New Jersey Administrative Code

(a) All covered pharmaceutical services shall be provided within the scope of 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 pharmace…

(a) The following classes of prescription drugs or conditions shall not be covered under the New Jersey Medicaid or NJ FamilyCare program: 1. Prescriptions which are not for medically accepted indications as defined in Section 1927(k)(6) of the Social Security Act; 2. Antiobesics…

When the quantity of a drug or medication is not indicated in writing by the prescriber, the pharmacy provider shall dispense an appropriate quantity of medication not to exceed a one month supply (see N.J.A.C. 10:51-2.16, Prescription Refill). Notes N.J. Admin. Code § 10:51-2.12…

(a) Dosage and directions for use shall be included as part of all prescriptions or in-patient medication orders. Prescriptions or inpatient medication orders written and dispensed with no specific directions, such as "prn," "as directed" or "ad lib," etc. are not eligible for re…

(a) Telephone rendered and/or technologically transmitted (for example: Fax) original prescriptions shall be permitted in accordance with all applicable Federal and State laws and regulations. (b) For purposes of reimbursement, a telephone rendered and/or a technologically transm…

Changes or additions to the original prescription or in-patient medication order, 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 supp…

(a) Refills are not allowed. (b) For purposes of reimbursement, an order for continuation of medication shall be considered a new prescription requiring a new written prescription and new prescription number. Notes N.J. Admin. Code § 10:51-2.16

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

(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 4401 of OBRA 1990 and Section 1927 et seq. of the Social Security Act. (b) Price information is sup…

(a) A pharmacy with a retail or institutional permit may participate in the Medicaid and NJ FamilyCare programs as a provider of pharmaceutical services and as a provider of parenteral nutrition or intravenous therapy. (b) To be approved as a provider of pharmaceutical services, …

(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) Based on the level of service provided by an approved pharmacy to a nursing facility, a 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 ele…

(a) Pharmacies providing traditional pharmacy services, as described in N.J.A.C. 10:51-2.7, to nursing facilities 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…

(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 beneficiaries. As a component of the Medicaid and NJ FamilyC…

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

(a) The choice of prescribed drugs shall be at the discretion of the prescriber within the limits of applicable laws. 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 drug. The elements include the following: 1. Program restrictions affecting reimbursement for the dispensing of drugs as listed in N.J.A.C. 10:51-2.4; 2. Price information a…

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 § 10:51-2.6 Amended by R.1995 d.104, effective 2/21/1995. See: 26 New Jersey Regi…

(a) The New Jersey Medicaid and NJ FamilyCare programs capitate the dispensing fee for each prescription for beneficiaries in Medicaid approved nursing facilities in accordance with the total number of Medicaid and NJ FamilyCare fee-for-service beneficiary days in the facility(ie…

(a) Compounded prescriptions may be reimbursed by the Medicaid or NJ FamilyCare program. Compounded prescriptions are extemporaneously prepared mixtures of an active ingredient or ingredients and/or a pharmaceutical excipient or excipients and are dispensed by approved providers.…

When medication is prescribed by its non-proprietary or generic name, the pharmacist shall dispense the least expensive, therapeutically effective equivalent product available, preferably one listed in N.J.A.C. 8:71. The labeler code and drug product code of the actual product di…

All services required of a consultant pharmacist in nursing facilities as stipulated in Federal and State statutes, rules and regulations, including, but not limited to, those listed in this subchapter, shall be provided. Notes N.J. Admin. Code § 10:51-3.1 Amended by R.1998 d.488…

The term "consultant pharmacist" shall mean a pharmacist licensed by the New Jersey State Board of Pharmacy, and who meets the qualifications in N.J.A.C. 10:51-3.3. Notes N.J. Admin. Code § 10:51-3.2

Qualifications shall include holding a valid license as a registered pharmacist issued by the New Jersey State Board of Pharmacy. Notes N.J. Admin. Code § 10:51-3.3

(a) The consultant pharmacist shall in cooperation and consultation with the nursing facility staff: 1. Assure that all drugs are dispensed, and in cooperation with the director of nursing, "shall assure all drugs" are administered in compliance with all Federal and State laws; 2…

(a) This chapter outlines the policies and procedures of the Division for the provision of inpatient and outpatient (including emergency room) hospital services to Medicaid/NJ FamilyCare fee-for service beneficiaries. These policies and procedures apply to general hospitals, spec…

(a) Prior authorization shall be required for certain dental procedures (see N.J.A.C. 10:56, Dental Services) and partial hospitalization provided in the outpatient department of an acute care hospital beyond exempt time frames (see N.J.A.C. 10:52-2.10(d) and (e)). (b) Other serv…

(a) The Department of Health and Senior Services is the agency responsible for administering the Preadmission Screening Program. The following is provided to hospitals so that they understand the process and the rules a hospital shall follow to ensure Medicaid or NJ FamilyCare-Pl…

Hospitals shall be required to keep legible individual records as are necessary to fully disclose the kind and extent of services provided, as well as the medical necessity for those services. This information shall be available upon the request of the Division or its agents. Not…

(a) A second opinion shall be obtained for any elective surgical procedures listed under (b) below. The outcome of the second opinion shall have no bearing on reimbursement. Once the second opinion is rendered, the beneficiary shall retain the right to decide whether or not to pr…

(a) Payment for "Social Necessity Days" shall be made to hospitals for a maximum of 12 calendar days per hospitalization for a Medicaid/NJ FamilyCare-Children's Program fee-for-service beneficiary child admitted with the diagnosis of child abuse or suspected child abuse, if speci…

(a) This section provides information on the requirements for utilization control for inpatient services for approved acute general hospitals, special hospitals, and private psychiatric hospitals, with the exception of inpatient psychiatric hospital services for individuals under…

(a) This section specifies the unique requirements for certification of the need for inpatient psychiatric services provided to beneficiaries under 21 years of age in private psychiatric hospitals. In accordance with Section 1905(a)16 and (h) of the Social Security Act, a team, c…

(a) The following requirements in this rule were developed to help ensure the appropriate utilization of outpatient psychiatric services. These include the role of the evaluation team in relation to the patient's treatment regimen, with emphasis placed on intake evaluation, devel…

All hospitals participating in the New Jersey Medicaid/NJ FamilyCare program are subject to the provisions of State and Federal statutes regarding advance directives including, but not limited to, appropriate notification to patients of their rights, development of policies and p…

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise. "Adult acute partial hospital" or "APH" means an intensive and time-limited acute psychiatric service for beneficiaries 18 years of age or …

Notes N.J. Admin. Code § 10:52-1.2A Recodified to N.J.A.C. 10:52-1.3 by R.2000 d.29, effective 1/18/2000. See: 31 New Jersey Register 3151(a), 32 New Jersey Register 276(a).

(a) The Division shall reimburse approved hospitals to provide covered outpatient hospital services, where applicable, in accordance with all the provisions of this chapter. In order to be approved and reimbursed as an outpatient hospital service, effective in accordance with the…

(a) A hospital shall adhere to the following procedure for completing the form, the "Public Assistance Inquiry (PA-1C)" to inform the appropriate agency that an individual intends to file a Medicaid/NJ FamilyCare application: 1. For those aged, blind or disabled persons with limi…

(a) Hospital services shall not be reimbursed by the Medicaid/NJ FamilyCare fee-for-service program when hospital services were rendered prior to or after the period of beneficiary eligibility, as determined in accordance with N.J.A.C. 10:49-2.7; except that, when a Medicaid/NJ F…

(a) The Division will cover those inpatient services ordinarily furnished by an approved hospital maintained for the treatment and care of patients, and provided to any Medicaid/NJ FamilyCare fee-for-service beneficiary, for whom professionally developed criteria and standards of…

The Division shall, upon receipt of documentation from the Department of Health, apply an offset to a hospital's disproportionate share hospital Medicaid/NJ FamilyCare payments to collect delinquent statutory and regulatory debts owed by the hospital to the State arising under th…

(a) The following non-covered services (inpatient and outpatient) shall not be eligible for payment by the Division:1. Hospital admissions of the following description: i. Admission for any condition for which hospitalization is not medically necessary; ii. Admission primarily fo…

(a) For a patient who is no longer in need of inpatient acute level of care and who is awaiting placement in a nursing facility, payment shall be made for "administrative days" if the general, special, rehabilitation, or the private psychiatric hospital is able to demonstrate the…

(a) The New Jersey Medicaid/FamilyCare fee-for-service program utilizes the Centers for Medicare & Medicaid Services' (CMS's) Healthcare Common Procedure Coding System (HCPCS) for 2009, established and maintained by CMS in accordance with the Health Insurance Portability and Acco…

IND HCPCS Code Mod Office Total Fee Maximum Fee Allowance $ Prof. Comp N 36415 $ 1.80 36416 $ 1.80 36430 $ 13.00 36440 $ 30.00 36450 $ 100.80 36455 $ 126.00 36460 $ 151.00 36516 $ 49.00 80047 $ 9.89 N 80048 $ 9.30 N 80050 $ 36.00 N 80051 $ 5.90 N 80053 $ 10.50 N 80055 $ 15.00 N 8…