New Jersey Administrative Code

(a) The following shall not be considered covered services in the capitation rate, if provided: 1. All claims arising directly or indirectly from services provided by or in institutions owned or operated by the Federal government; 2. Elective cosmetic surgery; 3. Rest cures; 4. P…

All services, including, but not limited to, those listed in N.J.A.C. 10:74-3.9 and 3.10, shall be reported on encounters despite the limitations or exclusions, and the contractor shall document and verify that the services were provided. Notes N.J. Admin. Code § 10:74-3.11

(a) Each contractor shall demonstrate the availability and accessibility of institutional facilities and professional, allied and supporting paramedical personnel to perform the agreed-upon services. (b) Each contractor shall ensure that no distinctions will be made with regard t…

Notes N.J. Admin. Code § 10:74-3.13 Amended by R.1998 d.116, effective 1/30/1998 (operative February 1, 1998; to expire July 31, 1998). See: 30 N.J.R. 713(a). Adopted concurrent proposal, R.1998 d.426, effective 7/24/1998. See: 30 N.J.R. 713(a), 30 N.J.R. 3034(a). Readopted provi…

Notes N.J. Admin. Code § 10:74-3.14 Recodified from N.J.A.C. 10:74-3.5 and amended by R.2006 d.17, effective 1/3/2006. See: 37 N.J.R. 2787(a), 38 N.J.R. 294(d). Updated N.J.A.C. references. Recodified to N.J.A.C. 10:74-3.11 by R.2012 d.041, effective 2/21/2012. See: 43 N.J.R. 257…

Notes N.J. Admin. Code § 10:74-3.15 Amended by R.1998 d.116, effective 1/30/1998 (operative February 1, 1998; to expire July 31, 1998). See: 30 N.J.R. 713(a). Inserted references to NJ KidCare throughout. Adopted concurrent proposal, R.1998 d.426, effective 7/24/1998. See: 30 N.J…

(a) The contractor shall make available emergency services, as defined in N.J.A.C. 10:74-1, on a 24-hour-a-day, seven-day-a-week basis. (b) The contractor shall offer health education services as an integral part of its health care delivery system to its enrollees in order to ass…

(a) The MCO shall provide all services required by the managed care contract, including, but not limited to, the services listed in (a)1 through 29 below and at N.J.A.C. 10:49-5, for all Medicaid/NJ FamilyCare-Plans A, B, C, and D enrollees, with the exception of those services i…

(a) The following services shall be provided to Plans A, B, C, and D enrollees through the Medicaid/NJ FamilyCare fee-for-service program and may necessitate contractor assistance to the enrollee (such as, for example, providing medical orders) to access the services: 1. Personal…

(a) The following services shall be provided to Plans A, B, C, and D enrollees through the Medicaid/NJ FamilyCare fee-for-service program without requiring case management by the MCO: 1. Inpatient psychiatric hospital services for individuals under 21 and for individuals 65 years…

Notes N.J. Admin. Code § 10:74-3.6 Reserved by 51 N.J.R. 1359(a), effective 8/19/2019

Notes N.J. Admin. Code § 10:74-3.7 Reserved by 51 N.J.R. 1359(a), effective 8/19/2019

Notes N.J. Admin. Code § 10:74-3.8 Reserved by 51 N.J.R. 1359(a), effective 8/19/2019

(a) The following service requirements and limitations shall apply in the standard service package or capitation payments, even if provided by the MCO: 1. Although services of podiatrists shall be provided, New Jersey Medicaid/NJ FamilyCare does not ordinarily cover routine foot …

(a) The contractor shall obtain written approval from the Division prior to the commencement of marketing activities, regarding the form and content of the following: 1. Informational and instructional materials to be distributed to inform Medicaid/NJ FamilyCare enrollees of the …

(a) At such time as a Medicaid/NJ FamilyCare beneficiary signs an enrollment application of an MCO, the contractor shall inform the beneficiary that: 1. There is normally a minimum 30 to 45-day processing period between the date of application and the effective date of enrollment…

All managed care organizations providing services under the New Jersey Medicaid/NJ FamilyCare program shall be subject to the provisions of State and Federal statutes regarding advance directives, including, but not limited to, appropriate notification to enrolled beneficiaries o…

(a) Prior to implementation, the contractor shall obtain written approval from the Division of the method of enrollment and the enrollment forms to be used in enrolling Medicaid/NJ FamilyCare beneficiaries. The contractor shall adhere to the enrollment procedures required by the …

(a) Disenrollment shall occur: 1. Upon death or whenever the enrollee is no longer Medicaid/NJ FamilyCare eligible, unless otherwise specified in the contract; 2. Except for the aged, blind, or disabled populations, whenever the enrollee moves outside of the MCO's enrollment area…

Notes N.J. Admin. Code § 10:74-7.2 Amended by R.1998 d.116, effective 1/30/1998 (operative February 1, 1998; to expire July 31, 1998). See: 30 N.J.R. 713(a). In (c), inserted "Medicaid or NJ KidCare--Plan A" preceding "enrollee". Amended by R.1998 d.154, effective 2/27/1998 (oper…

Notes N.J. Admin. Code § 10:74-7.3 Repealed by R.2000 d.287, effective 7/3/2000. See: 32 New Jersey Register 1345(a), 32 New Jersey Register 2498(a). Section was "Disenrollment from a non-Federally Qualified HMO".

(a) Medicaid eligible persons and NJ FamilyCare-Plan A children who reside in geographically defined enrollment areas designated for mandatory enrollment and who are not institutionalized, excluded or exempt, and who belong to one of the eligibility categories listed at (b) below…

(a) The following persons shall be excluded from enrollment in the managed care program: 1. Individuals who are institutionalized in an inpatient psychiatric institution, a long term care nursing facility, or an inpatient psychiatric program for children under the age of 21 or in…

(a) The following individuals shall be excluded from the automatic assignment process but may enroll voluntarily: 1. Individuals whose Medicaid or NJ FamilyCare-Plan A eligibility will terminate within three months or less after the projected date of effective enrollment; 2. Indi…

Notes N.J. Admin. Code § 10:74-8.4 Reserved by 51 N.J.R. 1359(a), effective 8/19/2019

If the beneficiary needs Medicaid/NJ FamilyCare-Plan A covered services from the date of eligibility prior to the completion of the enrollment process, care shall be given by fee-for-service providers enrolled in the New Jersey Medicaid/NJ FamilyCare program. These providers shal…

(a) The MCO shall issue an identification card to the beneficiary indicating the effective enrollment date in the MCO. (b) Beneficiaries shall consult their primary care provider (PCP)/APN for necessary medical care and services. (c) The PCP/APN shall provide all necessary treatm…

(a) If a fee-for-service or managed care provider, whether or not a participant in a program administered in whole or in part by the Division of Medical Assistance and Health Services (DMAHS), renders a covered service to a beneficiary of a program administered in whole or in par…

(a) The contractor shall, on a 24-hour-a-day, seven-day-a-week basis, make available emergency services, that is, those services within or outside of the contractor's enrollment area, required to be provided to an enrollee as a result of an onset of a medical or behavioral condit…

(a) This chapter outlines the policies and procedures relevant to the provision of psychiatric residential treatment facility services to individuals under age 21 enrolled in Medicaid/NJ FamilyCare-Plan A. The rules of this chapter also apply to children/youth/young adults enroll…

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise: "Active treatment" means the implementation of a professionally developed and supervised plan of care that is developed and implemented no …

(a) A psychiatric residential treatment facility (PRTF) that is not licensed as a hospital, but meets the requirements in 42 CFR Part 441 Subpart D and 42 CFR Part 483 Subpart G, shall be eligible for participation in the New Jersey Medicaid/NJ FamilyCare program. (b) All PRTF pr…

(a) Medicaid/NJ FamilyCare beneficiaries under age 21, and those non-Medicaid/NJ FamilyCare-eligible children who are enrolled with the DCSOC who require PRTF services, shall be eligible to receive services in a psychiatric residential treatment facility (PRTF). (b) A Medicaid/NJ…

(a) PRTFs shall keep such legible individual records for each resident as are necessary to fully disclose the kind and extent of services provided, as well as the medical necessity for those services. This information shall be available upon the request of the DHS and/or DCF/DCSO…

(a) In the event of any serious occurrence, all PRTF providers shall report the occurrence to the appropriate authorities in accordance with 42 CFR 483.374(b) and (b) through (d) below. (b) All reports of serious occurrences shall include, at a minimum, the following information:…

(a) Reimbursable PRTF services under the Medicaid/NJ FamilyCare/DCF/DCSOC programs shall be those services determined to be medically necessary, using professionally developed criteria and standards of care, and shall be provided under the direction of a physician in a facility t…

(a) Prior to admission to the facility, PRTF services shall be certified in writing to be necessary, in accordance with 42 CFR 441.152. Certification of the need for services shall be made by an interdisciplinary team, composed of DCF/DCSOC, Care Management Organization (CMO), or…

(a) Authorization shall be required for all PRTF services rendered to children/youth/young adults who are enrolled with the DCF/DCSOC. The agency arranging for the child/youth/young adult's admission to the PRTF shall secure the authorization as indicated in (b) and (c) below, an…

(a) PRTF services shall include "active treatment" in accordance with 42 C.F.R. 441.154. Active treatment means the implementation of a professionally developed and supervised plan of care that is developed and implemented no later than 14 days after admission and designed to ach…

(a) Each resident's individual treatment plan shall be developed by a treatment team comprised of physicians and other personnel responsible for rendering services to the resident in the PRTF. See 42 C.F.R. 441.156. The team shall: 1. Assess the long and short term therapeutic ne…

In accordance with 42 C.F.R. 456.22, all Medicaid/NJ FamilyCare services shall have procedures that provide for review of each resident's need for the services. For the Utilization Review (UR), each PRTF shall perform on-going evaluations of the necessity and appropriateness of P…

(a) A provider may seek reimbursement for a resident's temporary absence from the facility due to a hospital leave or therapeutic leave for periods of up to 14 continuous days per episode. If the beneficiary is present in the facility for any part of the day, beginning and ending…

This subchapter describes the requirements of 42 CFR 483.350 through 483.376, related to the use of restraints and seclusion, as these requirements are applied to PRTF providers of Medicaid/NJ FamilyCare services. Notes N.J. Admin. Code § 10:75-3.1 Amended by 49 N.J.R. 101(a), ef…

(a) The facility shall notify the parent(s) or legal guardian(s) of the resident as soon as possible after the initiation of the intervention. (b) Documentation shall be included in the resident's file, and shall include, but shall not be limited to: 1. The name of the individual…

(a) Immediately after the drug or mechanical restraint or seclusion is over, for in-State facilities, a physician, an advance nurse practitioner, a registered nurse or a physician's assistant who is trained in the use of emergency safety interventions shall evaluate the physical …

(a) Staff shall immediately obtain medical treatment from qualified medical personnel for treatment of any injury sustained by any individual as a result of an emergency safety intervention. (b) The facility shall have affiliations or written transfer agreements in effect with th…

(a) As soon as reasonably possible, but no later than 24 hours after the incident, the staff members and beneficiaries involved in the incident shall have a face-to-face discussion. This discussion may include other staff members and/or the resident's legal guardians, as deemed a…

The following words and terms, as used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise: "Drug used as a restraint" means any drug that is administered to manage a resident's behavior in a way that reduces the safety risk to th…

(a) Restraint and seclusion shall be considered emergency safety interventions and shall be used in emergency situations solely to minimize or avoid the likelihood of harm to the residents or staff of the PRTF. (b) Restraint and seclusion shall never be ordered or used as a means…

(a) All residents shall be informed of all facility policies related to the use of restraint or seclusion upon admission to the facility. In the case of a resident who is under the age of 18, the resident's parent or legal guardian shall be informed of the policies. (b) The polic…