New Jersey Administrative Code

(a) The Division covers hysterectomy procedures performed on Medicaid/NJ FamilyCare fee-for-service beneficiaries based on Federal regulations (42 CFR 441.250 through 441.258) and related requirements outlined in this section and in the billing instructions. For hysterectomy requ…

(a) The Division shall reimburse for medically necessary termination of pregnancy procedures on Medicaid/NJ FamilyCare beneficiaries when performed by a physician in accordance with N.J.A.C. 13:35-4.2. These services are reimbursed fee-for-service for all beneficiaries, including…

(a) Transportation shall be recognized by the Division as a covered outpatient hospital service under the following conditions: 1. Hospital-based emergency ambulance service for inpatient admission or outpatient services. For the definition of "emergency conditions", see N.J.A.C.…

(a) Reimbursement may be made for blood provided to an inpatient or an outpatient of an approved hospital when prescribed and supervised by a licensed physician. (b) Whole blood and derivatives, and necessary processing and administration thereof, may be reimbursed with the follo…

(a) Dental services in the outpatient department shall be provided in accordance with the requirements contained in N.J.A.C. 10:56, Dental Services. The outpatient dental department shall be subject to the same policies and procedures that apply to the Medicaid/NJ FamilyCare fee-…

(a) Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is a Federally-mandated comprehensive and preventive child health program for Medicaid/NJ FamilyCare-Children's Program fee-for-service beneficiaries from birth through 20 years of age (see 42 CFR 441 Subpart B). T…

(a) Family planning services shall include medical history and physical examination (including pelvis and breast), diagnostic and laboratory tests, drugs and biologicals, medical supplies and devices, counseling, continuing medical supervision, continuity of care and genetic coun…

(a) A home health agency (hospital-based) shall be licensed by the New Jersey State Department of Health, certified as a home health agency under Title XVIII (Medicare), possess a valid and current provider agreement from the Division, and be an identifiable part of a hospital. (…

(a) An adult or pediatric day health services facility shall be affiliated and identified as part of a hospital which is licensed by the New Jersey State Department of Health, in accordance with its Manual of Standards for Licensure of Adult and Pediatric Day Health Services and …

(a) Division requirements for substance use disorder treatment facilities are located in N.J.A.C. 10:66, Independent Clinic Services. Services provided to a Medicaid/NJ FamilyCare fee-for-service beneficiary by a free standing hospital-affiliated substance use disorder treatment …

(a) The Division shall reimburse for medically necessary transplantation services, including organ procurement, except those transplants categorized as experimental. (See (d) below for further information on organ procurement and transplantation.) 1. Claims for transplant service…

The purpose of HealthStart shall be to provide comprehensive maternity care services to pregnant Medicaid/NJ FamilyCare fee-for-service beneficiaries, (including those determined to be presumptively eligible) and preventive child health care services for Medicaid/NJ FamilyCare fe…

(a) All HealthStart comprehensive maternity care services shall be delivered through a team approach by qualified professionals. (b) Physicians and certified nurse midwives shall be Medicaid/NJ FamilyCare fee-for-service providers and have obstetrical admitting privileges at a li…

(a) HealthStart maternity care providers shall have policies which protect patient confidentiality, provide for informed consent and document prenatal, labor, delivery, and postpartum services in accordance with the Department of Health's "HealthStart Comprehensive Maternity Care…

(a) Pediatric care services shall be comprehensive, integrated and coordinated. (b) HealthStart pediatric care providers shall be Medicaid/NJ FamilyCare fee-for-service providers and shall: 1. Directly provide preventive child health care, maintenance of complete patient history,…

All HealthStart pediatric care providers shall be pediatricians or have a physician on staff who possesses a knowledge of pediatrics. This may be demonstrated by eligibility for board certification by the American Academy of Pediatrics, the American Osteopathic Board of Pediatric…

(a) HealthStart pediatric care providers shall provide preventive health visits in accordance with the recommended guidelines of the American Academy of Pediatrics. The schedule shall include a two-to four-week visit, two-month visit, four-month visit, six-month visit, nine-month…

(a) HealthStart pediatric care providers shall have policies which protect patient confidentiality, provide for informed consent and document comprehensive care services. (b) An individual record shall be maintained for each patient. (c) Each record shall be confidential and shal…

(a) The HealthStart HCPCS procedure codes listed in this subchapter are governed by the same rules that appear in the HCPCS subchapter of each non-institutional provider services manual (Independent Clinic, Physician and the Nurse Midwifery Services Chapters). The maximum fee all…

(a) HealthStart Maternity Care billing code requirements shall be as follows: 1. Separate reimbursement shall be available for maternity medical care services and maternity health support services. 2. Maternity medical care services shall be billed as a total obstetrical package,…

(a) HealthStart maternity care services provided by a HealthStart-certified provider shall be obstetrical care services provided in accordance with the recommendations of the American College of Obstetricians and Gynecologists and a program of support services provided in accorda…

(a) The following Medicaid/NJ FamilyCare fee-for-service-enrolled provider types shall be eligible to participate as HealthStart providers: 1. Independent clinics; 2. Federally qualified health centers; 3. Hospital outpatient departments; 4. Local health departments; 5. Physician…

(a) The New Jersey State Department of Health shall enforce its requirements for HealthStart Comprehensive Maternity Provider Certificates and for evaluation and enforcement of its requirements within the standards and guidelines for HealthStart providers. (b) Failure to comply w…

(a) Comprehensive maternity care services shall be integrated and coordinated. (b) HealthStart maternity care providers, excluding physicians and nurse midwives who are in private practice, shall provide comprehensive maternity care services within the following organizational re…

(a) All HealthStart services shall be accessible to patients. (b) HealthStart maternity care providers shall facilitate patient access to services by scheduling an initial medical visit appointment within two weeks of the patient's first request for services. (c) HealthStart mate…

(a) A plan of care shall be developed and maintained by the case coordinator for each patient. (b) A plan of care shall be based on the medical, nutritional, social-psychological and health education assessments. (c) A plan of care shall include, but shall not be limited to: iden…

(a) Maternity medical care services shall include antepartum, intrapartum, and postpartum care provided by the obstetrical care practitioner(s) in accordance with New Jersey State Department of Health's HealthStart Comprehensive Maternity Care Services Program Guidelines. (b) Pre…

(a) Case coordination services shall facilitate the delivery of continuous, coordinated, and comprehensive services for each patient in accordance with the New Jersey State Department of Health's "HealthStart Comprehensive Maternity Care Services Program Guidelines," as follows: …

(a) For inpatient services with discharge dates prior to August 3, 2009, the Division will reimburse acute care general hospitals for inpatient services based upon rates determined under N.J.A.C. 10:52-5 through 7 and 9, except for distinct units of acute care general hospitals. …

(a) The Division will reimburse special hospitals (Classification A) (acute and short term special hospitals) and Classification B (Rehabilitation hospitals), excluding specialized pediatric facilities licensed to provide pediatric comprehensive rehabilitation services, effective…

(a) The Division shall reimburse general hospitals, special hospitals (Classification A), rehabilitation hospitals (Classification B), private and governmental psychiatric hospitals, and distinct units of acute care hospitals for covered outpatient hospital services provided in o…

(a) Any qualifying hospital that has completed a capital facilities construction project with an approved certificate of need from the New Jersey Department of Health, which meet both conditions in (a)1 below will be eligible for increased payments for capital project funding rel…

(a) The Division shall reimburse an out-of-State approved acute care general hospital (see N.J.A.C. 10:52-1.2, Definitions) for providing inpatient and outpatient hospital services to New Jersey Medicaid/NJ FamilyCare beneficiaries if the hospital meets the requirements of the Di…

(a) For beneficiaries for whom any third-party liability exists, claims for hospital services provided that are not the responsibility of a Medicaid/NJ FamilyCare managed care organization shall be reimbursed in accordance with N.J.A.C. 10:49-7.3 and the provisions of this chapte…

(a) Some patients may be covered under both Medicare and Medicaid or Medicare and NJ FamilyCare. When the Medicaid/NJ FamilyCare beneficiary is covered under both programs, Item 57 on the hospital claim form shall be completed showing the Medicaid/NJ FamilyCare Eligibility Identi…

(a) General policies regarding the collection of personal contribution to care for NJ FamilyCare-Plan C and copayments for NJ FamilyCare-Plan D fee-for-service are set forth at N.J.A.C. 10:49-9. (b) Personal contribution to care for NJ FamilyCare-Plan C services are $ 5.00 a visi…

(a) The New Jersey Medicaid settlement agent for New Jersey acute care general (excluding inpatient services), special, rehabilitation, and private psychiatric and county governmental psychiatric hospitals shall determine the amount of disbursements, recoupments, and/or changes i…

For general acute care hospitals, the Division of Medical Assistance and Health Services (hereafter referred to as the Division or its designee), on or before March 12, 1993 and on or before January 31 of each subsequent rate year shall implement a rate. For hospitals with a fisc…

(a) The standard to be used in the calculation of the proposed rates for each inpatient DRG is as follows: 1. For services provided on or after October 1, 1996, the standard to be used in the calculation of the proposed rates for each inpatient DRG is determined as the median non…

(a) Inpatient direct cost per case shall be determined as follows: 1. The reasonable direct cost per Medicaid/NJ FamilyCare fee-for-service case for those hospitals receiving rates in accordance with this subchapter for every DRG shall include incentives and disincentives, as app…

(a) The net gain (loss) from Other Operating and Non Operating Revenues (as defined in N.J.A.C. 10:52-6.25 through 6.32) and expenses of the reporting period which are items considered as recoveries of or increases to the Costs Related to Patient Care (see N.J.A.C. 10:52-6.25 thr…

(a) The economic factor is the measure of the change in prices of goods and services used by New Jersey hospitals. The economic factor will be the factor recognized under the TEFRA target limitations. 1. The hospital-specific economic factor is the weighted average of the recorde…

(a) Capital Facilities, as defined in N.J.A.C. 10:52-6.18, shall be included in the rate in the following manner:1. Building and fixed equipment:i. The yearly Capital Facilities Allowance is computed using information provided by the Share Cost Reports. For hospitals on a calenda…

(a) Any modifications including any statutory or regulatory changes or changes in patient care physician compensation arrangements shall be classified as direct or indirect, and as to the financial elements affected and each element adjusted proportionately. (b) The Division shal…

(a) Apportionment of Financial Elements based on direct costs shall be as follows: 1. All other Financial Elements are added to direct Medicaid/NJ FamilyCare fee-for-service patient care costs as percentages of direct costs per Medicaid/NJ FamilyCare case. The Schedule of Rates i…

All rates issued pursuant to this subchapter, as approved or modified, shall be effective as of October 1, 1996, of the rate year and then January 31 for subsequent years. Notes N.J. Admin. Code § 10:52-5.17 Amended by R.1997 d.43, effective 1/21/1997. See: 28 New Jersey Register…

Notes N.J. Admin. Code § 10:52-5.18 Recodified to N.J.A.C. 10:52-5.14 by R.2000 d.29, effective 1/18/2000. See: 31 New Jersey Register 3151(a), 32 New Jersey Register 276(a).