New Jersey Administrative Code

PATHOLOGY/LABORATORY HCPCS Maximum Fee IND Code MOD Procedure Description Allowance G0027 Semen analysis; presence 2.40 and/or motility of sperm excluding Huhner test G0123 Screening cytopathology, 23.50 cervical or vaginal, thin prep, auto G0141 Screening cytopathology 10.00 sme…

(a) Qualifiers for pathology and laboratory services are summarized below: 1. Organ or Disease Oriented Laboratory Panels NOTE: The following calculations and ratios are not eligible for separate or additional reimbursement. A/G Ratio Globulin BUN/Creatinine Ratio FTI (T7) Free C…

(a) Services and procedures may be modified under certain circumstances. When applicable, the modifying circumstance has been identified by the addition of alphabetic and/or numeric characters at the end of the code. The New Jersey Medicaid/NJ FamilyCare fee-for-service programs'…

(a) The Department of Health shall conduct an audit of disproportionate share hospitals' charity care reported as written-off each calendar year. The Department of Health shall audit charity care at least once, but no more than six times each calendar year. (b) The Department of …

(a) An applicant shall provide proof that:1. His or her individual assets as of the date of service do not exceed $ 7,500; and 2. His or her family's assets, if applicable, do not exceed $ 15,000 as of the date of service. (b) Family members whose assets must be considered are al…

The total of all sample dollars in which identification, New Jersey residency, income, and assets documented by the alternative procedures described in N.J.A.C. 10:52-11.6(a)3, 11.7(a)3, 11.9(a)3, or 11.10(d) 3 shall be limited to no more than 10 percent of the total dollars samp…

(a) A hospital shall, as a condition of finding any applicant eligible for charity care or reduced charge charity care, require the applicant to furnish any information that is reasonably necessary to substantiate the applicant's income and assets and that is within the applicant…

(a) Consistent with the requirements of N.J.A.C. 10:52-11.6, 11.7, 11.8, 11.9, 11.10, 11.11, and 11.12, the Department of Health shall specify the elements to be included in charity care application and eligibility determination forms used by all disproportionate share hospitals …

Persons determined to be eligible for charity care shall not receive a bill for services or be subject to collection procedures. Persons determined to be eligible for reduced charge charity care shall not be billed or subject to collection procedures for the portion of the bill t…

(a) The following words and terms, when used in this section, shall have the following meanings, unless the context clearly indicates otherwise: "Alternative documentation adjustment" means an adjustment to a hospital's charity care write-off amount as a result of the periodic au…

(a) If a charity care applicant is admitted through the hospital's emergency room, the requirements set forth in this section shall apply. 1. The hospital shall notify the patient, orally and by providing a copy of the individual written notice referenced in N.J.A.C. 10:52-11.5(a…

Notes N.J. Admin. Code § 10:52-11.17 New Rule, R.2000 d.299, effective 7/17/2000. See: 32 New Jersey Register 1123(a), 32 New Jersey Register 2615(a). Repealed by R.2005 d.214, effective 7/5/2005. See: 37 New Jersey Register 436(a), 37 New Jersey Register 2506(a). Section was "Ch…

(a) The Department of Health shall audit charity care claims based on a sample which will be developed from the charity claims submitted for pricing as described in N.J.A.C. N.J.A.C. 10:52-12.2. (b) The Department of Health shall require hospitals to make a small number of additi…

(a) The Department of Health shall value charity care claims at the Medicaid/NJ FamilyCare rate. The Medicaid/NJ FamilyCare rate, for purposes of valuing a given charity care claim, shall be based on the New Jersey Medicaid/NJ FamilyCare program's pricing and program policies pur…

N.J.A.C. 10:52-11.5 through 11.10 govern documentation requirements for all charity care applications except those for patients admitted through the hospital's emergency room. Documentation requirements for applications of patients admitted through the emergency room are governed…

(a) The hospital shall provide all patients with an individual written notice of the availability of charity care and Medicaid/NJ FamilyCare, in a form provided by the Department of Health, at the time of service, but no later than the issuance of the first billing statement to t…

(a) Applicants for charity care shall provide the hospital with the following proper identification: paragraph (a)3 below represents an alternative measure for documenting identification as described in N.J.A.C. 10:52-11.11. 1. The applicant shall provide the hospital with one of…

(a) Applicants for charity care shall provide the hospital with proof of New Jersey residency. An applicant shall provide proof that he or she has been residing in New Jersey since the time of service, has no residency in any other state or country, and has the intent to remain i…

(a) The hospital shall determine the applicant's family size in accordance with this section. Family size for an adult applicant includes the applicant, spouse, any minor children whom he or she supports, and adults for whom the applicant is legally responsible. The family size f…

(a) Applicants for charity care shall provide the hospital with proof of income as listed below. Paragraph (a)3 below shall be considered alternative documentation, as described in N.J.A.C. 10:52-11.11. 1. An applicant shall provide the hospital with proof of income, which includ…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise: "Adjudication" means the processing of all submitted claims accepted by the Fiscal Agent during a monthly adjudication cycle, with the o…

(a) This subchapter sets forth the requirements of the New Jersey State Department of Health that the provider shall adhere to when submitting a charity care claim. (b) A charity care claim shall be submitted in accordance with the electronic media claims (EMC) manual, which is p…

(a) All hospital outpatient and inpatient charity care claims shall be priced based on the New Jersey Medicaid/NJ FamilyCare program's pricing and program policies for hospital outpatient and inpatient hospital services. (See this chapter, and, specifically, N.J.A.C. N.J.A.C. 10:…

(a) A disproportionate share hospital (DSH) shall be a hospital designated as such by the Commissioner of the Department of Human Services. At a minimum, each hospital with a Medicaid/NJ FamilyCare inpatient hospital utilization rate that is one standard deviation above the mean …

The disproportionate share adjustment shall include an adjustment amount annually determined, as to N.J.A.C. 10:52-13.4, by the Commissioner, Department of Health in consultation with the Commissioner, Department of Human Services and, as to N.J.A.C. 10:52-13.3, 13.5, 13.6, and 1…

N.J.S.A. 18A:64G-1 For facilities operating under N.J.S.A. 18A:64G-1 et seq., the disproportionate share allocation may be increased by an amount recommended by the Office of Management and Budget which will consider the total operating cost of the facility less any third-party p…

(a) The recommendation from the Department of Health shall be calculated in the following manner pursuant to N.J.S.A. 26:2H-18.1. The determination of the value of the Charity Care Component of the Health Care Subsidy Fund shall be calculated in the following manner: i. The Depar…

(a) Hospitals eligible for additional disproportionate share payments may receive an additional payment determined by the Commissioner of the Department of Human Services from the Hospital Relief Subsidy Fund. This additional payment shall be based upon the facility's percentage …

(a) Disproportionate Share Hospitals which service a large number of low-income mentally ill or developmentally disabled clients may also be eligible to receive increased disproportionate share payments. The amount of payment to be made to facilities which serve a large number of…

(a) The purpose of this rule is to provide a procedure to redistribute disproportionate share hospital (DSH) payments to provide for the patients who would have been served by a closed general hospital, had the hospital remained open. Hospital closure is defined as cessation of o…

(a) Effective for inpatient services with discharge dates on or after August 3, 2009, general acute care hospitals will be paid in accordance with the New Jersey Medicaid Diagnosis Related Groups (DRG) Reimbursement System described in this subchapter. (b) If the initial rate yea…

The standard DRG payment is the hospital's final rate multiplied by the DRG weight. Notes N.J. Admin. Code § 10:52-14.10

(a) A cost outlier is defined as an inpatient stay with an estimated cost, which exceeds the greater of the State designated cost outlier threshold or the cost outlier statistical limit for a certain DRG. The cost outlier calculation is set forth in (e) below. (b) The cost outlie…

(a) The day outlier calculation only applies to claims in which there are alternate level of care days (for example, skilled nursing facility, intermediate care facility). This calculation is only used to determine qualification for payment of nursing facility days for those clai…

If a covered hospital inpatient stay is determined to be eligible for both a cost outlier and a day outlier payment, the total reimbursement will be the sum of the standard DRG payment, the cost outlier payment and the day outlier payment. Notes N.J. Admin. Code § 10:52-14.13…

(a) When a patient is transferred during a covered general acute care hospital inpatient stay from one hospital to another hospital, the reimbursement to the general acute care hospitals involved in the transfer(s) will be calculated as follows: 1. The reimbursement to each trans…

In cases where the patient has been admitted and is discharged on the same day, reimbursement will be paid at the DRG daily rate. Notes N.J. Admin. Code § 10:52-14.15

(a) For New Jersey hospitals, if a patient is readmitted to the same hospital for the same or similar diagnosis within seven days, the second claim submitted for payment will be denied. For dates of service before October 1, 2015, the same or similar principal diagnosis is define…

(a) For the purposes of submitting and adjudicating calculation error and rate appeals, a hospital may designate an individual or firm to represent it. This designation shall be in writing, signed by the chief executive officer of the hospital, and shall contain the representativ…

The following words and terms, as used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Add-on amount" means an amount, calculated as a percentage of the Statewide base rate, which is added to the Statewide base rate, and whi…

(a) A Statewide relative weight for each DRG was developed using the most recent available audited Medicare cost report data and Medicaid/NJ FamilyCare paid claims data for the same year. The cost data used excludes direct and indirect medical education costs. In the initial rate…

(a) Initial DRG weights used to calculate reimbursement amounts for inpatient hospital services under this subchapter are as follows: DRG Description DRG WEIGHTS 001 Craniotomy Age >17 W CC 3.2119 002 Craniotomy Age >17 W/O CC 2.7378 006 Carpal Tunnel Release 0.6633 007 Periph & …

(a) The Division determined a single Statewide base rate, referred to as the "Statewide base rate," for all general acute care hospitals as described in N.J.A.C. 10:52-14.6. (b) The Statewide base rate is used in conjunction with increases to the Statewide base rate referred to a…

(a) The Division established an initial Statewide base rate, which applies to all hospitals. Those hospitals meeting the criteria for add-on amounts in accordance with N.J.A.C. 10:52-14.7 have rates higher than the Statewide base rate. The initial Statewide base rate is establish…

(a) Each rate year, the Division will determine if each general acute hospital participating in the New Jersey Medicaid/NJ FamilyCare program is eligible for add-on amounts. The Division determined hospital eligibility for add-on amounts in the initial rate year as described in (…

(a) The Division will calculate DRG daily rates for each DRG for each hospital. These rates are used for calculating reimbursement in cases involving transfers, same-day discharges, and for cases in which Medicaid/NJ FamilyCare eligibility began or ended during the inpatient stay…

(a) For the initial rate year and every year thereafter, the Division will calculate hospital-specific initial inpatient cost-to-charge ratios (CCR) using the most recent available submitted Medicare cost report data. (b) The hospital-specific CCRs are calculated using total cost…

(a) An Ambulatory Surgical Center (ASC) shall be any distinct entity that operates for the purpose of providing surgical services to patients not requiring hospitalization which has an agreement with the Centers for Medicare & Medicaid Services (CMS) to participate in the Medicar…

(a) Partial hospitalization (PH) means a psychiatric service whose primary purpose is to maximize the client's independence and community living skills in order to reduce unnecessary hospitalization. It is directed toward the acute and chronically disabled individual. A PH progra…

(a) The provisions of this section shall apply when prevocational services are provided within a partial hospitalization program, in accordance with N.J.A.C. 10:52-2.10(a)8. (b) The following words and terms, when used in this chapter, shall have the following meanings, unless th…