New Jersey Administrative Code

(a) A CNM may claim reimbursement for clinical laboratory services performed for his or her own patients within his or her own office, except when provided in a birth center. Laboratory services provided in a birth center shall be billed to Medicaid/NJ FamilyCare-Plan A fee-for-s…

(a) When any part of the clinical laboratory test(s) is performed on site, the venipuncture is not reimbursable as a separate procedure: its cost is included within the reimbursement for the laboratory procedure. Venipuncture is reimbursable if the total specimen is referred to t…

(a) When the CNM refers a laboratory test to an independent clinical reference laboratory: 1. The clinical reference laboratory shall be certified under CLIA requirements to perform the required laboratory test(s) (see Section 1902(a)9 of the Social Security Act; 42 U.S.C. 1396 a…

Rebates by reference laboratories, service laboratories, physicians or other utilizers or providers of laboratory services are prohibited under the New Jersey Medicaid/NJ FamilyCare programs. This refers to rebates in the form of refunds, discounts or kickbacks, whether in the fo…

(a) Family planning services may be provided by the CNM, including 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 …

(a) The Norplant System (NPS) is a Medicaid/NJ FamilyCare covered service when provided as follows: 1. The NPS is used only in reproductive age women with established regular menstrual cycles; 2. The Food and Drug Administration (FDA)-approved physician prescribing information is…

(a) The purpose of HealthStart is 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 Medicaid …

(a) All covered pharmaceutical services provided under the New Jersey Medicaid/NJ FamilyCare programs shall be provided to Medicaid/NJ FamilyCare-Plan A fee-for-service beneficiaries within the scope of N.J.A.C. 10:49, Administration chapter; N.J.A.C. 10:51, Pharmaceutical Servic…

(a) Birth center facility services shall include, but not be limited to, administrative, nursing, and technical services related to labor and delivery. (b) Other services and items not directly related to the care of the patient, such as guest meals and accommodations, television…

(a) For office visits and for other care apart from inpatient hospital, CNMs shall bill for an initial visit only once for a specific patient, subject to the exceptions contained in (b) below. When a shared health care facility, a group of physicians and/or other practitioners (C…

Office or other outpatient service, or subsequent hospital care visits shall conform to the CPT description of provider involvement and time. The setting could be office or hospital. The documentation requirements for these visits are found in N.J.A.C. 10:58-1.9. Notes N.J. Admin…

(a) In the absence of patient complaints, the procedure codes identified as preventive medicine services shall be used for adults and for children. (b) Preventive medicine services codes (new patient) are comparable, in respect to reimbursement level, to an initial visit and, the…

(a) A consultation shall be reimbursed by the New Jersey Medicaid/NJ FamilyCare fee-for-service programs when performed by a physician specialist (other than her collaborating physician) recognized as such by the Medicaid/NJ FamilyCare programs and when the request is made by or …

(a) The home services recognized as "house calls" refer to a practitioner visit to an individual who would be too ill to go to a practitioner's office and/or is "home bound," as determined by the attending physician, due to his or her physical condition. CNMs shall be reimbursed …

(a) When a practitioner sees the patient in the emergency room instead of his or her office, the practitioner shall use the same codes for the visit that would have been used if seen in the practitioner's office. Records of that visit shall become part of the notes in the office …

(a) The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program is a comprehensive health program for Medicaid/NJ FamilyCare beneficiaries from birth through 20 years of age. The goal of the program is to assess the beneficiary's health needs through initial and per…

(a) Clinical laboratory services shall be furnished by clinical laboratories and by provider office laboratories (POLs) that meet the Centers for Medicare and Medicaid Services (CMS) regulations pertaining to clinical laboratory services (Section 1902(a)9 of the Social Security A…

(a) The New Jersey Medicaid/NJ FamilyCare programs adopted the Centers for Medicare & Medicaid Services (CMS) Healthcare Common Procedure Coding System (HCPCS) codes for 2006, established and maintained by CMS in accordance with the Health Insurance Portability and Accountability…

(a) The list of HCPCS procedure codes for nurse midwifery services are arranged in tabular form with specific information for a code given under columns with titles such as: "IND," "HCPCS CODE," "MOD," "DESCRIPTION," "FOLLOW-UP DAYS," "MAXIMUM FEE ALLOWANCE SCHEDULE" and "ANESTHE…

Click here to view image. Notes N.J. Admin. Code § 10:58-3.3 Amended by R.1998 d.209, effective 5/4/1998. See: 30 N.J.R. 57(a), 30 N.J.R. 1613(a). Added new codes. Amended by R.2001 d.204, effective 6/18/2001. See: 33 N.J.R. 1160(a), 33 N.J.R. 2188(a). Added Codes 90746 and 90746…

HCPCS Maximum Fee Codes Descriptions Allowance J2790 RhoGAM, Rho (D) Immune $ 26.00 Globulin (Human) Single dose (Micro-Dose) J2790 22 RhoGAM, Rho (D) Immune $ 45.00 Globulin (Human) Single dose (Full dose) (22--Services greater than usual) J1050 Medroxyprogesterone acetate, 100 …

HCPCS Follow-up Maximum Fee IND Codes MOD Days Descriptions Allowance (a) Intrauterine Devices: W0001 WM 30 Supplying and inserting the $ 304.00 intrauterine device "Paragard" by a CNM including the post-insertion visit. W0002 WM 30 Supplying and inserting the $ 137.00 intrauteri…

(a) Surgical services: Norplant System (NPS) 11975 WM QUALIFIER: Reimbursed for the insertion and reinsertion of the Norplant System (six Levonorgestrel Implants) and the post-insertion visit when provided in a hospital setting, when the CNM bills for the service. When using this…

This chapter outlines the policies and procedures of the New Jersey Medicaid/NJ FamilyCare program relevant to medical supplies and durable medical equipment, including enteral, total parenteral nutrition and other intravenous therapies. This chapter provides specific requirement…

(a) When a Medicaid/NJ FamilyCare beneficiary has other health insurance, the Medicaid/NJ FamilyCare program requires that such benefits be used first and to the fullest extent. Supplementation may be made for Medicaid/NJ FamilyCare covered services, but the combined total paymen…

(a) The New Jersey Medicaid and NJ FamilyCare programs shall utilize the services of a durable medical equipment (DME) recycling contractor, acting as an agent of the State, to recycle certain DME for reuse by Medicaid and NJ FamilyCare fee-for-service beneficiaries when such equ…

(a) Parenteral therapy refers to the administration of a drug by the intravenous or subcutaneous route of administration. (b) Total parenteral nutrition (TPN) means the administration of a patient's total daily nutritional needs via the parenteral route of administration. (c) All…

(a) ACS requires prior authorization. Requests for prior authorization shall include the following: 1. A list of specialists involved in the multi-disciplinary team evaluation of the beneficiary, including, at a minimum, a speech-language pathologist, physical therapist, occupati…

(a) Pressure reduction systems include:1. Air fluidized bed systems which employ the circulation of filtered air through silicone-coated ceramic beads creating the characteristics of fluid; 2. Powered low air loss bed systems which incorporate the use of an air-bladder system con…

(a) Apnea monitors shall require prior authorization (PA) for initial certification and subsequent recertification.1. To obtain authorization, providers shall complete the "Home Apnea Monitor Certification" form FD-287 which requires the prescriber's signature. The FD-287 may be …

The following words and terms, when used in this chapter, have the following meanings unless the context clearly indicates otherwise: "Apnea monitor" means an electronic device used to measure respiration and cardiac functions in patients experiencing episodic apnea related to a …

(a) Effective July 1, 2006, P.L. 2006, c. 45 and P.L. 2007, c. 111, as amended by P.L. 2007, c. 336, require the Division to institute a moratorium on, among other services, medical supply services. 1. Any provider that was not an approved Medicaid or NJ FamilyCare fee-for-servic…

(a) The New Jersey Medicaid/NJ FamilyCare program does not cover medical supplies and durable medical equipment under the following conditions: 1. A particular item of DME is not covered when, in the opinion of the Division, the item is not considered cost-effective or safe and e…

(a) Medical supplies and equipment require a legible, dated prescription or a Certificate of Medical Necessity (CMN) personally signed by the prescribing practitioner. Either document shall contain the following information: 1. The beneficiary's name, address and Medicaid/NJ Fami…

(a) Prior authorizations issued by the Medicaid/NJ FamilyCare program are intended to reflect decisions regarding medical necessity and purchase/rental options. The issuance of prior authorization is not a guarantee of Medicaid/NJ FamilyCare payment. Payment is determined based o…

(a) Medical suppliers may request payment for medical supply services only after the supply/equipment has been delivered to the beneficiary (see N.J.A.C. 10:49-9.5). All requests for payment shall be submitted timely, in accordance with N.J.A.C. 10:49-7.2. (b) For durable medical…

(a) Payment for purchase of medical supplies or DME shall be based on the following methods: 1. If there is no Medicaid/NJ FamilyCare Fee schedule, reimbursement shall be based on the lesser of the provider's usual and customary charge to the general public or a calculated maximu…

(a) When a Medicaid/NJ FamilyCare beneficiary also has Medicare coverage, the Medicaid/NJ FamilyCare program requires that Medicare benefits be used first and to the fullest extent. Responsibility for payment by the New Jersey Medicaid/NJ FamilyCare program shall be limited to th…

(a) The New Jersey Medicaid/NJ FamilyCare Program utilizes the Centers for Medicare & Medicaid Services (CMS) Healthcare Common Procedure Coding System codes for 2006, established and maintained by CMS in accordance with the Health Insurance Portability and Accountability Act, of…

(a) The list of HCPCS procedure codes in N.J.A.C. 10:55-2.4 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" indicates th…

HCPCS Maximum Fee Code Description Allowance A4206 Syringe with needle, sterile 1cc B.R. A4207 Syringe with needle, sterile 2cc B.R. A4208 Syringe with needle, sterile 3cc B.R. A4209 Syringe with needle, sterile 5cc or greater B.R. A4210 Needle-free injection device B.R. A4211 Su…

(a) The purpose of this chapter is to explain the rules under which home care services are administered to those individuals determined eligible to receive such services on a fee-for-service basis. (b) This chapter provides requirements for, and information about, the following s…

Providers and Medicaid/NJ FamilyCare-Plan A beneficiaries can request fair hearings as set forth in the Administration chapter at N.J.A.C. 10:49-9.14. NJ FamilyCare-Plan B and C fee-for-service beneficiaries can utilize the grievance board as set forth at N.J.A.C. 10:49-9. Notes …

Notes N.J. Admin. Code § 10:60-1.11 Recodified to N.J.A.C. 10:60-3.7 by R.2001 d.14, effective 1/2/2001. See: 32 New Jersey Register 3940(a), 33 New Jersey Register 66(a).

Notes N.J. Admin. Code § 10:60-1.12 Recodified to N.J.A.C. 10:60-1.5 by R.2001 d.14, effective 1/2/2001. See: 32 New Jersey Register 3940(a), 33 New Jersey Register 66(a).

Notes N.J. Admin. Code § 10:60-1.13 Repealed by R.2001 d.14, effective 1/2/2001. See: 32 New Jersey Register 3940(a), 33 New Jersey Register 66(a). Section was "Eligibility for early and periodic screening and diagnosis and treatment/Private duty nursing services".

Notes N.J. Admin. Code § 10:60-1.14 Recodified to N.J.A.C. 10:60-1.6 by R.2001 d.14, effective 1/2/2001. See: 32 New Jersey Register 3940(a), 33 New Jersey Register 66(a).