New Jersey Administrative Code

(a) The Division covers sterilization procedures performed on Medicaid/NJ FamilyCare program 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 sterilization policy and…

(a) The Division will cover hysterectomy procedures performed on Medicaid beneficiaries based on Federal regulation (42 CFR 441.250 through 42 CFR 441.258) and related requirements outlined in the billing instructions. For billing instructions, see Fiscal Agent Billing Supplement…

(a) The Division shall reimburse for medically necessary termination of pregnancy procedures on Medicaid/NJ FamilyCare program beneficiaries when performed by a physician in accordance with N.J.A.C. 13:35-4.2, of the rules of the New Jersey State Department of Law and Safety, Div…

(a) The Division recognizes transportation services as covered services when a beneficiary is transported for the purpose of obtaining a Medicaid/NJ FamilyCare covered service. The mode of transportation is based upon the beneficiary's medical condition, as follows: 1. An ambulat…

(a) The Division recognizes vision care services, and optical appliances and services provided only by the following eligible providers, within the restrictions of their respective licensure or requirements in the state in which they are located: 1. An ophthalmologist means a lic…

(a) For diagnostic endoscopic procedures which do not involve biopsy(ies), if an endoscopic procedure is performed as a single procedure, the maximum reimbursement shall be 100 percent of the HCPCS code. (b) Reimbursement shall be made for either the endoscopic procedure or the o…

(a) For diagnostic endoscopic procedures with biopsies, the pricing logic for multiple surgical procedures applies (see N.J.A.C. 10:54-4.15). In some instances, there is a specific CPT (HCPCS) code associated with that procedure which includes the biopsy and that HCPCS code must …

(a) Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program is a comprehensive health program for Medicaid/NJ FamilyCare program beneficiaries under 21 years of age. The goal of the program is to assess the beneficiaries health needs through initial and periodic exa…

(a) As a condition of participation in Medicaid/NJ FamilyCare, all ambulatory care facilities (including hospital outpatient departments) providing primary care to children and adolescents from birth through 20 years of age, shall participate in the EPSDT program and shall provid…

(a) The required EPSDT services include the following: 1. Screening services (see (f) below for components of screening services); 2. Vision services; 3. Dental services; 4. Hearing services; and, 5. Other medically necessary health care, diagnostic services and treatment and oth…

The purpose of HealthStart shall be to provide comprehensive maternity and child health care services for all pregnant women (including those determined to be presumptively eligible) and for children (under two years of age) in the State of New Jersey who are eligible for Medicai…

(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 and Senior Services Guidelines for HealthStart Maternity Care Providers," as follows: …

(a) All HealthStart Maternity Care services shall be delivered through an integrated approach by qualified professionals. (b) Physicians and/or certified nurse midwives shall be Medicaid providers and have obstetrical admitting privileges at a licensed maternity care facility. (c…

(a) HealthStart Maternity Medical Care providers must have policies and procedures which protect patient confidentiality, provide for informed consent and document prenatal, labor, delivery and postpartum services in accordance with the "New Jersey State Department of Health and …

(a) Pediatric care services shall be comprehensive, integrated and coordinated. (b) HealthStart Pediatric Care providers shall be Medicaid providers and shall: 1. Directly provide preventive, well-child care, maintenance of complete patient history, outreach for preventive care, …

(a) HealthStart Pediatric Care Providers shall be primary care physicians 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, and/or having hospital admitting …

(a) HealthStart Pediatric Care Providers shall provide preventive health visits in accordance with the recommended guidelines of the American Academy of Pediatrics and the New Jersey State Department of Health and Senior Services Guidelines for HealthStart Pediatric Care (N.J.A.C…

All HealthStart Pediatric Care providers shall make provision for consultation for specialized health and other pediatric services. Services shall include medical services, as well as social, psychological, educational and nutrition services. This may include, but is not limited …

(a) HealthStart Pediatric Care providers shall have policies which protect patient confidentiality, provide for informed consent and document comprehensive care services in accordance with New Jersey State Department of Health and Senior Services Guidelines for HealthStart Pediat…

(a) The HealthStart HCPCS procedure codes listed in this subchapter are governed by the same policies and rules that appear in the HCPCS subchapter of each chapter concerning non-institutional provider services. (See the Chapters on Independent Clinic Services, (N.J.A.C. 10:66), …

(a) HealthStart Maternity Care code requirements are 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, when feasibl…

(a) HealthStart maternity care services shall include all medical services recommended by the American College of Obstetricians and Gynecologists (ACOG) and the American College of Nurse Midwives (ACNM), as well as a program of health support services. HealthStart pediatric care …

(a) Providers that are eligible to participate as HealthStart providers shall be: independent clinics (including local health departments meeting the New Jersey Department of Health and Senior Services Improved Pregnancy Outcome criteria); hospital outpatient departments; Federal…

(a) The New Jersey State Department of Health and Senior Services will be responsible for enforcement of its requirements for HealthStart Provider Certificates and for evaluation and enforcement of its requirements within the Standards and Guidelines for HealthStart providers. 1.…

(a) HealthStart maternity care services shall be integrated and coordinated. (b) HealthStart Maternity Care providers shall provide for comprehensive maternity care services, that is, maternity medical and health support services, as follows: 1. Providers shall provide directly o…

(a) Physicians and certified nurse midwives in private practice shall meet the requirements in N.J.A.C. 10:54-6.5, except they may provide just the medical care component as long as they have entered into a written agreement with a single HealthStart provider who shall provide th…

(a) All HealthStart services shall be accessible to patients. (b) HealthStart Maternity Care providers shall facilitate patient access to services by scheduling appointments for the HealthStart enrollment visit, the initial antepartum maternity medical care and other health suppo…

(a) Definition: A Plan of Care is a written document available to and used by all providers for the purpose of assuring the provision of comprehensive and coordinated care. The Plan of Care documents: the identified patient needs for medical, nutritional, social/psychological ser…

(a) Maternity medical care services shall include antepartum, intra-partum and postpartum care provided by the obstetrical care practitioner(s) in accordance with the "New Jersey State Department of Health and Senior Services Guidelines for HealthStart Maternity Care Providers." …

(a) The following words and terms, when used in this section, shall have the following meanings, unless the context clearly indicates otherwise. "Pre-admission screening" (PAS) means that process by which all Medicaid/NJ FamilyCare program beneficiaries and individuals who may be…

(a) The following policies and procedures were developed to help ensure the appropriate utilization of hospital 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…

(a) PASRR Level I Identification Screens shall be required for individuals diagnosed as mentally ill, mentally retarded or with related conditions. (b) An individual is considered to have a mental illness if he or she has a "serious mental illness such as: schizophrenia; mood dis…

(a) The criteria for serious mental illness includes: 1. A diagnosis of a mental illness that may lead to chronic disability, such as, schizophrenia, mood disorder, paranoia, panic or other severe anxiety disorder, somataform disorder, personality disorder, or other psychotic dis…

(a) PASRR Level II screens shall be conducted for mentally ill or mentally retarded individuals only if the RSN's assessment or the assessment by the professional staff designated by the DHSS results in authorization for NF placement. (b) Level II screens require that a psychiatr…

Readmission of an individual to a nursing facility following hospitalization in a psychiatric unit of an acute care hospital or from a psychiatric hospital for treatment of an acute episode of a serious mental illness is exempt from preadmission NF and Specialized Services screen…

For individuals diagnosed with Alzheimer's or related dementias, documentation must be provided to the admitting Medicaid certified nursing facility for the individual's clinical record on the history, physical examination and diagnostic workup to support the diagnosis of dementi…

(a) The determination of the necessity for NF services shall be performed through Pre-admission Screening (PAS) as mandated by N.J.S.A. 30:4D-17.10. The Regional Staff Nurse (RSN) or other professional staff designated by the DHSS shall determine the necessity for nursing facilit…

(a) Physician services that are rendered to a patient registered in the hospital outpatient department that are reimbursed as part of hospital costs shall not be billed directly by the physician to the Medicaid/NJ FamilyCare program. Any arrangement, contractual, employment, gran…

(a) The New Jersey Medicaid/NJ FamilyCare program recognizes as a covered service, a medically necessary inpatient service that is provided to a Medicaid/NJ FamilyCare program beneficiary in an approved private psychiatric hospital or the psychiatric section of an approved genera…

(a) All covered pharmaceutical services shall be provided under the New Jersey Medicaid program shall be provided to Medicaid/NJ FamilyCare program beneficiaries within the scope of N.J.A.C. 10:49, Administration; 10:51, Pharmaceutical Services; and this subchapter. (b) All drugs…

(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 the requirements of the following rules are not met: 1. Covered …

(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 Drug Utilization Review Board (NJ DURB) and approved by the Commissioners of the Department of Human Services …

(a) The New Jersey Medicaid/NJ FamilyCare program shall reimburse physicians for certain approved drugs administered by inhalation, intradermally, subcutaneously, intramuscularly or intravenously in the office, home or independent clinic setting according to the following reimbur…

(a) The New Jersey Vaccines for Children (VFC) program provides free vaccines for administration to beneficiaries under 19 years of age who are eligible for New Jersey Medicaid and NJ FamilyCare-Children's Program services. Medicaid and NJ FamilyCare-Children's Program will not p…

(a) The New Jersey Medicaid program utilizes the Federal Centers for Medicare & Medicaid Services' (CMS) Healthcare Common Procedure Coding System (HCPCS), incorporated herein by reference, as amended and supplemented. Revisions to the Healthcare Common Procedure Coding System ma…

(a) Introduction: 1. The following is a list of procedure codes with the "modifier L" in the IND column on the list of HCPCS Procedure Codes representing procedure codes specifically used by New Jersey Medicaid and not included in the CPT-4. (b) Mental Health services: H5025 Psyc…

(a) Anesthesia: The following HCPCS procedure codes do not require the AA modifier when the professional services are rendered by an anesthesiologist: Click here to view image. (b) Incidental Surgery: Certain surgical procedures when performed incidental to other surgical procedu…

(a) The lists of HCPCS procedure code for use of physicians and other practitioners are arranged in tabular form with specific information for a code given under columns with titles such as "IND", "HCPCS CODES", "MOD", "DESCRIPTION", "FOLLOW-UP DAYS", "MAXIMUM FEE ALLOWANCE" and …

(a) Services and procedures may be modified under certain circumstances. When applicable, the modifying circumstance should be identified by the addition of alphabetic and/or numeric characters at the end of the code. The New Jersey Medicaid/NJ FamilyCare program's recognized mod…

Maximum Fee Anes HCPCS Allowance Basic IND Code Mod S $ NS Units N 99183 27.00 NA N 99190 45.00 NA N 99191 33.75 NA N 99192 22.50 NA 99195 28.00 28.00 99199 BR BR N 99201 16.00 14.00 N 99202 16.00 14.00 N 99203 22.00 17.00 N 99204 22.00 17.00 N 99205 22.00 17.00 E N 99211 16.00 1…