New Jersey Administrative Code

(a) The following is a list of Level I HCPCS procedure codes with their associated qualifiers (except for Pathology and Laboratory procedure codes). Providers are to recognize the requirements inherent in billing each of the HCPCS. The qualifiers related to Pathology/Laboratory S…

(a) Qualifiers for pathology and laboratory services are summarized below: 1. Chemistry Automated, Multichannel Tests Applies to CPT Codes: 80002, 80003, 80004, 80005, 80006, 80007, 80008, 80009, 80010, 80011, 80012, 80016, 80018, and 80019. The following list contains those test…

(a) This chapter of the manual N.J.A.C. 10:55 outlines the rules of the New Jersey Medicaid/NJ FamilyCare programs relevant to the provision of prosthetic and orthotic services to Medicaid/NJ FamilyCare fee-for-service beneficiaries. It also lists the specific requirements which …

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise. "Accredited" means those facilities that have met the standards of qualification as established by the American Board for Certification in …

(a) In order to be a fully approved New Jersey Medicaid/NJ FamilyCare fee-for-service provider of prosthetic and orthotic services, the applicant shall: 1. Submit a completed application (see N.J.A.C. 10:49-3.2) together with a copy of the facility and personnel accreditation/cer…

(a) An approved Medicaid/NJ FamilyCare fee-for-service provider of prosthetic and orthotic services shall be responsible for the following: 1. Assuring that an appliance furnished by the approved facility conforms to the prescriber's prescription and the description of the applia…

(a) This section specifies the services that require prior authorization and the procedures to follow. Prior authorization shall be required for: 1. Any prosthetic appliance (except for preparatory (temporary) upper and lower prostheses) for which the provider's charge is $ 1,000…

(a) A personally signed and dated order (prescription) by the prescriber shall be required for the following:1. Prosthetic and orthotic appliances; 2. Repair and replacement of parts for custom-made prosthetic and orthotic appliances; and 3. Orthopedic footwear. (b) The prescript…

(a) For purposes of the New Jersey Medicaid/NJ FamilyCare programs policies, an "orthopedic shoe" means footwear, with or without accompanying appliances, used to prevent or correct gross deformities of the feet, which is properly fitted as to length and width, and consists of th…

(a) This section outlines the Program's policy of reimbursement for prosthetic and orthotic services and specifies the procedure for submitting a claim to request payment. (b) Providers of prosthetic and orthotic appliances shall be reimbursed on a fee-for-service basis not to ex…

(a) The New Jersey Medicaid NJ FamilyCare fee-for-service programs have adopted the Centers for Medicare and Medicaid's Healthcare Common Procedure Coding System (HCPCS). The HCPCS procedure codes listed in this subchapter shall be used when filing a claim for prosthetic and/or o…

(a) The list of HCPCS procedure codes in N.J.A.C. 10:55-2.3 and 2.4 is arranged in tabular form with specific information for each code given under columns with the titles "HCPCS Code," "Description," and "Maximum Fee Allowance." (b) The column titled "MAXIMUM FEE ALLOWANCE" indi…

HCPCS Description Maximum Code Fee Allowance $ (a) ORTHOTIC DEVICES (L0100-L0999) 1. SPINAL: CERVICAL L0112 Cranial cervical orthosis, congenital torticollis 879.82 type, with or without soft interface material, adjustable range of motion joint, custom fabricated L0113 Cranial ce…

HCPCS Description Maximum Code Fee Allowance $ (a) PROSTHETIC PROCEDURES--LOWER LIMB (L5000-L5999) The procedures in this section are considered as "base" or "basic procedures" and may be modified by listing items/procedures or special material from the "additions" section and ad…

This chapter describes the requirements of the New Jersey Medicaid/NJ FamilyCare fee-for-service programs pertaining to the provision of, and reimbursement for, medically-necessary dental services to eligible beneficiaries. In addition to the provider's private office, dental ser…

(a) For the purposes of the New Jersey Medicaid/NJ FamilyCare fee-for-service program, utilization review, quality control and peer review are considered to be ongoing components in regard to the dental services provided to eligible beneficiaries. (b) Utilization refers to that s…

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise. "Ambulatory Surgical Center (ASC)" means any distinct entity that: operates exclusively for the purpose of providing surgical services to p…

(a) A Doctor of Dental Medicine (DMD) or a Doctor of Dental Surgery (DDS), pursuant to N.J.A.C. 13:35 (incorporated herein by reference), who is authorized to provide dental and surgical services by the State of New Jersey, who is an approved Medicaid/NJ FamilyCare fee-for-servic…

(a) For dental services that require prior authorization, a Prior Authorization Form, (MC-10A), and the Dental Claim Form (MC-10), shall be submitted to: Division of Medical Assistance and Health Services Office of Utilization Management Bureau of Dental Services, Mail Code 21 PO…

(a) Reimbursement for covered services furnished under the New Jersey Medicaid/NJ FamilyCare fee-for-service programs shall be the customary and usual fee of the provider when it does not exceed Federal regulatory maximums and reasonable rates as determined by the Commissioner of…

(a) To obtain reimbursement as a specialist in the Medicaid/NJ FamilyCare programs, a specialist shall:1. Obtain a specialty certification from the licensing agency of the State of New Jersey or of the state where dental services are to be rendered; or 2. In those states not requ…

(a) General policies regarding the collection of personal contribution to care for NJ FamilyCare-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-Plan C services shall be $ 5.00 per visit for den…

(a) A non-covered service is that procedure which is primarily for cosmetic purposes, for which dental necessity cannot be demonstrated, or which is determined to be beyond the scope of the program by a Medicaid/NJ FamilyCare dental consultant as specified in this chapter. (b) Me…

(a) Dentists shall maintain individual records which fully disclose the type and extent of services provided to the New Jersey Medicaid/NJ FamilyCare fee-for-service programs beneficiary, including detailing all services rendered for each encounter date. These records shall also …

(a) In accordance with good dental practice, a plan of treatment or services shall be developed and described for each Medicaid/NJ FamilyCare patient on the Dental Claim Form (MC-10) following a comprehensive evaluation. If no treatment is necessary, this fact shall be entered on…

(a) Restorative treatment shall be limited to those services necessary to adequately restore and maintain the integrity and contours of the natural tooth, as follows: 1. Filling restorations shall be reimbursed as follows:i. Reimbursement for restorations in primary teeth shall b…

(a) Reimbursement for root canal therapy for all teeth shall include pulpal extirpation, endodontic treatment to include complete filling of the root canal(s) with permanent material, all necessary radiographs during treatment, a radiograph demonstrating proper completion, and fo…

(a) Reimbursement shall be provided for periodontal scaling and root planing for four quadrants annually without prior authorization. Prior authorization shall be obtained for additional quadrants of periodontal scaling and root planing, and all other periodontal services. Such r…

(a) Removable prosthodontic services shall be provided as follows: 1. Dentures, both partial and complete, may be prior authorized when submitted evidence indicates masticatory deficiencies likely to impair the general health of the beneficiary. Prefabricated dentures or dentures…

(a) Dental extraction services shall be provided as follows: 1. Extraction of teeth other than those classified as non-restorable shall require prior authorization. i. If a provider is considering any extraction which will necessitate the insertion of a dental prosthesis, the pro…

(a) The procedures in this section shall be followed for orthodontic referral, evaluation, and treatment. (b) Comprehensive orthodontic treatment shall be limited to handicapping malocclusions. Cases with 24 or more points on the New Jersey Handicapping Malocclusion Assessment Sy…

(a) In recognition of the unique needs of providing dental care for children, and in conformance with the Federally mandated Early and Periodic Screening, Diagnosis and Treatment program for providing services for children, a special HCPCS code has been defined, "D0150 EP," to be…

(a) General anesthesia, parenteral conscious sedation, enteral sedation and analgesia rules are as follows: 1. For general anesthesia, parenteral conscious sedation, enteral sedation and analgesia, dental providers shall comply with all applicable rules, including, but not limite…

(a) This section is intended to describe the practitioner's responsibility in the writing of prescriptions in order to maintain the traditional beneficiary-prescriber-provider relationship, and to insure the beneficiary free choice of provider. Practitioners are urged to familiar…

Following receipt of a prescription from the dentist, prior authorization from the Medical Assistance Customer Center shall be obtained by the medical supplier for certain medical supplies; therefore, the practitioner shall be prepared to certify and document dental necessity to …

(a) The dental treatment plan provided shall be in accordance with the ethical and professional standards of the dental profession and meet the same high standard of quality normally provided to the community at large. (b) All materials used and all therapeutic agents used or pre…

(a) Consultations shall be subject to the following conditions: 1. A written report which includes diagnosis and recommendations for future management shall be provided to the referring practitioner. A copy shall be retained with the beneficiary's records and must be available, u…

(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 shall be denied (except for dentist's prescriptions) if the requirements of the f…

(a) For pharmacy claims with service dates on or after September 1, 1999, which exceed PDUR standards recommended by the New Jersey DUR Board and approved by the Commissioners of DHS and DHSS, the Division of Medical Assistance and Health Services has established a Medical Except…

(a) Dental services for which no specific procedure code and description are noted, or which are limited or prohibited by this chapter, may be considered on a case-by-case basis, upon request. Such a request shall be submitted on the two part Dental Prior Authorization Form (MC-1…

(a) In addition to the private office, dental services may be provided in the home, a hospital, ambulatory surgical center, approved independent clinic, nursing facility, residential treatment center and elsewhere. (b) Services should be provided in any appropriate setting, gover…

(a) A provider may be reimbursed for a house call/visit (procedure code D9410) in addition to any other services provided on that day. Procedure code D9410 shall include house calls/visits to nursing homes, long-term care facilities, hospice sites, institutions, and other types o…

(a) A complete evaluation of the oral cavity shall be a comprehensive and thorough inspection of the oral cavity to include diagnosis, an oral cancer screening, charting of all abnormalities, and development and recording of a complete treatment plan. It should permit a Division …

(a) Radiological procedures shall be limited to those normally required to make a diagnosis and shall show all areas where treatment is anticipated with the exception of soft tissue lesions. (b) All radiographs should be examined carefully by the provider to assure quality care a…

(a) "Clinical laboratory services" includes services provided by: 1. Independent clinical laboratories, including physician/dentist operated, out of hospital laboratories which perform primarily diagnostic work referred by other practitioners; and 2. Hospital laboratories and lab…

(a) In addition to an oral evaluation every six months for beneficiaries through age 20 and once every 12 months for beneficiaries 21 years of age or older, preventive dental care encompasses the following recommended services: 1. Prophylaxis, as follows: i. Dental prophylaxis me…

(a) The New Jersey Medicaid/NJ FamilyCare program utilizes the American Dental Association's Code on Dental Procedures and Nomenclature as published in the Current Dental Terminology (CDT) and incorporated herein by reference, as amended and supplemented, and designated by the Ce…