New Jersey Administrative Code

The rules in this chapter shall apply to assisted living residences, comprehensive personal care homes, and assisted living programs licensed by the Department of Health, in accordance with N.J.A.C. 8:36 that are also enrolled Medicaid/NJ FamilyCare providers, providing services …

The purpose of this chapter is to implement HCBS waiver provisions for services provided by assisted living residences, comprehensive personal care homes, and assisted living programs to Medicaid/NJ FamilyCare beneficiaries, which supplement the licensing requirements included at…

The following words and terms, as used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise: "Assisted living program" means a program, licensed by the New Jersey Department of Health, in accordance with N.J.A.C. 8:36, that offers ass…

(a) In order for service providers to receive Medicaid/NJ FamilyCare reimbursement for HCBS, beneficiaries in assisted living residences, comprehensive personal care homes, and assisted living programs must have person-centered service plans that meet the requirements for general…

(a) In order to be eligible to receive Medicaid/NJ FamilyCare reimbursement for the provision of HCBS to Medicaid/NJ FamilyCare beneficiaries in assisted living residences, assisted living programs, and comprehensive personal care homes, these beneficiaries must be integrated in,…

(a) In addition to the requirements at N.J.A.C. 8:36, assisted living residences and comprehensive personal care homes must meet the following criteria for HCBS Medicaid/NJ Family Care reimbursement:1. The unit or dwelling must be a specific physical place that can be rented or o…

(a) In addition to the notice requirements at N.J.A.C. 8:36, the assisted living residence or comprehensive personal care home must post its license from the Department of Health in a conspicuous location near the main entrance or office of the facility. (b) The assisted living p…

(a) The assisted living residence or comprehensive personal care home must conspicuously post the most recent inspection report from the Department of Health in the entry or another equally prominent location in the building and, upon request, shall provide a copy of the report t…

(a) Assisted living residences and comprehensive personal care homes must post the following contact information in a conspicuous location in the facility: 1. "911" for the police department and the fire department that serve the municipality in which the facility is located; 2. …

(a)The Physician Services chapter outlines the policies and procedures of the New Jersey Medicaid/NJ FamilyCare program for a physician who prescribes, provides directly, or personally directs medically necessary health services to Medicaid/NJ FamilyCare beneficiaries. The polici…

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise. "APN" means an advanced practice nurse, as that term is defined at N.J.A.C. 10:58A-1.2. "Appropriate State agency" means an agency that has…

(a) All physicians, licensed doctors of medicine or surgery (M.D.) or doctors of osteopathy (D.O.) or podiatric medicine pursuant to N.J.A.C. 13:35 (incorporated herein by reference), authorized to provide medical and surgical services by the State of New Jersey, who are an appro…

(a) Reimbursement rates for physician services are differentiated as specialist or non-specialist according to the criteria for specialist designation listed in (b) below. (b) An applicant for specialist designation by the New Jersey Medicaid/NJ FamilyCare program, except as note…

(a) All physician providers shall be required to certify that the services billed on any claim were personally rendered by the physician or under his or her personal direction, except under the circumstances listed in (b) below. (b) Physician services furnished by another physici…

(a) All claim forms for covered services shall be personally signed by the physician or by an authorized representative of the physician. (See Fiscal Agent Billing Supplement.) The following signature types shall not be accepted: 1. Initials instead of signature; 2. Stamped signa…

The patient shall be allowed free choice of physicians, except for individuals enrolled as Medicaid/NJ FamilyCare program beneficiaries in Managed Care organizations (such as HMOs), in which case, the provisions of N.J.A.C. 10:74 shall apply. Notes N.J. Admin. Code § 10:54-2.1 Am…

(a) In a hospital or nursing facility, documentation shall include: 1. An update of symptoms; 2. An update of physical findings; 3. A resume of findings of procedures, if any are applicable; 4. The pertinent positive and negative findings of laboratory, X-Ray, electrocardiograms …

(a) When an inpatient is discharged from the hospital to the care of another medical facility (such as a nursing facility or a community home care agency), a legible discharge and medical summary shall be prepared and signed by the attending physician. (b) The summary should cove…

(a) For each patient contact made by a physician for psychiatric therapy, written documentation shall be developed and maintained to support each medical or remedial therapy, service, activity, or session for which billing is made. The documentation, at a minimum, shall consist o…

(a) Personal direction of physicians or other permitted and qualified health care professionals means that the services listed in this section shall be rendered in the participating physician's physical presence during part or all of the procedure or service, as specified in this…

(a) Anesthesia services provided by an Advanced Practice Nurse specializing in anesthesia (APN/Anesthesia), according to the conditions for practice in N.J.A.C. 13:37-13.1 and 13.2, shall be eligible for reimbursement provided: 1. The APN/Anesthesia is employed by a physician who…

(a) A Certified Nurse Midwife shall work with a physician under the collaborative arrangement specified by the Board of Medical Examiners in N.J.A.C. 13:35-2A, incorporated herein by reference. (b) Under the New Jersey Medicaid/NJ FamilyCare program, the Certified Nurse Midwife m…

(a) An advanced practice nurse (APN) shall collaborate with a physician, or physician/practitioner group in accordance with N.J.A.C. 10:58A, Advanced Practice Nurse Services, and N.J.A.C. 13:37-6.3 and 7.6, incorporated herein by reference.1. Under the New Jersey Medicaid/NJ Fami…

(a) All physicians shall keep such 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. (b) The minimum recordkeeping requirements for services performed in the office, home, r…

(a) The following minimum documentation shall be entered on the medical record, regardless of the setting where the examination is performed, for the service claimed by use of the procedure codes for Initial visit--New patient: 1. Chief complaint(s); 2. Complete history of the pr…

(a) The following minimum documentation shall be entered in the progress notes of the medical record for the service designated by the procedure codes for ESTABLISHED PATIENT: 1. In an office or Residential Health Care Facility:i. The purpose of the visit; ii. The pertinent physi…

For HOME VISIT and HOUSE CALL codes, in addition to the components listed in N.J.A.C. 10:54-2.8, the office progress notes shall include treatment plan status relative to present or pre-existing illness(es), plus pertinent recommendations and actions. Notes N.J. Admin. Code § 10:…

(a) The Medical Justification Program of the New Jersey Medicaid/NJ FamilyCare program defines certain surgical and diagnostic procedures that are reimbursable only when acceptable written justification by the physician accompanies the claim form. The procedures that require medi…

(a) Prior authorization, as used in this chapter, is the approval granted by the New Jersey Medicaid/NJ FamilyCare program before a service is rendered or an item provided. For additional information about prior and retroactive authorization, see also N.J.A.C. 10:49-6 and 10:54-5…

(a) A request for authorization for reimbursement for out-of-State hospital services shall be directed to the Medical Assistance Customer Center (MACC) in the area where the beneficiary resides (see N.J.A.C. 10:49, Appendix), except that: 1. Prior authorization of out-of-State ps…

(a) For a beneficiary residing in New Jersey in other than a hospital, who is to be admitted or referred to an out-of-State hospital or physician for elective inpatient or outpatient hospital services, the physician planning such action shall sign a statement that the medically n…

(a) Prior authorization shall not be required for emergencies nor for interstate hospital transfers. However, in these instances, the hospital shall attach the attending physician's signed statement to the claim, attesting to the nature of the emergency; or, for a hospital inters…

(a) Payment for physician services covered under the New Jersey Medicaid or NJ FamilyCare program is based upon the customary charge prevailing in the community for the same service but shall not exceed a "Maximum Fee Allowance Schedule" which has been determined reasonable by th…

For routine hospital newborn care for a well baby, the HCPCS code 99431 requires documentation, for reimbursement purposes, of minimum routine newborn care by a physician/practitioner other than the physician(s)/practitioner(s) rendering maternity service, complete initial and di…

For sick newborns in a hospital inpatient setting, HCPCS code 99221 shall be used for initial hospital care. HCPCS codes 99231, 99232, and 99233 shall be used for all other hospital care. If a prolonged period of hospital inpatient care is applicable, HCPCS codes 99356 and 99357 …

(a) A hospital-based physician who is salaried and whose services are reimbursed as part of the hospital's cost shall not bill fee-for-service to the New Jersey Medicaid/NJ FamilyCare program. (b) A physician practicing in a hospital outpatient department whose reimbursement is n…

(a) The New Jersey Medicaid/NJ FamilyCare program shall reimburse for surgical services based on a surgical package concept, which includes the following components: 1. Pre-operative care, which shall include any consultations and/or evaluations performed within 48 hours prior to…

Consultation and evaluation services provided prior to surgery by specialists other than the surgeon performing the procedure may be separately reimbursed from the payment for surgical procedures when provided within 48 hours prior to surgery. Notes N.J. Admin. Code § 10:54-4.14 …

(a) If the physician bills for an office/outpatient visit at the time of the surgical procedure, reimbursement may be made for either the surgical procedure, at 100 percent of the Medicaid/NJ FamilyCare maximum fee allowance, or for the office/hospital outpatient visit. (b) The f…

(a) Multiple surgical procedures during the same operative session shall be reimbursed as follows: 1. The primary surgical procedure shall be reimbursed at 100 percent of the Maximum Fee Allowance; 2. The secondary surgical procedure(s) shall be reimbursed at 50 percent of the Ma…

If the beneficiary is returned to the operative suite for a repeat or revisitation of the operation, by the same surgeon on the same day, the billing for the operative procedure shall include the "WB" modifier for the reimbursement for the second operative session. The use of thi…

(a) Ligation or transection of fallopian tube(s), when done at the operative session (time) of a Caesarean Section or intra-abdominal surgery, shall be reimbursed by the New Jersey Medicaid/NJ FamilyCare program for additional reimbursement from the primary surgical procedure (Ca…

(a) Anesthesiologists shall be reimbursed for anesthesia services provided to a Medicaid/NJ FamilyCare program beneficiary for the total of the anesthesia base units (ABUs) plus anesthesia time. (b) The use of a HCPCS procedure code which has anesthesia base units (ABUs) assigned…

(a) General policies regarding the collection of personal contribution to care for NJ FamilyCare-Children's Program-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-Children's Program-Plan C serv…

Radiological services shall ordinarily be provided only by a physician who is a specialist in radiology, nuclear medicine, and/or radiation oncology. However, a physician, other than one of those listed above, who is a specialist may provide radiological services which are relate…

(a) Reimbursement for radiological services provided by a physician(s) other than those physicians listed in N.J.A.C. 10:54-4.19 shall be limited to diagnostic radiology of long bones and/or radiological chest examination, in emergency situations to the physician's own patients, …

(a) For documented, necessary, combined abdominal and pelvic body scans (CT and/or MRI), reimbursement for the second or subsequent procedures shall be limited to an additional 50 percent of the payment for the first procedure. (b) For computerized tomography scan (CT) guidance (…

(a) Nuclear medicine, diagnostic and therapeutic radiopharmaceuticals shall be reimbursed separately when provided by a physician in an office setting, as applicable. (See HCPCS 78990 and 79900.)1. Lung ventilation and perfusion study combined codes shall be used when both these …

(a) The treatment planning process shall include interpretation of special testing, tumor localization, treatment volume determination, treatment time/dosage determination, choice of treatment ports, selection of appropriate treatment devices and other procedures. Consultation se…

(a) Portable and mobile diagnostic radiological services shall be provided only by a physician who is a specialist in radiology. (b) Portable and mobile diagnostic radiological services may be provided to Medicaid patients in long term care settings, in an emergency situation, or…