New Jersey Administrative Code

(a) Each independent clinic, including each satellite, shall be individually approved by the New Jersey Medicaid and NJ FamilyCare fee-for-service programs and enrolled with the Division's fiscal agent, for approved service(s). If a clinic wishes to add a service(s), approval fro…

(a) In addition to N.J.A.C. 10:49-6.1, this section outlines prior authorization (PA) requirements for dental, mental health, substance use disorder, and vision care services, as specified in (b), (c), and (d) below. Prior authorization as specified in N.J.A.C. 10:49-6.2 shall be…

(a) Except as indicated at (c) through (e) below, reimbursement to independent clinics is in accordance with the maximum fee schedule indicated at N.J.A.C. 10:66-6.2 and is based on the same fees, conditions, and definitions for corresponding services governing the reimbursement …

(a) An individual record shall be prepared and retained by an independent clinic that fully discloses the kind and extent of the service provided to a Medicaid or NJ FamilyCare fee-for-service beneficiary, as well as the medical necessity for the service. (b) At a minimum, a bene…

(a) General policies regarding the collection of personal contribution to care for NJ FamilyCare-Plan C and copayments for NJ FamilyCare-Plan D fee-for-service 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 a visit…

(a) For pharmacy claims that exceed Prospective Drug Utilization Review (PDUR) standards recommended by the New Jersey DUR Board and approved by the Commissioners of DHS and DOH, the Division of Medical Assistance and Health Services has established a Medical Exception Process (M…

This subchapter describes the New Jersey Medicaid and NJ FamilyCare fee-for-service programs' policies and procedures for the provision of Medicaid-covered and NJ FamilyCare fee-for-service covered services in an independent clinic setting. Services, as described in N.J.A.C. 10:4…

(a) For covered pharmaceutical services, see the New Jersey Medicaid and NJ FamilyCare fee-for-service program's Pharmaceutical Services chapter, N.J.A.C. 10:51. (b) For specific requirements for the provision of pharmaceutical services in independent clinics, in addition to thos…

(a) Podiatric services that are medically necessary are Medicaid and NJ FamilyCare fee-for-service reimbursable when performed by a licensed podiatrist in an independent clinic which is specifically approved to perform such services by the New Jersey Medicaid and NJ FamilyCare fe…

Specified radiological services may be reimbursed when provided in a clinic that is specifically approved to provide such services by the New Jersey Department of Environmental Protection, Radiation Protection Element, and performed by or under the direction of a physician who is…

(a) Rehabilitative services, as provided in an independent clinic setting, include physical therapy, occupational therapy, speech-language pathology and audiology, including the use of such supplies and equipment as are necessary in the provision of such services. Rehabilitative …

An independent clinic providing renal dialysis service for end-stage renal disease (ESRD) shall comply with all applicable Federal regulations and State rules in accordance with N.J.A.C. 8:43A. Notes N.J. Admin. Code § 10:66-2.14 New Rule, R.1998 d.577, effective 12/7/1998. See: …

(a) Sterilization is any medical procedure, treatment, or operation performed for the purpose of rendering an individual permanently incapable of reproducing. 1. The individual to be sterilized shall be at least 21 years of age at the time the sterilization consent form is signed…

(a) Termination of pregnancy is a Medicaid and NJ FamilyCare fee-for-service-covered service when the following conditions are present: 1. The procedure is performed in an appropriately licensed ambulatory care facility, an ambulatory surgical center, or an ambulatory care/family…

(a) Transportation services shall be covered under the Medicaid and NJ FamilyCare-Plan A, B, C, and D programs and the Alternate Benefit Program (ABP) when the following conditions are met: 1. The clinic is approved to provide transportation service by the Division to partial car…

Vision care services are reimbursable when administered by a licensed ophthalmologist or optometrist as indicated in the New Jersey Medicaid and NJ FamilyCare fee-for-service programs' Vision Care Services chapter, N.J.A.C. 10:62. See the New Jersey Medicaid and NJ FamilyCare fee…

Notes N.J. Admin. Code § 10:66-2.19 Reserved by 49 N.J.R. 1405(a), effective 6/5/2017

(a) All diagnostic, preventive or corrective dental procedures shall be administered by, or under, the direct supervision of a dentist enrolled in the New Jersey Medicaid and NJ FamilyCare fee-for-service program. (b) Dental services provided in an independent clinic shall follow…

(a) The 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--Plan A services. The vaccines covered under the VFC program may also be provided to any child w…

(a) Substance use disorder treatment services provided in independent clinics include: substance use disorder outpatient rehabilitative services; substance use disorder intensive outpatient (IOP) services; substance use disorder partial care services; non-hospital based withdrawa…

(a) The early and periodic screening, diagnostic and treatment (EPSDT) services program is a Federally mandated comprehensive child health program for Medicaid and NJ FamilyCare fee-for-service beneficiaries from birth through 20 years of age. (See 42 CFR 441 Subpart B.) (b) EPSD…

(a) Family planning services include medical history and physical examination (including pelvis and breast), diagnostic and laboratory tests, drugs and biologicals, medical supplies and devices, counseling, continued medical supervision, continuity of care, and genetic counseling…

(a) As required by the Clinical Laboratory Improvement Amendments of 1988 (CLIA), referenced at 42 CFR 493, all facilities or entities that perform clinical laboratory testing shall have their CLIA identification number on file with the New Jersey Medicaid and NJ FamilyCare fee-f…

(a) Mental health services shall include comprehensive intake evaluation, individual psychotherapy, off-site crisis intervention, family therapy, family conference, group psychotherapy, psychological testing, partial care, and medication management. Mental health services shall n…

Notes N.J. Admin. Code § 10:66-2.8 New Rule, R.1998 d.577, effective 12/7/1998. See: 30 New Jersey Register 3434(a), 30 New Jersey Register 4225(b). Former N.J.A.C. 10:66-2.8, Miscellaneous, recodified to N.J.A.C. 10:66-2.19. Repealed by R.2004 d.208, effective 6/7/2004. See: 36 …

Other services, such as evaluation and management (E/M), and minor surgery are reimbursable when billed by an independent clinic individually approved to provide the service(s) as indicated at N.J.A.C. 10:66-1.3, Provisions for provider participation. See N.J.A.C. 10:66-6 (HCPCS)…

(a) The purpose of HealthStart is to provide for comprehensive maternity care services to pregnant Medicaid and NJ FamilyCare fee-for-service beneficiaries, including those determined to be presumptively eligible, and preventive child health care services for Medicaid beneficiari…

(a) All HealthStart comprehensive maternity care services shall be delivered through a team approach by qualified professionals. (b) Physicians and/or certified nurse midwives shall be Medicaid and NJ FamilyCare fee-for-service providers and have obstetrical admitting privileges …

(a) HealthStart maternity care providers shall have policies which protect patient confidentiality, provide for informed consent, and document prenatal, labor, delivery and postpartum services in accordance with N.J.A.C. 10:54-6. (b) An individual record shall be maintained for e…

(a) Pediatric care services shall be comprehensive, integrated and coordinated. (b) HealthStart pediatric care providers shall: 1. Directly provide preventive child health care, maintenance of complete patient history, outreach for preventive care, initiation of referrals for app…

(a) All HealthStart pediatric care providers shall be pediatricians 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, the American Osteopathic Board of Pedia…

(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 Guidelines for HealthStart Pediatric Care. The schedule shall include …

(a) 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 nutritional services. 1. This may include, but is no…

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

(a) HealthStart maternity care services provided by a HealthStart-certified provider are obstetrical care services provided in accordance with the recommendations of the American College of Obstetricians and Gynecologists and a program of support services provided in accordance w…

(a) The following Medicaid-enrolled and NJ FamilyCare fee-for-service-enrolled provider types are eligible to participate as HealthStart providers: independent clinics, hospital outpatient departments, local health departments, physician groups, and certified nurse midwives meeti…

(a) The New Jersey State Department of Health shall 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. (b) Failure to comply…

(a) Comprehensive maternity care services must be integrated and coordinated. (b) HealthStart maternity care providers, excluding physicians and nurse midwives who are in private practice, shall provide comprehensive maternity care services within the following organizational req…

(a) All HealthStart services shall be accessible to patients. (b) HealthStart maternity care providers shall facilitate patient access to services by scheduling an initial medical visit appointment within two weeks of the patient's first request for services. (c) HealthStart mate…

(a) A care plan shall be developed and maintained by the case coordinator for each patient. (b) A care plan shall be based on the medical, nutritional, social-psychological and health education assessments. (c) A care plan shall include, but not be limited to: identification of r…

(a) Maternity medical care services include antepartum, intrapartum and postpartum care provided by the obstetrical care practitioner(s) in accordance with N.J.A.C. 10:54-6. (b) Prenatal services are as follows: 1. Frequency of prenatal visits for an uncomplicated pregnancy shall…

(a) Case coordination services shall facilitate the delivery of continuous, coordinated and comprehensive services for each patient in accordance with N.J.A.C. 10:54-6 as follows: 1. A permanent case coordinator shall be assigned to each patient no later than two weeks after the …

(a) Federally qualified health center (FQHC) services are services provided by physicians, physician assistants, advanced practice nurses, nurse midwives, psychologists, dentists, clinical social workers, and services and supplies incident to such services as would otherwise be c…

(a) An inpatient hospital visit performed by a clinic physician for a registered Medicaid or NJ FamilyCare fee-for-service patient of a Federally qualified health center shall be reimbursed only if the clinic is specifically approved to provide this service by the programs.1. For…

(a) The audited financial statement of a Federally qualified health center shall be: 1. Conducted by one of the following: i. A licensed certified public accountant or persons working for a licensed certified public accounting firm; or ii. A public accountant licensed on or befor…

(a) Medicaid and NJ FamilyCare fee-for-service covered procedures in an ambulatory surgical center (ASC) are those surgical and medical procedures that appear at 42 CFR 416.166, the Federal regulations governing ASC services. (b) Medicaid-covered and NJ FamilyCare fee-for-service…

(a) If a covered surgical procedure requires anesthesia, the anesthesia shall be: 1. Local or regional anesthesia; or 2. General anesthesia of 90 minutes or less duration. Notes N.J. Admin. Code § 10:66-5.2 Amended by R.1998 d.577, effective 12/7/1998. See: 30 New Jersey Register…

(a) Facility services include, but are not limited to: 1. Nursing services, services of technical personnel, and other related services; 2. The use by the patient of the ASC's facilities; 3. Drugs, biologicals, surgical dressings, supplies, splints, casts, appliances and equipmen…

(a) In addition to the requirements set forth at 42 CFR 416.47, medical records in an ASC shall include, but not be limited to: 1. Patient identification; 2. Significant medical history and results of physical examination; 3. Pre-operative diagnostic studies (entered before surge…

(a) The New Jersey Medicaid and NJ FamilyCare fee-for-service programs utilize the Centers for Medicare & Medicaid Services (CMS)'s Healthcare Common Procedure Code System (HCPCS) for 2009, established and maintained by CMS in accordance with the Health Insurance Portability and …