New Jersey Administrative Code

(a) Any provider of services shall meet Medicaid requirements and be enrolled as a Medicaid provider. Requirements regarding enrollment and provision of service are set forth in the appropriate chapters of the New Jersey Administrative Code. (b) The administrative requirements of…

(a) The Medicaid/NJ FamilyCare fiscal agent shall reimburse only those WFNJ/GA program covered services listed below in this subsection when provided in an ambulatory setting, except as specified in N.J.A.C. 10:49-24.4(a)14. These services include: 1. Advanced practice nurse serv…

(a) Consistent with N.J.A.C. 10:90-13.1(a)2, the following services shall not be processed by the fiscal agent: 1. Case management for early intervention services; 2. Early and periodic screening, diagnosis, and treatment (EPSDT) screenings, and any other EPSDT services needed to…

Except as noted under N.J.A.C. 10:49-24.3(a)16 ii, payment for services shall be based upon the Medicaid reimbursement methodology for the respective service. (See specific provider chapter(s) for reimbursement methodology and requirements.) According to the Paperwork Reduction A…

(a) Effective July 1, 2006, P.L. 2006, c. 45 and P.L. 2007, c. 111, as amended by P.L. 2007, c. 336, require the Division to institute a moratorium on new Medicaid/NJ FamilyCare providers of chiropractic services, medical supplies except those sold in a pharmacy, partial care ser…

(a) Providers shall complete a Provider Application and sign a Provider Agreement (see Appendix, N.J.A.C. 10:49) or a specialized agreement, and submit such other information or documentation, including, but not limited to, social security number and date of birth, as the program…

(a) All providers participating in the Medicaid or NJ FamilyCare program shall identify all locations from which they are providing services to Medicaid or NJ FamilyCare beneficiaries. (b) Each location shall comply with provider participation requirements and shall be assigned a…

(a) A seven digit Provider Billing Number shall be assigned by the fiscal agent to all providers approved for participation. The Provider Billing Number shall be entered upon all claims submitted in accordance with the instructions in the Fiscal Agent Billing Supplement. The Prov…

(a) Any potential provider that is licensed or certified by the State of New Jersey as one of the provider types listed at N.J.A.C. 10:49-3.1(a), or that is licensed or certified as such by a comparable state agency in the state in which the potential provider is located, and tha…

The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise. "Discipline" means a branch of instruction or learning, such as medicine, dentistry, chiropractic, and so forth. "Patient" means anyone e…

(a) This subchapter shall apply to shared health care facilities as defined herein and to providers located in a specific health care facility. (b) This subchapter shall apply to purveyors, whether or not located in a building which houses a shared health care facility. (c) Nothi…

(a) No shared health care facility shall be operated under the program unless it has been registered with the Division. The Office of Quality Management and Program Integrity, PO Box 712, Mail Code #7, Trenton, New Jersey 08625-0712 is responsible for registration. 1. Providers w…

(a) The Division shall not enter into any agreement of Medicaid or NJ FamilyCare participation, nor shall any payment be made to any provider in a shared health care facility where the rental fee for the letting of space or supportive professional or clerical services to a provid…

(a) To ensure quality, continuity and proper coordination of medical care, each shared health care facility shall:1. Where feasible, designate an individual who, on a full-time basis, shall coordinate and manage the facility's activities; 2. Devise an appropriate means of insurin…

(a) The services listed in N.J.A.C. 10:49-5.2 are available to beneficiaries eligible for the regular New Jersey Medicaid or the NJ FamilyCare-Plan A programs. Services available to Medically Needy beneficiaries are listed in N.J.A.C. 10:49-5.3. The services listed in N.J.A.C. 10…

(a) The services listed below are available to beneficiaries eligible for NJ FamilyCare-Plan I, on a fee-for-service basis, when medically necessary: 1. Advanced practice nurse services; 2. Clinic services (services in an independent outpatient health care facility, other than a …

(a) The services listed below shall be provided under the managed care program: 1. Advanced practice nurse services; 2. Chiropractic services; 3. Clinic services in an independent outpatient health care facility, other than hospital, that provides Family Planning, Dental, Optomet…

(a) Regular Medicaid services are available to Medically Needy beneficiaries except for the following services, which are not available or are only available to certain eligible Medically Needy groups: Group A--pregnant women, Group B--needy children, and Group C--aged, blind and…

(a) Most legal aliens who entered the United States on or after August 22, 1996 are restricted in their entitlement to emergency services for five years from their date of entry. Undocumented aliens and temporarily documented aliens, that is visitors, workers, and students, are a…

(a) Listed below are some general services and items excluded from payment under the New Jersey Medicaid and NJ FamilyCare-Plan A program. There are additional specific exclusions and limitations detailed in the second chapter of each Provider Services Manual. Payment is not made…

(a) Except for the exceptions at N.J.A.C. 10:79-6.5, which concern services for newborns enrolling into NJ FamilyCare-Plan C, the services listed below are available to beneficiaries eligible for NJ FamilyCare-Plan B or C, through an HMO selected by the NJ FamilyCare-Plan B or C …

(a) Except as indicated at N.J.A.C. 10:79-2.5, which concerns services for newborns enrolling into NJ FamilyCare-Plan C and D, the services listed below are available to beneficiaries eligible for NJ FamilyCare-Plan D and Plan D for Adults, when medically necessary and provided t…

(a) Effective for dates of service on or after July 1, 2007, all beneficiaries previously covered under Plan H are covered under NJ FamilyCare Plan D. The information in (b) through (g) below applies only to claims for former NJ FamilyCare Plan H beneficiaries with dates of servi…

(a) General assistance-eligible individuals shall receive Plan G services, which shall be those services delineated at N.J.A.C. 10:49-24.3. (b) The mental health and mental health rehabilitation services listed below may be available to beneficiaries under 21 years of age who are…

(a) Under the Programs, payment for certain services shall require prior authorization except in an emergency. It is the responsibility of the provider to obtain prior authorization before furnishing or rendering a service. Specific instructions are detailed in the appropriate Pr…

(a) Any covered service that requires prior authorization as a prerequisite for reimbursement to New Jersey Medicaid providers shall also require prior authorization if it is to be provided in any other state. 1. Services which require prior authorization are described in the spe…

(a) The following information outlines the policies and regulations of the New Jersey Medicaid/NJ FamilyCare program that the provider shall adhere to when submitting a claim and requesting payment for services provided to a New Jersey Medicaid/NJ FamilyCare beneficiary. (To iden…

(a) A Medicaid claim is defined as a request for payment from the New Jersey Medicaid program for a Medicaid reimbursable service provided to a Medicaid recipient. 1. A Medicaid claim or any other provider claim submitted for payment from or through the Division of Medical Assist…

(a) Third-party liability (TPL) exists when any person, institution, corporation, insurance company, health insurer, self-insured plan, group health plan as defined in section 607(1) of the Federal Employee Retirement and Income Security Act of 1974, 29 U.S.C. § 1167(1), service …

(a) A "factor" means an individual or an organization, such as a collection agency or service bureau, that advances money to a provider for accounts receivable that the provider has assigned, sold or transferred to the individual organization for an added fee or deduction of a po…

(a) Payment may be made to a business agent, such as a billing service or an accounting firm, that furnishes statements and receives payment in the name of the provider if the agent's compensation for this service is: 1. Related to the cost of processing the billing; 2. Not relat…

(a) A charity care claim is defined as a request for the New Jersey charity care program to price the hospital services rendered and consider those services when determining the amount of the charity care component of the disproportionate share subsidies of the Health Care Trust …

The State of New Jersey uses a fiscal agent for the processing of Medicaid claims, the pricing of charity care claims, and payment to providers. Notes N.J. Admin. Code § 10:49-8.1 Amended by R.1997 d.520, effective 1/5/1998. See: 29 New Jersey Register 1006(a), 30 New Jersey Regi…

(a) The Fiscal Agency will process Medicaid claims daily and produce provider payments and associated Remittance Advice (RA) statements once each week. The RA is the provider's account statement and reflects the status of all Medicaid claims currently entered into the Medicaid Ma…

(a) If a claim is incorrectly paid, so that the provider receives an overpayment or underpayment, within 60 days of such receipt, the provider shall correctly adjust the claim by utilizing the web-based claims resolution process or another approved method of automated data exchan…

(a) Each provider or other entity receiving reimbursement from or through the Division, except those enrolled for a specified limited period of time pursuant to N.J.A.C. 10:49-3.5, will receive claims payment automatically as a direct deposit to the provider's or entity's checkin…

(a) After Medicaid checks are outstanding for a period of six months, a follow-up letter shall be sent to the payee. This procedure shall only apply to checks of $ 5.00 or more. (b) All Medicaid checks remaining outstanding after 12 months shall be cancelled in monthly lots rathe…

(a) Under NJ FamilyCare-Plan C, personal contribution to care in the amounts indicated below shall be collected by the provider for the services indicated below: 1. Outpatient hospital clinic services: $ 5.00 personal contribution to care for outpatient visits. No personal contri…

(a) When the Division, in accordance with 42 C.F.R. 455.23, receives reliable evidence of fraud or willful misrepresentation by a provider, including an HMO, as well as a practitioner or entity participating in an HMO's network (whether or not the HMO practitioner or entity is al…

The Division, in order to maintain the integrity of the programs it administers in whole or in part, strictly prohibits its employees, or representatives of its contractors, subcontractors or fiscal agents, from accepting gifts or gratuities of any kind and of any value from repr…

The New Jersey Medicaid and NJ FamilyCare programs shall employ methods to identify situations in which a question of fraud and/or abuse in the program may exist. The Division shall refer to law enforcement officials situations in which there is valid reason to suspect that fraud…

(a) All Medicaid and NJ FamilyCare-Plan A claimants and NJ FamilyCare Plan D parents with incomes up to 133 percent of the Federal poverty level shall be informed of the following, in writing, at the time of application and at the time of any action affecting their claim: 1. Of t…

(a) Pursuant to N.J.A.C. 10:49-10, Notices, Appeals, and Fair Hearings, providers, Medicaid beneficiaries and NJ FamilyCare-Plan A beneficiaries and NJ FamilyCare Plan D parents with incomes up to 133 percent of the Federal poverty level shall have the right to file for fair hear…

(a) The following words and terms, when used in this section, shall have the following meanings, unless the context clearly indicates otherwise. "Advance directive" means a written expression of a patient's preferences regarding the provision, withholding or withdrawal of a medic…

(a) For children in families with income at or below 150 percent of the Federal poverty limit, there shall be no premiums under NJ FamilyCare-Plan B. (b) For families with gross income above 150 percent and at or below 200 percent of the Federal poverty level (NJ FamilyCare Plan …

(a) There shall be a family limit on cost-sharing equal to 5 percent of household income for Plan C beneficiaries. (b) The cost-sharing limit shall be calculated annually starting with the date of initial enrollment of any children in the family or the annual reenrollment date. F…

Federal regulations require that services provided to any Medicaid beneficiary shall be given without discrimination on the basis of race, color, national origin, or handicap. Therefore, payments shall be limited to providers of service who are in compliance with the nondiscrimin…