New Jersey Administrative Code

(a) MLTSS/private duty nursing is available only to a beneficiary who meets nursing facility level of care criteria (see N.J.A.C. 10:60-6.2), is based on medical necessity, and is prior approved by the NJ FamilyCare MCO in a plan of care prepared by a MLTSS care manager. Private …

(a) MLTSS/PDN services shall be provided in the community only and not in an inpatient hospital or nursing facility setting. Services shall be provided by a registered nurse (RN) or a licensed practical nurse (LPN). 1. Private duty nursing services rendered during hours when the …

(a) Managed long-term services and supports (MLTSS) under the New Jersey 1115 Comprehensive Medicaid Waiver expands existing managed care programs to include managed long-term care services and supports and expands home and community-based services. The purpose of MLTSS is to inc…

(a) Individuals qualify for MLTSS by meeting established Medicaid financial requirements and Medicaid clinical and age and/or disability requirements for nursing facility services contained in N.J.A.C. 10:69, 70, 71, or 72. 1. For children who meet the nursing home level of care,…

Notes N.J. Admin. Code § 10:60-7.1 Reserved by 50 N.J.R. 1992(b), effective 9/17/2018

Notes N.J. Admin. Code § 10:60-7.2 Reserved by 50 N.J.R. 1992(b), effective 9/17/2018

Notes N.J. Admin. Code § 10:60-7.3 Reserved by 50 N.J.R. 1992(b), effective 9/17/2018

Notes N.J. Admin. Code § 10:60-7.4 Reserved by 50 N.J.R. 1992(b), effective 9/17/2018

Notes N.J. Admin. Code § 10:60-7.5 Reserved by 50 N.J.R. 1992(b), effective 9/17/2018

Notes N.J. Admin. Code § 10:60-7.6 Reserved by 50 N.J.R. 1992(b), effective 9/17/2018

Notes N.J. Admin. Code § 10:60-8.1 Reserved by 50 N.J.R. 1992(b), effective 9/17/2018

Notes N.J. Admin. Code § 10:60-8.2 Reserved by 50 N.J.R. 1992(b), effective 9/17/2018

Notes N.J. Admin. Code § 10:60-8.3 Reserved by 50 N.J.R. 1992(b), effective 9/17/2018

Notes N.J. Admin. Code § 10:60-8.4 Reserved by 50 N.J.R. 1992(b), effective 9/17/2018

Notes N.J. Admin. Code § 10:60-8.5 Reserved by 50 N.J.R. 1992(b), effective 9/17/2018

Notes N.J. Admin. Code § 10:60-9.1 Reserved by 50 N.J.R. 1992(b), effective 9/17/2018

Notes N.J. Admin. Code § 10:60-9.2 Reserved by 50 N.J.R. 1992(b), effective 9/17/2018

Notes N.J. Admin. Code § 10:60-9.3 Reserved by 50 N.J.R. 1992(b), effective 9/17/2018

Notes N.J. Admin. Code § 10:60-9.4 Reserved by 50 N.J.R. 1992(b), effective 9/17/2018

Notes N.J. Admin. Code § 10:60-9.5 Reserved by 50 N.J.R. 1992(b), effective 9/17/2018

Notes N.J. Admin. Code § 10:60-9.6 Reserved by 50 N.J.R. 1992(b), effective 9/17/2018

Notes N.J. Admin. Code § 10:60-9.7 Reserved by 50 N.J.R. 1992(b), effective 9/17/2018

Notes N.J. Admin. Code § 10:60-9.8 Reserved by 50 N.J.R. 1992(b), effective 9/17/2018

This chapter outlines the policies and procedures for coverage of clinical laboratory services that must be met in order to qualify for reimbursement under the Medicaid/NJ FamilyCare fee-for-service programs. The services of a qualified clinical laboratory for which reimbursement…

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise: "Automated multichannel tests" means laboratory tests which can be and are frequently performed as groups and combinations (profiles) on au…

Each laboratory shall provide the New Jersey Health Services Program, Office of Utilization Management, Mail Code #33, PO Box 712, Trenton, New Jersey 08625-0712, with a listing of tests, including panels and profiles actually performed on its premises (address to be identified) …

(a) To qualify for participation as a clinical laboratory under the Medicaid/NJ FamilyCare program, the following requirements must be met: 1. Licensure and/or approval by the New Jersey State Department of Health or comparable agency in the state in which the facility is located…

(a) Upon approval as an independent laboratory provider for Title XIX Medicaid participation and reimbursement, the requirements for independent laboratory services under the Title XVIII Medicare program shall be followed. (b) A laboratory approved for Medicaid/NJ FamilyCare part…

(a) All orders for clinical laboratory services shall be in the form of an explicit order personally signed by the physician or other licensed practitioner requesting the services, or be in an alternative form of order specifically authorized in (b)1 through 3 below. The written …

Reimbursement shall be on the basis of the lowest professional charge, not to exceed an allowance determined reasonable by the Commissioner of Human Services, and further limited by Federal policy relative to payment of clinical laboratory services. The maximum fee schedule (allo…

(a) All independent clinical laboratories and other entities providing clinical laboratory services to Medicaid/NJ FamilyCare beneficiaries must meet the requirements of the Clinical Laboratory Improvement Amendments (CLIA) of 1988. These requirements include that the provider mu…

(a) The sum of any number of the components of a battery of tests shall not exceed the total charged for the group offering (panel or profile), whether done by automation or bench testing, whether or not the equipment is available in the facility. A battery of tests is considered…

(a) Tests performed by a non-approved laboratory are not reimbursable. The referring laboratory shall verify approved status. (b) Additional payment will not be made to a laboratory for obtaining specimens, except when performed in a long-term care facility, boarding home, or hom…

Rebates by reference laboratories, service laboratories, physicians or other utilizers or providers of laboratory service are prohibited under the Medicaid/NJ FamilyCare program. Rebates shall include refunds, discounts or kickbacks, whether in the form of money, supplies, equipm…

(a) The Medicaid/NJ FamilyCare program uses the Centers for Medicare & Medicaid Services (CMS) Healthcare Common Procedure Coding System (HCPCS), for 2006, established and maintained by CMS in accordance with the Health Insurance Portability and Accountability Act, of 1996, 42 U.…

Click here to view image. Notes N.J. Admin. Code § 10:61-3.2 Amended by R.2001 d.79, effective 3/5/2001. See: 32 New Jersey Register 4167(a), 33 New Jersey Register 781(c). Rewrote the section. Amended by R.2002 d.323, effective 10/7/2002. See: 34 New Jersey Register 959(a), 34 N…

Click here to view image. Notes N.J. Admin. Code § 10:61-3.3 Amended by R.2001 d.79, effective 3/5/2001. See: 32 New Jersey Register 4167(a), 33 New Jersey Register 781(c). Rewrote the section. Amended by R.2003 d.15, effective 1/6/2003. See: 34 New Jersey Register 2676(a), 35 Ne…

Click here to view image. Notes N.J. Admin. Code § 10:61-3.4 Amended by R.2006 d.37, effective 1/17/2006. See: 37 New Jersey Register 3182(a), 38 New Jersey Register 807(a). Rewrote the section.

(a) Qualifiers for pathology and laboratory services are summarized below: 1. Codes 80048, 80050, 80051, 80053, 80055, 80061, 80069, 80074, 80076. The panels listed must include the laboratory tests assigned by the CPT as the components of the panel. The tests listed with each of…

This subchapter delineates the New Jersey Medicaid/NJ FamilyCare fee-for-service programs' standards for examinations and care for vision defects and/or eye diseases for the purpose of maintaining or improving the health of New Jersey Medicaid/NJ FamilyCare fee-for-service benefi…

Notes N.J. Admin. Code § 10:62-1.10 Reserved by 49 N.J.R. 2279(b), effective 7/17/2017

(a) When a physician sees the patient in the emergency room instead of the practitioner's office, the physician shall use the same HCPCS for the visit that would have been used if seen in the physician's office: 99211, 99212, 99213, 99214 or 99215 only. Records of that visit shal…

(a) To qualify as documentation that the service was rendered by the practitioner during an inpatient stay, the beneficiary's medical record must contain the practitioner's notes indicating that the practitioner personally: 1. Reviewed the beneficiary's medical history with the b…

(a) A consultation shall be eligible for reimbursement only when the consultation has been performed by a specialist recognized as such by the Medicaid/NJ FamilyCare programs, the request has been made by or through the patient's attending physician, and the need for such a reque…

(a) The home visit HCPCS 99344 and 99353 shall not apply to residential health care facility or nursing facility settings. These HCPCS refer to a physician visit limited to the provision of medical care to an individual who would be too ill to go to a physician's office and/or is…

HCPCS 99082 may be used for travel costs only associated and billed with Home Visit. (See codes 99341, 99342 and 99344.) Notes N.J. Admin. Code § 10:62-1.15 New Rule, R.1999 d.4, effective 1/4/1999. See: 30 New Jersey Register 3899(a), 31 New Jersey Register 61(a). Amended by R.2…

(a) Form FD-358 (Request for Prior Authorization for Vision Care Services) shall be used to request prior authorization for professional services. Instructions for completing the form are provided in the Fiscal Agent Billing Supplement. The completed form, clearly indicating the …