New Jersey Administrative Code

(a) Nothing in the Medicaid program shall be construed to require any beneficiary to undergo any medical screening, examination, diagnosis, or treatment, or to accept any other health care or services provided under the program for any purpose (other than for the purpose of disco…

(a) The concept of freedom of choice shall apply to both provider and beneficiary. 1. A Medicaid fee-for-service beneficiary shall be free to choose providers of service who meet program standards and who elect to participate in the Medicaid program. The MACC shall assist any ben…

(a) All information concerning applicants and beneficiaries acquired under this program shall be confidential and shall not be released without the written consent of the individual or his or her authorized representative. If, because of an emergency situation, time does not perm…

(a) All program providers, except institutional, pharmaceutical, and transportation providers, shall be required to certify that the services billed on any claim were rendered by or under his or her supervision (as defined and permitted by program regulations); and all providers …

Notes N.J. Admin. Code § 10:49-9.9 Amended by R.1997 d.354, effective 9/2/1997. See: 29 N.J.R. 2512(a), 29 N.J.R. 3856(a). Amended section name; substituted "beneficiary" and "beneficiary's" for "recipient" and "recipient's" throughout and deleted "form" following "claim" through…

This chapter describes the policies and procedures of the New Jersey Medicaid/NJ FamilyCare program regarding transportation services. Questions about this chapter may be directed to the Transportation Coordinator, Division of Medical Assistance and Health Services, PO Box 712, T…

Notes N.J. Admin. Code § 10:50-1.10 New Rule, R.2006 d.213, effective 6/19/2006. See: 37 N.J.R. 4850(a), 38 N.J.R. 2713(a). Reserved by 54 N.J.R. 620(b), effective 4/4/2022

Notes N.J. Admin. Code § 10:50-1.11 New Rule, R.2006 d.213, effective 6/19/2006. See: 37 N.J.R. 4850(a), 38 N.J.R. 2713(a). Reserved by 54 N.J.R. 620(b), effective 4/4/2022

Notes N.J. Admin. Code § 10:50-1.12 New Rule, R.2006 d.213, effective 6/19/2006. See: 37 N.J.R. 4850(a), 38 N.J.R. 2713(a). Reserved by 54 N.J.R. 620(b), effective 4/4/2022

Notes N.J. Admin. Code § 10:50-1.13 New Rule, R.2006 d.213, effective 6/19/2006. See: 37 N.J.R. 4850(a), 38 N.J.R. 2713(a). Reserved by 54 N.J.R. 620(b), effective 4/4/2022

(a) Each independent transportation provider shall prepare daily log sheets which shall be maintained for a period of at least five years from the date the service was rendered to the Medicaid/NJ FamilyCare beneficiary. (b) The daily log sheets shall be made available for immedia…

(a) An independent transportation provider shall implement a complaint/grievance procedure. (b) An independent transportation provider shall prepare and maintain a complaint log, containing all complaints and/or grievances from beneficiaries or their representatives. (c) An indep…

(a) An independent transportation provider shall comply with the following requirements: 1. Each claim, certification form, and daily log sheet entry shall correspond to an actual trip provided to a Medicaid/NJ FamilyCare beneficiary; 2. No remuneration, compensation, or other co…

(a) The Division may review and evaluate the care and services provided to Medicaid/NJ FamilyCare beneficiaries to ensure that independent transportation providers comply with the provisions of their contracts with the Division and with applicable Federal and State laws, rules, a…

(a) An independent transportation provider shall ensure that each Medicaid/NJ FamilyCare beneficiary is picked up without delay and is transported by a safe driver, in a safe manner, and in accordance with the requirements of all State and Federal laws, rules, and regulations. (b…

The following words and terms, when used in this chapter, shall have the following meanings unless the context clearly indicates otherwise. "Advanced life support-Level 1" means transportation by a ground ambulance vehicle licensed by the Department of Health (DOH) with the provi…

(a) The approval process for becoming an independent transportation service provider is as follows: 1. Each independent transportation provider must be individually approved for each type of service provided. The Division of Medical Assistance and Health Services, Department of H…

(a) All non-emergency medical transportation services shall be provided by an independent transportation broker under contract with the Department of Human Services. These services may include, but are not limited to: 1. Ground ambulance service (non-emergency); 2. Mobility assis…

(a) Authorization from the Division of Medical Assistance and Health Services' contracted transportation broker is required for all fixed wing air ambulance services. 1. The use of a rotary wing air ambulance is retroactively authorized and includes the approval for fee-for-servi…

(a) The least expensive mode of emergency transportation suitable to the Medicaid/NJ FamilyCare fee-for-service beneficiary's needs shall be used. (b) Mileage for ground ambulance service shall be measured by odometer from the point at which the Medicaid/NJ FamilyCare fee-for-ser…

(a) The Fiscal Agent Billing Supplement contains a sample transportation certification form and instructions for the form's proper completion. The elements appearing on the sample transportation certification form shall appear on all certification forms furnished and prepared by …

Notes N.J. Admin. Code § 10:50-1.8 New Rule, R.2006 d.213, effective 6/19/2006. See: 37 N.J.R. 4850(a), 38 N.J.R. 2713(a). Reserved by 54 N.J.R. 620(b), effective 4/4/2022

(a) An independent transportation provider shall have the following insurance, upon initial application to enroll, and shall fully maintain that insurance, in order to participate in the Medicaid/NJ FamilyCare program: 1. Workers compensation, in amounts as required by law, inclu…

(a) The New Jersey Medicaid/NJ FamilyCare program adopted the Federal Centers for Medicare & Medicaid Services' (CMS) Healthcare Common Procedure Coding System (HCPCS) codes for 2006, established and maintained by CMS in accordance with 42 CFR 424, incorporated herein by referenc…

HCPCS Code Mod. Description Maximum Fee Allowance (a) AMBULANCE SERVICE A0420 Waiting Time-Ambulance Service--One Way Trip Only 1/4 hour 2.50 1/2 hour 5.00 3/4 hour 7.50 1 hour 10.00 NOTE: Reimbursable only on one way trips and only after 30 minutes have elapsed. It is reimbursab…

(a) This chapter provides information about the provision of pharmaceutical services under the New Jersey Medicaid program and NJ FamilyCare program. It is divided into three subchapters.1.N.J.A.C. 10:51-1 provides a pharmacy operating under a retail permit with the policies and …

(a) The provider's usual and customary charge or advertised charge is an element considered in the calculation of the basis of payment for legend drugs (see N.J.A.C. 10:51-1.5, Basis of payment). (b) The usual and customary charge to the Medicaid or NJ FamilyCare program is defin…

(a) All covered pharmaceutical services shall be provided within the scope of the N.J.A.C. 10:49, Administration, and this chapter, and billed to the fiscal agent on the claim form or other approved billing method (see Appendix, Fiscal Agent Billing Supplement). (b) Covered pharm…

(a) General policies regarding the collection of personal contribution to care for NJ FamilyCare-Plan C and copayments for NJ FamilyCare-Plan D are set forth at N.J.A.C. 10:49-9. (b) Personal contribution to care for NJ FamilyCare-Plan C services are $ 1.00 per dispensing for gen…

(a) The following classes of prescription drugs or conditions are not covered under the Medicaid or NJ FamilyCare fee-for-service programs. For beneficiaries in the Medically Needy component of the New Jersey Care... Special Medicaid Programs, pharmaceutical services are not avai…

(a) The provider shall obtain prior authorization, when required by this chapter, by phone or in writing, from the professional staff of the Division's prior authorization agent for pharmacy services. The pharmacy prior authorization agent is available at a toll-free telephone nu…

(a) The quantity of medication prescribed shall provide a sufficient amount of medication necessary for the anticipated duration of the illness or, if required, an amount sufficient to provide medication during intervals between prescriber visits. The amount of medication dispens…

(a) Dosage and directions for use shall be indicated on all prescriptions. Prescriptions written and dispensed with no specific directions, such as "prn," "as directed" or "ad lib," etc. are not eligible for reimbursement. Specific directions such as "1 tablet 4 times a day PRN" …

(a) Telephone orders from prescribers for original prescriptions shall be permitted in accordance with all applicable Federal and State laws, rules and regulations. (b) For purposes of reimbursement, telephone authorization to refill an original prescription with no refill remain…

Changes or additions to the original prescription, when approved by the prescriber, shall be clearly indicated (including date and time) and signed by the dispensing pharmacist. No changes (for example, dosage, quantity, number of refills, days supply, etc.) are permitted on the …

(a) The provider shall submit a properly completed claim form or electronic claim in the proper EMC claim format to the fiscal agent for reimbursement of an allowable refill. An allowable refill shall comply with the following instructions in order to be reimbursed as such: 1. Re…

(a) A pharmacy with a retail or institutional permit may participate in the Medicaid or NJ FamilyCare program as a provider of pharmaceutical services and as a medical supplier providing medical supplies and durable medical equipment and as a provider of parenteral nutrition or i…

(a) The Prescription Drug Price and Quality Stabilization Act, N.J.S.A. 24:6E-1 et seq., shall apply to the New Jersey Medicaid and NJ FamilyCare programs. This law requires that every prescription blank contain the statements "Substitution Permissible" and "Do Not Substitute." T…

(a) "Less than effective drugs" are subject to a Notice of Opportunity for Hearing (NOOH) by the Food and Drug Administration (FDA). 1. Reimbursement is not available for the purchase or administration of any drug product that meets all of the following conditions: i. The drug pr…

(a) In order for legend drug products to be reimbursed by the New Jersey Medicaid or NJ FamilyCare program, manufacturers must have in effect a rebate agreement pursuant to Section 1927 et seq. of the Social Security Act (42 U.S.C. § 1396R-8(i)). (b) Price information is supplied…

(a) "Bundled drug service" means a drug or service that is marketed or distributed by the manufacturer or distributor as a combined package which includes in the cost the drug product and ancillary services such as, but not limited to, case management services and laboratory test…

(a) An approved pharmacy provider may choose to: 1. Submit a properly completed hard copy pharmacy claim form approved by the New Jersey Division of Medical Assistance and Health Services (DMAHS). 2. Submit an electronic media claim (EMC) by modem, diskette or magnetic tape in an…

(a) Medicaid or NJ FamilyCare fee-for-service pharmacy claims may be submitted through a POS system and adjudicated by the State's fiscal agent on-line and in real time. The POS system is an alternative to other methods of claim submission, including magnetic tape, diskette, and …

(a) The Division of Medical Assistance and Health Services has established a prospective drug utilization review (PDUR) program to assist pharmacy providers with monitoring drug utilization by Medicaid and NJ FamilyCare fee-for-service beneficiaries. As a component of the Medicai…

(a) For pharmacy claims with service dates on or after September 1, 1999, which exceed prospective drug utilization review (PDUR) standards recommended by the New Jersey DUR Board and approved by the Commissioner of the Department of Human Services (DHS) and the Commissioner of t…

(a) All participating pharmacies shall provide complete prescription services, including injectables and injectable anti-neoplastic agents, compounding, and prescription refill services, when allowable. Prescriptions must be dispensed in compliance with all current existing Feder…

(a) The choice of prescribed drugs shall be at the discretion of the prescriber within the limits of applicable law. However, the prescriber's discretion is limited for certain drugs. Reimbursement may be denied if any of the following requirements, or any of the requirements of …

(a) This section provides a summary of the elements involved in the calculation of the payment of a legend or non-legend drug for both the Medicaid and NJ FamilyCare programs. The elements include the following: 1. Program restrictions affecting reimbursement for the dispensing o…

For claims with service dates on or after July 15, 1996, the discount shall be 10 percent for each eligible prescription claim not covered by the Maximum allowable cost price. Notes N.J. Admin. Code § 10:51-1.6 Amended by R.1995 d.104, effective 2/21/1995. See: 26 New Jersey Regi…

(a) The dispensing fee for legend drugs, dispensed by providers having retail permits to beneficiaries other than those in long-term care facilities, including State-operated Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID), nursing facilitie…