New Jersey Administrative Code

(a) Upon request, a beneficiary must be provided with his or her prescription for an optical appliance. The following information shall be indicated on the prescription: name, address, New Jersey Medicaid/NJ FamilyCare fee-for-service Identification Number, date of examination, a…

(a) All covered pharmaceutical services provided by licensed professionals of vision care services under the New Jersey Medicaid/NJ FamilyCare fee-for-service programs shall be prescribed in accordance with the scope of their practice. (b) The Pharmaceutical Services manual, N.J.…

(a) (Reserved) (b) Clinical laboratory services are furnished by clinical laboratories and by physician office laboratories (POLs) that meet the CMS regulations pertaining to clinical laboratory services defined in the Clinical Laboratory Improvement Amendments (CLIA) of 1988, se…

The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise: "Clinical laboratory services" means professional and technical laboratory services performed by a clinical laboratory certified by CMS i…

(a) General policies regarding the collection of personal contribution to care for NJ FamilyCare-Plan C and copayments for NJ FamilyCare-Plan D services are set forth at N.J.A.C. 10:49-9. (b) Personal contribution to care for NJ FamilyCare-Plan C services is $ 5.00 per visit for …

(a) Providers 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. Data shall include such quantitative positive and negative findings as will be meaningful in …

(a) Instructions for submitting claims for payment of vision care services are provided in the Fiscal Agent Billing Supplement. (b) Vision care services shall be identified by means of procedure codes, utilizing the CMS Healthcare Common Procedure Coding System (HCPCS). The codes…

(a) Within the restrictions of their respective licensure, the following are eligible providers of eye care upon fulfilling the Enrollment Process requirements in N.J.A.C. 10:49-3.2: 1. Ophthalmologists or optometrists licensed in the State of New Jersey; 2. Ophthalmologists or o…

Professional services include office visits for evaluation and management, comprehensive eye examinations, low vision examinations, low vision work-ups, vision training work-ups, vision training program visits as well as other specific procedures as listed at N.J.A.C. 10:62-3.2. …

(a) A comprehensive eye examination may include cycloplegics and a post cycloplegic visit. All findings and data, including positive and negative, shall be clearly recorded. A comprehensive eye examination shall include the following, as a minimum, where possible unless contraind…

Notes N.J. Admin. Code § 10:62-1.6 Reserved by 49 N.J.R. 2279(b), effective 7/17/2017

For purposes of the New Jersey Medicaid/NJ FamilyCare fee-for-service programs, a low vision work-up consists of certain testing techniques and procedures to determine what optical aids and devices can be prescribed for an individual to increase range of vision. A low vision work…

(a) For purposes of the New Jersey Medicaid/NJ FamilyCare fee-for-service programs, vision training is the use of certain procedures and modalities for the development of and/or increase in the vision capacity of the eye(s) with poor and/or inconsistent or distorted vision locali…

(a) HCPCS 99201, 99202, 99203, 99204, 99205, 99301, 99302, 99303, 99321, 99322 and 99323 are not reimbursable with 92002, 92004, 92012 or 92014 on the same day. (b) When multiple special ophthalmological services or ophthalmoscopic services are billed on the same day for the same…

This subchapter covers the provision of optical appliances necessary for the correction of any eye vision defects. Notes N.J. Admin. Code § 10:62-2.1 Amended by R.1994 d.6, effective 1/3/1994. See: 25 New Jersey Register 3907(a), 26 New Jersey Register 225(a).

(a) For purposes of the New Jersey Medicaid/NJ FamilyCare fee-for-service programs, an approved fabricating laboratory shall have the necessary equipment, licensed personnel and capability to completely surface and finish new optical glass or plastic lenses or partially finished …

(a) Providers 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, which are subject to post audit review. Such information shall be readily available to the re…

(a) Instructions for submitting claims for payment of optical appliances are provided in the Fiscal Agent Billing Supplement. (b) Optical appliances must be identified by means of procedure codes, utilizing the CMS Healthcare Common Procedure Coding System (HCPCS). The codes and …

The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise: "Ocularist" means a provider of artificial eyes. "Optical appliances" mean those items, devices or appliances prescribed by a practitione…

(a) Within the restrictions of their respective licensure, the following are eligible providers upon fulfilling the Enrollment Process requirements in N.J.A.C. 10:49-3.2: 1. Ophthalmologists as defined in N.J.A.C. 10:62-1.2; 2. Optometrists as defined in N.J.A.C. 10:62-1.2; 3. Op…

(a) The following optical appliances and related services are covered under the New Jersey Medicaid/NJ FamilyCare fee-for-service programs. In order to determine whether an optical appliance or related service requires prior authorization, and for details regarding such prior aut…

(a) Form MC-9(A) (Request for Authorization and Payment--Optical Appliances) shall be used for requesting prior authorization for optical appliances. Instructions for completing the form are provided in the Fiscal Agent Billing Supplement. The completed form clearly indicating th…

(a) Lenses shall be first quality ophthalmic lenses meeting the requirements published by American National Standard Institute (available from the American National Standards Institute, 25 W. 43rd St, 4th floor, New York, NY 10036, tel. 212-642-4900, website http://www.ansi.org/.…

(a) Plastic, nonflammable frames acceptable to the New Jersey Medicaid/NJ FamilyCare fee-for-service programs shall meet the following minimum criteria: 1. The manufacturer's name and the size of the frame shall be properly identifiable on the frame; 2. The temples shall be wire-…

All rights, benefits, and services applicable to a private paying patient shall apply to the same extent to the New Jersey Medicaid/NJ FamilyCare fee-for-service beneficiary. Notes N.J. Admin. Code § 10:62-2.8 Amended by 49 N.J.R. 2279(b), effective 7/17/2017

Artificial eyes and intraocular lenses, stock or custom-made, shall be of plastic material. Notes N.J. Admin. Code § 10:62-2.9

(a) The New Jersey Medicaid/NJ FamilyCare fee-for-service programs utilize the CMS Healthcare Common Procedure Coding System (HCPCS). HCPCS follows the American Medical Association's Physicians' Current Procedural Terminology (CPT) architecture, employing a five-position code and…

HCPCS Maximum Fee Ind Code Mod Allowance 65205 $ 16.00 65210 32.00 65220 32.00 65222 48.00 65430 16.00 66999 B.R. 67820 16.00 67850 42.00 67938 $ 30.00 67999 B.R. 68040 16.00 68399 B.R. 68761 30.00 68801 8.00 68840 14.13 68899 B.R. 76511 40.00 76511 26 18.00 76511 TC 22.00 76512 …

Notes N.J. Admin. Code § 10:62-3.3 Reserved by 49 N.J.R. 2279(b), effective 7/17/2017

(a) Qualifiers for professional vision care services are summarized below: HCPCS Procedure Codes 1. COMPREHENSIVE EYE EXAMINATION 92002 Comprehensive Eye Examination--Refers to a 92004 new or established patient. 92012 92014 2. COMPREHENSIVE EYE EXAMINATION WITH DIAGNOSTIC FIELDS…

Click here to view image Click here to view image Click here to view image Click here to view image Click here to view image Notes N.J. Admin. Code § 10:62-3.5 Amended by R.1999 d.4, effective 1/4/1999. See: 30 N.J.R. 3899(a), 31 N.J.R. 61(a). In (b), substituted a reference to p…

(a) This chapter is concerned only with hearing aids for eligible beneficiaries of the New Jersey Medicaid/NJ FamilyCare program. It is the intent of the program to furnish hearing aids and related services to eligible beneficiaries who can benefit from them. (b) When a hearing a…

The following words and terms, when used in this chapter, shall have the following meanings unless the content clearly indicates otherwise. "Audiologist" means an individual who has received the Certificate of Clinical Competence in Audiology (CCC-A) from the American Speech-Lang…

(a) In order to participate in the Medicaid/NJ FamilyCare program as a hearing aid provider, the dispenser shall apply to and be approved by the New Jersey Medicaid/NJ FamilyCare program. Application for approval by the New Jersey Medicaid/NJ FamilyCare program as a hearing aid p…

(a) The hearing aid provider, in any and all settings, shall keep legible individual records as are necessary to fully disclose the kind and extent of service(s) provided, the HCPCS procedure code being billed, and proof of medical necessity for those services. (b) Documentation …

(a) Reimbursement for a new hearing aid shall be the lower of the following charges: 1. The provider's usual and customary charges; or 2. A charge consisting of the following: i. Wholesale cost of the instrument; plus ii. Wholesale cost of the earmold, as per laboratory invoice o…

(a) An otologic examination and a hearing aid examination shall be performed prior to prescribing a hearing aid. The physician or advanced practice nurse performing the medical examination of the Medicaid/NJ FamilyCare eligible beneficiary shall determine if an audiological exami…

(a) Coverage of hearing aid devices in a nursing facility shall be based on the requirements of hearing aid candidacy described under N.J.A.C. 10:64-2.1(b) and 2.5. (b) A medical examination of a beneficiary's ear may be performed by an otologist or beneficiary's attending physic…

(a) Delivery of the hearing aid shall be made to the beneficiary within 21 days of receipt of an original prescription for such services. (b) When the new hearing aid is delivered the provider shall: 1. Supply the new instrument; 2. Supply a custom-fitted earmold; 3. Supply tubin…

(a) When the hearing aid is dispensed the provider shall: 1. Guarantee that all instruments and earmolds provided conform to the prescription as set forth in Form FD-36, Section C, Audiologic and Hearing Aid Examinations and fit comfortably and adequately to the extent that the b…

(a) The original hearing aid shall be replaced by a provider only under the following conditions: 1. The aid is lost or stolen or broken. There shall be reasonable expectation that a replacement aid is not likely to be lost, stolen or broken; 2. The aid is malfunctioning and the …

For beneficiaries other than nursing home residents, follow-up shall consist of counseling and testing in the sound field by an audiologist, otologist, or hearing aid dispenser within 21 days of the date the aid was provided to evaluate the adequacy, performance, and utilization …

(a) A signed and dated prescription is not required for the following hearing aid services: 1. Hearing aid repairs; 2. Replacement earmolds; 3. Replacement batteries; and 4. Replacement cords, receivers, and garment bags. Notes N.J. Admin. Code § 10:64-2.7

(a) The audiological examination and hearing aid testing shall be performed in an environment that meets standards published by the American National Standards Institute as ANSI S3.1-1991 Maximum Permissible Ambient Noise for Audiometric Test Rooms, incorporated herein by referen…

(a) The New Jersey Medicaid/NJ FamilyCare program uses 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 1996…

HCPCS Maximum Fee IND Codes Mod Description Allowance $ V5030 Hearing Aid, Monaural, Body B.R. Worn, Air Conduction V5040 Hearing Aid, Monaural, Body B.R. Worn, Bone Conduction V5050 Hearing Aid, Monaural, In The Ear B.R. V5060 Hearing Aid, Monaural, Behind The Ear B.R. V5070 Gla…

HCPCS Maximum Fee IND Code Mod Description Allowance $ V5050 52 Returned Hearing Aid 30.00 V5014 Hearing Aid Repair, Laboratory Invoice B.R. Cost N V5014 52 Hearing Aid Repair, Dispenser's Service B.R. Fee V5265 Earmold, Laboratory Invoice Cost B.R. V5265 52 Earmold, Dispenser's …

(a) The following is a list of HCPCS procedure codes with associated qualifiers. Providers shall recognize the requirements inherent in billing each of the HCPCS. V5014 52 The repair charges are broken down into the laboratory costs and the dispenser's service fees. This code wil…

(a) This chapter describes the policies and procedures of the New Jersey Medicaid and NJ FamilyCare fee-for-service programs pertaining to the provision of, and reimbursement for, medically necessary services in an independent clinic setting. The term independent clinic includes,…

The following words and terms, when used in this chapter, shall have the following meanings, unless the context indicates otherwise: "Ambulatory care facility" means a health care facility or a distinct part of a health care facility, licensed by the New Jersey State Department o…