid case number. Ensure accuracy as this information is crucial for processing.
4. Input the Medicaid Eligibility Approval Effective Date, which marks when eligibility begins.
5. For each month requested (up to three), provide Dates of Service, Medicaid daily rate for room and board, and total reimbursements received from other insurance.
6. Calculate and enter the Total room and board amount requested using the formula provided on the form. Repeat for each month.
7. Complete any additional charges if applicable, ensuring all documentation is attached for verification.
8. Finally, have the Nursing Facility Representative sign and date at the bottom of the form before submission.

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