New Jersey Administrative Code

(a) For persons of legal school age, when disputes arise relating to educational program issues, mediation pursuant to N.J.A.C. 6A:14-2.6 shall be available through the Office of Special Education Programs, Department of Education. (b) An appeal may be settled at any time by a se…

(a) Appeals of licensing actions relative to Division programs may be appealed under the Administrative Procedures Act as described at N.J.A.C. 1:1. (b) Appeals of licensing actions relative to Division programs shall be directed to the Department of Human Services, Office of Lic…

The following words and terms, when used in this chapter, shall have the meanings as defined in N.J.A.C. 1:1-2.1 or this section unless the context clearly indicates otherwise. "Administrative hearing" means a proceeding which is conducted by the Office of Administrative Law. "Ad…

(a) An initial appeal shall be made in writing to the Administrative Practice Office, Division of Developmental Disabilities, P.O. Box 726, Trenton, NJ 08625-0726. (b) Appeals of eligibility under N.J.A.C. 10:46-2 or specific offers of non-waiver-funded services shall be initiate…

(a) Except in emergencies, an appellant may request that the Assistant Commissioner defer the placement of an individual pending resolution of an administrative appeal, as set forth in N.J.A.C. 10:48-2, when the following circumstances apply: 1. The appeal is received verbally or…

(a) Appeals of the denial, suspension, reduction, or termination of waiver-funded services are contested. A fair hearing, as described in N.J.A.C. 10:49-10, shall be offered for appeals of waiver-funded services. The Division may also offer an alternate dispute resolution confere…

(a) Appeals of eligibility determinations under N.J.A.C. 10:46-2 and appeals of specific offers of non-waiver-funded placements shall be considered to be contested. (b) If the matter is determined to be contested, prior to transmittal to the OAL, a settlement conference, as descr…

(a) Appeals of non-waiver-funded services that are funded only by State funds and for which there are no statutory or regulatory rights of appeal shall be considered non-contested. (b) If the matter is determined to be non-contested, an informal conference, as described at N.J.A.…

(a) Informal conference requirements are as follows:1. An informal conference shall be scheduled by the Administrative Practice Office in response to a non-contested matter. The informal conference shall be scheduled no more than 30 working days from the date that a matter is det…

(a) For all issues not resolved at the informal conference, the appellant may submit a written request to the Assistant Commissioner for an administrative review. 1. A written request for an administrative review shall be made within 25 working days from the date on the written i…

(a) Administrative paper review requirements are as follows: 1. Each party shall submit written arguments supporting their position to the administrative review officer within 20 working-days of written notification of the paper review. Evidence may also be provided. 2. The Rules…

Notes N.J. Admin. Code § 10:48-4.4 Repealed by 46 N.J.R. 2364(a), effective 12/1/2014

(a) The appellant shall be notified in writing of a time and date of a settlement conference. (b) The settlement conference shall require a meeting of the parties unless both parties agree to a conference by telephone. 1. The settlement conference shall be chaired by a designee o…

(a) Alternate dispute resolution conference requirements are as follows: 1. An alternate dispute resolution conference shall be scheduled by the Administrative Practice Office. The alternate dispute resolution conference shall be scheduled no more than 30 working days from the da…

(a) Appeals of the denial, suspension, reduction, or termination of waiver services shall be heard in accordance with N.J.A.C. 10:49-10. (b) Such request for hearing shall be made in writing within 20 days from the date of the notice of the Division's action giving rise to said c…

(a) Those matters determined to be contested shall be referred to the Office of Administrative Law (OAL) for a hearing, in accordance with the Administrative Procedure Act at N.J.S.A. 52:14B-2(b) and the Uniform Administrative Procedure Rules, N.J.A.C. 1:1. (b) If the contested n…

Emergent relief shall be available as provided in N.J.A.C. 1:1-12.6. Notes N.J. Admin. Code § 10:48-8.1

(a) The Division of Medical Assistance and Health Services, under the Department of Human Services, is designated in accordance with 42 C.F.R. 412.30, as the single State agency for the administration of the New Jersey Medicaid program. Under the authority of N.J.S.A. 30:4D-1 et …

(a) Regarding the organization of the Division of Medical Assistance and Health Services, the Department of Human Services is the single State agency for receipt of Federal funds under Title XIX (Medicaid) and Title XXI (the State Children's Health Insurance Program (SCHIP)) of t…

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise. "Adult mental health rehabilitation services provided in/by community residence programs" means community residential mental health service…

(a) The Medicaid Fiscal Agent and the Division of Medical Assistance and Health Services maintain New Jersey Medicaid and NJ FamilyCare provider manuals. Each is designed for use by a specific type of provider that provides services to Medicaid and/or NJ FamilyCare beneficiaries.…

(a) Notwithstanding any other provision of N.J.A.C. 10:49 through 10:79A, and except as provided in (c) and (d) below, the New Jersey Medicaid/NJ FamilyCare program (including, but not limited to, the program's administration, reimbursement, payment, provider screening, provider …

Notes N.J. Admin. Code § 10:49-1.6 Recodified to N.J.A.C. 10:49-22.3 and amended by R.1997 d.354, effective 9/2/1997. See: 29 New Jersey Register 2512(a), 29 New Jersey Register 3856(a).

Notes N.J. Admin. Code § 10:49-1.7 Repealed by R.1997 d.354, effective 9/2/1997. See: 29 New Jersey Register 2512(a), 29 New Jersey Register 3856(a). Section was "State funded programs".

Notes N.J. Admin. Code § 10:49-1.8 Recodified to N.J.A.C. 10:49-1.4 and amended by R.1997 d.354, effective 9/2/1997. See: 29 New Jersey Register 2512(a), 29 New Jersey Register 3856(a).

The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise. "Applicant" means any person who has made application for purpose of becoming a "qualified applicant." "Claimant," when used within these…

Claimants shall receive a written final decision, in the name of the Department and shall be notified of their right to judicial review. Notes N.J. Admin. Code § 10:49-10.10

When the final hearing decision is favorable to claimants or when the Department decides in favor of claimants prior to the hearing, the Department shall make corrective payments retroactively to the date the incorrect action was taken or such earlier date as may be provided unde…

(a) A final decision by the Medicaid Agent's or DMAHS' head shall specify the reasons for the decision and identify the supporting evidence or may incorporate by reference the findings, conclusions, and recommendations, contained in the initial decision. (b) Final decisions shall…

The Medicaid Agent or DMAHS shall establish and maintain a method for informing, at least in summary form, all local agencies of all fair hearing decisions by the hearing authority and the decisions shall be accessible to the public (subject to the provisions of safeguarding publ…

(a) The New Jersey Medicaid or NJ FamilyCare program may print a notice of prospective policy changes affecting Medicaid or NJ FamilyCare beneficiaries or providers generally in one or more newspapers in New Jersey. 1. This public notice will be accompanied by a proposed rulemaki…

(a) An opportunity for a fair hearing may be granted to any provider requesting a hearing on any valid complaint or issue arising out of the Medicaid or NJ FamilyCare claims payment process, exclusive of HMO claims processing or HMO-provider contract issues: 1. Such issues shall …

(a) In cases of any proposed action to terminate, reduce or suspend assistance, the Medicaid Agent or DMAHS shall give the claimant timely and adequate notice detailing the reasons for the proposed action. Under these requirements: 1. "Timely" means that the notice is dated at le…

The hearing shall be conducted at a reasonable time, date and place after adequate written notice of the hearing is given. Notes N.J. Admin. Code § 10:49-10.5

The hearing shall be conducted by an Administrative Law Judge from the Office of Administrative Law or by other persons eligible to conduct hearings pursuant to the New Jersey Administrative Procedure Act, set forth in N.J.S.A. 52:14B-1 et seq. and 52:14F-1 et seq. Notes N.J. Adm…

When the hearing involves medical issues, such as those concerning a diagnosis or an examining physician's report or the medical review team's decision, and if the hearing officer considers it necessary to have a medical assessment other than that of the person or persons involve…

The hearing shall be conducted pursuant to the procedures set forth in the Administrative Procedure Act and the Uniform Administrative Procedure Rules (N.J.A.C. 1:1). The Special Hearing Rules set forth in N.J.A.C. 1:10B apply to claimant (beneficiary) hearings. (See 42 C.F.R. 43…

Prompt, definitive and final administrative action shall be taken within 90 days from the date of the request for a fair hearing, except where claimant requests an adjournment. Notes N.J. Admin. Code § 10:49-10.9

(a) The provisions of this section were adopted and issued pursuant to Executive Order No. 34, dated March 29, 1976, and the authority vested in the Division of Medical Assistance and Health Services to implement the New Jersey Medicaid and NJ FamilyCare programs by rules and reg…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise: "Committee" means the Provider Reinstatement Committee. "Person" means any natural person, company, firm, corporation, professional asso…

Persons who have been debarred, disqualified or suspended from participating in the New Jersey Medicaid or the NJ FamilyCare program shall petition the Director for reinstatement in writing. Notes N.J. Admin. Code § 10:49-12.2 Amended by R.1997 d.354, effective 9/2/1997. See: 29 …

(a) Persons debarred or disqualified for a definitely stated period of time may petition the Director for reinstatement 90 days prior to the expiration of the period of debarment or disqualification. (b) Persons disqualified for an indefinitely stated period of time may petition …

The Director may on his or her own motion order the reinstatement of debarred, disqualified or suspended persons or may refer the matter to the Provider Reinstatement Committee. Notes N.J. Admin. Code § 10:49-12.4

(a) The Provider Reinstatement Committee shall be a non-standing committee that is convened for the purpose of evaluating requests for reinstatement. 1. The Committee shall be composed of three impartial officials of the New Jersey Medicaid or the NJ FamilyCare program appointed …

(a) Reinstatement will not be granted unless it is reasonably certain that the causes which led to the debarment, disqualification or suspension shall not be repeated. In determining a person's fitness for reinstatement, the Committee and the Director may consider, among other fa…

(a) The Committee shall meet at the Division's central offices. (b) Persons requesting reinstatement and/or their representative shall be notified, in writing, as to the time, date and place of the meeting. (c) All correspondence concerning the meeting shall be directed to the Ch…

Under the provisions of Federal and State law, the Medicaid Agent or DMAHS shall provide continuing review and evaluation of the care and services provided under the Medicaid and NJ FamilyCare programs. This includes review of utilization of services of practitioners and other pr…