reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 1 - EYE CARE: PROFESSIONAL SERVICES › Section 10:62-1.21 - Recordkeeping policies

Current through Register Vol. 56, No. 14, July 15, 2024
(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 subsequent review. Check marks are not
				acceptable. The information shall be readily available to representatives of
				the New Jersey Medicaid/NJ FamilyCare fee-for-service programs, or their
				agents, as required.
(b) Records
				shall be kept and maintained by the provider for a period of at least five
				years from the date the service was rendered.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 1 - EYE CARE: PROFESSIONAL SERVICES › Section 10:62-1.22 - Reimbursement policies

Current through Register Vol. 56, No. 14, July 15, 2024
(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 and maximum fee allowance schedule are listed
				in N.J.A.C. 10:62-3.
(c) The
				provider shall use the practitioner's usual and customary charge when
				submitting a claim for vision care services. Reimbursement for covered services
				furnished under the New Jersey Medicaid/NJ FamilyCare fee-for-service programs
				shall be made on the basis of the provider's customary charge, not to exceed an
				allowance determined to be reasonable by the Commissioner of the Department of
				Human Services, and further limited by Federal policy ( 42 CFR 447 Subpart B)
				relative to payment of practitioners and other individual providers.
1. In no event shall the charge to the New
				Jersey Medicaid/NJ FamilyCare fee-for-service programs exceed the charge by the
				provider for identical services to other governmental agencies, private
				nonprofit agencies, trade unions or other individuals in the
				community.
2. If a beneficiary
				receives care from more than one member of a partnership or corporation in the
				same discipline for the same service, the maximum payment allowance shall be
				the same as that of a single provider. For purposes of reimbursement,
				optometrist and or physician, optometrist and physician groups, shared health
				care facility, or optometrist and physician sharing a common record shall be
				considered a single provider.
3.
				Reimbursement shall not be made for, and beneficiaries may not be asked to pay
				for, broken appointments.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 2 - OPTICAL APPLIANCES AND SERVICES › Section 10:62-2.1 - Scope

Current through Register Vol. 56, No. 14, July 15, 2024
This subchapter covers the provision of optical appliances
				  necessary for the correction of any eye vision defects.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 2 - OPTICAL APPLIANCES AND SERVICES › Section 10:62-2.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
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 practitioner in order to aid or improve vision, or to replace
				  the eye.
"Optician" means an individual licensed by the New Jersey
				  State Board of Examiners of Ophthalmic Dispensers and Ophthalmic Technicians,
				  or licensed to practice as an optician in the state in which he or she performs
				  such functions.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 2 - OPTICAL APPLIANCES AND SERVICES › Section 10:62-2.3 - Providers of optical appliances and other services

Current through Register Vol. 56, No. 14, July 15, 2024
(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
				10:62-1.2;
2. Optometrists as defined in
				10:62-1.2;
3. Opticians as defined in
				10:62-2.2;
4. Ocularists as defined in
				10:62-2.2;
5. Independent clinics approved by the New
				Jersey Medicaid/NJ FamilyCare fee-for-service programs to render eye care
				services;
6. Hospitals approved by
				the New Jersey Medicaid/NJ FamilyCare fee-for-service programs for
				participation; and
7.
				Ophthalmologists, optometrists or opticians in another state who are duly
				licensed or meet the requirements of their own state with regard to the
				dispensing of optical appliances within that state.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 2 - OPTICAL APPLIANCES AND SERVICES › Section 10:62-2.5 - Optical appliances and related services requiring prior authorization

Current through Register Vol. 56, No. 14, July 15, 2024
(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 the reasons for requesting the appliance
				requiring prior authorization must be submitted to the Vision Care Unit,
				Division of Medical Assistance and Health Services, Mail Code #16, PO Box 712,
				Trenton, New Jersey 08625-0712. When a request for authorization is approved or
				denied, the provider shall receive a letter of notification from the fiscal
				agent.
(b) Items requiring prior
				authorization should not be provided to the Medicaid or NJ FamilyCare
				fee-for-service beneficiary until the authorization is received by the
				provider. (See N.J.A.C. 10:49-6 ).
(c) Authorization becomes invalid upon
				termination of eligibility for the New Jersey Medicaid/NJ FamilyCare
				fee-for-service programs, except when the termination occurs between the time
				the optical appliance is ordered and the time the optical appliance is
				dispensed. (Note: The provider shall use the date the optical appliance is
				ordered as the date of service when this situation occurs.)
(d) The following optical appliances require
				prior authorization:
1. Low vision devices
				when the total charge to the Medicaid or NJ FamilyCare fee-for-service program
				is $ 150.00 or more;
2. Vision
				training devices;
3. Repair of an
				optical appliance when the charge to the Medicaid or NJ FamilyCare
				fee-for-service program is $ 15.00 or more;
4. Replacement of optical appliances;
i. In circumstances not covered in
				N.J.A.C.
				10:62-2.4, the replacement of an optical
				appliance requires prior authorization. For example: If lost, broken and
				irreparable, stolen or a prescription change is less than 0.50 diopter or five
				degrees in axis.
5. Dual
				pairs of glasses instead of multifocal;
6. Optical tints;
7. High index lenses;
8. Special base curve;
9. Artificial eye if provided more frequently
				than once every three years;
10.
				Intraocular lenses implantations if for more than two implantation procedures
				per beneficiary per lifetime;
11.
				Replacement of a contact lens within two years;
12. Protective prescription eyewear;
				and
13. All other optical appliance
				items requiring additional charges or not identified in
				N.J.A.C.
				10:62-3.4.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 2 - OPTICAL APPLIANCES AND SERVICES › Section 10:62-2.6 - Standards and policies regarding lenses

Current through Register Vol. 56, No. 14, July 15, 2024
(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/
.
(b) Lenses shall meet impact resistant
				standards as set forth in the United States Food and Drug Administration
				regulations at
				21 CFR
				801.410.
(c) For pricing purposes, all prescriptions
				shall be written in minus cylinder form.
(d) The total correction shall be at least
				0.50 diopter in spherical or cylindrical power in the initial prescription for
				glasses.
(e) (Reserved)
(f) Contact lenses may be provided for:
1. Specific ocular pathological conditions
				including, but not limited to, Keratoconus, monocular surgical aphakia to
				effect binocular vision, anisometropia of 3.0 diopters or more; and
2. Patients whose vision cannot be improved
				to at least 20/70 with regular lenses but improvement of vision can be
				accomplished to 20/70 or better.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 2 - OPTICAL APPLIANCES AND SERVICES › Section 10:62-2.7 - Standards and policies regarding frames

Current through Register Vol. 56, No. 14, July 15, 2024
(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-reinforced;
3. A hinge rivet
				shall pass through the reinforcing temple wire;
4. The material shall contain no scratches,
				fissures or bubbles;
5. There shall
				be no material discoloration at the time of dispensing; and
6. The frame shall not be expanded beyond 1
				millimeter of the original size when the lenses are inserted.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 2 - OPTICAL APPLIANCES AND SERVICES › Section 10:62-2.8 - Standards regarding guarantee/warranty

Current through Register Vol. 56, No. 14, July 15, 2024
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.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 2 - OPTICAL APPLIANCES AND SERVICES › Section 10:62-2.9 - Ocular prostheses

Current through Register Vol. 56, No. 14, July 15, 2024
Artificial eyes and intraocular lenses, stock or
				  custom-made, shall be of plastic material.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 2 - OPTICAL APPLIANCES AND SERVICES › Section 10:62-2.10 - Approved fabricating laboratory

Current through Register Vol. 56, No. 14, July 15, 2024
(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 lenses.
(b) The laboratory shall be able to provide
				all services necessary to completely furnish eyeglasses as may be requested by
				an optical dispenser and is subject to approval by the New Jersey Medicaid/NJ
				FamilyCare fee-for-service programs. A provider may call the Provider Services
				hotline at 1-800-776-6334 to ascertain if a laboratory is New Jersey
				Medicaid/NJ FamilyCare fee-for-service-approved.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 2 - OPTICAL APPLIANCES AND SERVICES › Section 10:62-2.11 - Recordkeeping policies

Current through Register Vol. 56, No. 14, July 15, 2024
(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 representatives of the New Jersey Medicaid/NJ
				FamilyCare fee-for-service programs or their agents as required.
(b) The records as required by (a) above
				shall include the following:
1. Name of the
				beneficiary;
2. Address of the
				beneficiary;
3. New Jersey
				Medicaid/NJ FamilyCare fee-for-service identification number;
4. Original prescription;
5. Date of the prescription
				received;
6. Date of the dispensing
				to the beneficiary;
7. Invoice from
				fabricating laboratory and material purchase invoices, as applicable;
				and
8. All supportive statements
				and reports, for example fire report, police report, developmental
				disabilities, medical necessity, etc.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 2 - OPTICAL APPLIANCES AND SERVICES › Section 10:62-2.12 - Reimbursement policy

Current through Register Vol. 56, No. 14, July 15, 2024
(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 maximum fee allowance schedule are listed in
				N.J.A.C. 10:62-3.
(c) The
				reimbursement policy of the New Jersey Medicaid/NJ FamilyCare fee-for-service
				programs provides for payment to the provider of the actual invoice cost of the
				optical appliance plus a dispensing fee. Providers are requested to indicate
				the actual invoice cost of the material when submitting a claim. Actual invoice
				cost is defined as the net amount paid by the provider, reflecting all
				discounts or special purchase agreements. The service (dispensing) fee, to
				which the provider is entitled, should be indicated as a separate
				item.
(d) The maximum allowable
				reimbursement for frames is not to exceed an allowance determined to be
				reasonable by the Commissioner, Department of Human Services. However,
				providers shall only bill the New Jersey Medicaid/NJ FamilyCare fee-for-service
				programs for the actual invoice cost of the frame when submitting a claim for
				payment. Actual invoice cost is defined as the net amount paid by the provider,
				reflecting all discounts or special purchase agreements. Frames are
				reimbursable only if they meet the criteria listed in
				N.J.A.C.
				10:62-2.7.
(e) Optical appliances are reimbursable under
				the New Jersey Medicaid/NJ FamilyCare fee-for-service programs only when
				prescribed by a provider of professional eye services described in
				N.J.A.C.
				10:62-1.3.
(f) Non-physician services and
				equipment/supplies furnished to hospital inpatients by outside providers shall
				not be billed directly to the New Jersey Medicaid/NJ FamilyCare fee-for-service
				programs. Providers shall submit a bill/invoice to the hospital for
				payment.
(g) The cost of
				intraocular lenses is reimbursable to hospitals or ambulatory surgical centers
				where the surgery is performed.
(h)
				Reimbursement by the New Jersey Medicaid/NJ FamilyCare fee-for-service programs
				shall be made for covered services provided to eligible beneficiaries
				only.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:62-3.1 - Introduction

Current through Register Vol. 56, No. 14, July 15, 2024
(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 as many as two 2-position modifiers. Unlike the CPT numeric design,
				the CMS assigned codes and modifiers contain alphabetic characters. HCPCS is a
				two-level coding system.
1. Level I Codes
				(Narratives found in CPT): These codes are adapted from CPT for utilization
				primarily by Physicians, Podiatrists, Optometrists, Certified Nurse-Midwives,
				Independent Clinics and Independent Laboratories. CPT is a listing of
				descriptive terms and numeric identifying codes and modifiers for reporting
				medical services and procedures performed by physicians. Copyright restrictions
				make it impossible to print excerpts from CPT procedure narrative for Level I
				codes. Thus, in order to determine those narratives it is necessary to refer to
				CPT, which is incorporated herein by reference, as amended and supplemented.
				(The CPT is available from the Order Department of the American Medical
				Association, PO Box 109050, Chicago, Illinois 60610.)
2. Level II Codes (Narratives found in
				N.J.A.C.
				10:62-3.5 ): These codes are assigned by CMS
				for physician and non-physician services which are not in CPT.
3. Level III Codes (Narratives found in
				N.J.A.C.
				10:62-3.3 and 3.5): These codes are assigned
				by the Division to be used for those services not identified by CPT codes or
				CMS-assigned codes. Level III codes identify services unique to New
				Jersey.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:62-3.2 - HCPCS Procedure Codes and maximum fee schedule for professional vision care services

Current through Register Vol. 56, No. 14, July 15, 2024
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				  here to view image.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:62-3.5 - HCPCS Procedure Codes and maximum fee schedule for vision care appliances

Current through Register Vol. 56, No. 14, July 15, 2024
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				  here to view image.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 62 - VISION CARE SERVICES MANUAL › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Appendix A

Current through Register Vol. 56, No. 14, July 15, 2024
FISCAL AGENT BILLING SUPPLEMENT
AGENCY NOTE: The Fiscal Agent Billing Supplement is filed as
				  an incorporated Appendix of this chapter/manual but is not reproduced in the
				  New Jersey Administrative Code. The Fiscal Agent Billing Supplement can be
				  downloaded free of charge at
www.njmmis.com
. When revisions are made to the
				  Fiscal Agent Billing Supplement, a revised version will be placed on the
				  website and copies will be filed with the Office of Administrative Law. If you
				  do not have access to the internet and require a copy of the Fiscal Agent
				  Billing Supplement, write to:
Molina Medicaid Solutions
PO Box 4801
Trenton, New Jersey 08650-4801
or contact
Office of Administrative Law
Quakerbridge Plaza, Building 9
PO Box 049
Trenton, New Jersey 08625-0049
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 64 - HEARING AID SERVICES › Subchapter 1 - GENERAL POLICIES › Section 10:64-1.1 - Scope

Current through Register Vol. 56, No. 14, July 15, 2024
(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 aid is authorized and
				purchased on behalf of a Medicaid beneficiary, ownership of the hearing aid
				will vest in the Division of Medical Assistance and Health Services. The
				beneficiary will be granted a possessory interest for as long as the
				beneficiary requires use of the aid. When the beneficiary no longer needs the
				aid, possession and control will revert to the Division. The beneficiary shall
				sign an agreement to this effect as part of the process of authorizing purchase
				of the hearing aid.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 64 - HEARING AID SERVICES › Subchapter 1 - GENERAL POLICIES › Section 10:64-1.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
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-Language-Hearing Association, or who has completed the equivalent
				  academic and work experience necessary to receive the CCC-A, or who has
				  completed the academic program and is acquiring the supervised work experience
				  to qualify for the certificate and who is licensed by the State as an
				  audiologist, in accordance with
				  45:3B-8 and
				  13:44C-3.2, or who has a
				  comparable license from their state of practice.
"Dispenser" means an individual who is licensed by the State
				  as a hearing aid dispenser in accordance with
				  45:9A-9 and N.J.A.C. 13:35-8, or
				  is licensed or certified by a comparable agency in the state where they are
				  practicing.
"Hearing aid" means an ear-level or body-worn electroacoustic
				  instrument for amplifying sound whose basic components are a microphone,
				  amplifier, and receiver.
"Otologist" for purposes of this chapter refers to either a
				  physician who specializes in diseases of the ear or a physician who specializes
				  in diseases of the ear, nose and throat and who qualifies as a specialist
				  according to the definition and conditions in N.J.A.C. 10:54, Manual for
				  Physician Services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 64 - HEARING AID SERVICES › Subchapter 1 - GENERAL POLICIES › Section 10:64-1.3 - Provisions for provider participation

Current through Register Vol. 56, No. 14, July 15, 2024
(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 provider requires completion and submission
				of the "Medicaid Provider Application" (FD-20) and the "Medicaid Provider
				Agreement" (FD-62).
1. The documents
				referenced above are located as Forms No. 8 and No. 9 in the Appendix at the
				end of the Administration chapter (N.J.A.C. 10:49), and may be obtained from
				and submitted to:
Gainwell Technologies
Provider Enrollment
PO Box 4804
Trenton, New Jersey 08650-4804
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 64 - HEARING AID SERVICES › Subchapter 1 - GENERAL POLICIES › Section 10:64-1.4 - Recordkeeping

Current through Register Vol. 56, No. 14, July 15, 2024
(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 of services performed by
				the hearing aid provider shall include, but may not be limited to, the
				following:
1. The date of service;
2. The name of beneficiary;
3. The reason for visit;
4. Evaluation findings;
5. The service(s) provided;
6. Follow-up procedures or visits, if
				required;
7. The signature of the
				dispensing provider rendering the service(s); and
8. Other documentation required to support
				the services billed to the Medicaid program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 64 - HEARING AID SERVICES › Subchapter 1 - GENERAL POLICIES › Section 10:64-1.5 - Basis of reimbursement

Current through Register Vol. 56, No. 14, July 15, 2024
(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 or laboratory price list;
				plus
iii. Insurance, shipping, and
				handling costs included as a component of the manufacturer's cost;
				plus
iv. Wholesale cost of the
				batteries; plus
v. A dispensing fee
				of $ 175.00 for a monaural fitting or $ 280.00 for a binaural
				fitting.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 64 - HEARING AID SERVICES › Subchapter 2 - PROVISIONS OF SERVICES › Section 10:64-2.1 - Hearing aid program, policies, and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(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 examination is medically necessary for
				beneficiaries 21 years of age or older. If the physician or advanced practice
				nurse determines that an audiological examination is medically necessary for
				beneficiaries 21 years of age or older, the audiological examination shall be
				completed prior to prescribing a hearing aid. All Medicaid/NJ FamilyCare
				eligible beneficiaries under 21 years of age shall have an audiological
				examination completed prior to the prescribing of a hearing aid. If the
				beneficiary is a patient of a long-term care facility, a nursing facility
				hearing aid screening shall also be performed, as indicated at (a)3 below. (See
				Fiscal Agent Billing Supplement, FD-36.)
1.
				Otologic examinations shall consist of a history and physical examination of
				the ear, nose and throat with a relevant diagnosis supporting the need for
				audiologic and hearing aid examination, with such examination signed and dated
				by the otologist and forwarded to the individual providing the audiological and
				hearing aid examinations.
2.
				Audiological examinations performed by an audiologist or otologist shall
				include the following (data other than that in this section are acceptable for
				infants and non-verbal children):
i. Pure
				tone air and bone conduction thresholds;
ii. Speech reception thresholds;
iii. Speech discrimination scores;
iv. Masking when indicated;
v. Most comfortable listening levels
				(MCL);
vi. Uncomfortable loudness
				levels or thresholds of discomfort; and
vii. Middle ear measurements and reflex
				thresholds when indicated.
3. A hearing aid examination performed by an
				audiologist, otologist or hearing aid dispenser shall include initial hearing
				aid testing as described in this section, and follow-up as described in
				10:64-2.6;
i. Initial testing shall be as follows:
(1) Either in the sound field both with and
				without amplification (aided and unaided) to indicate benefit and effectiveness
				of the prescribed amplification; or
(2) With a master hearing aid.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 64 - HEARING AID SERVICES › Subchapter 2 - PROVISIONS OF SERVICES › Section 10:64-2.2 - Dispensing of a hearing aid to a Medicaid/NJ FamilyCare beneficiary residing in a nursing facility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Coverage of
				hearing aid devices in a nursing facility shall be based on the requirements of
				hearing aid candidacy described under
				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
				physician or other type of physician practicing in a nursing
				facility.
(c) Hearing aids
				dispensed in nursing facilities shall be subject to a prepayment review by the
				Medicaid program following the date the aid was provided to assess the
				appropriateness of the aid and the overall response of the beneficiary to the
				aid's availability.
(d) Completed
				documentation (see Fiscal Agent Billing Supplement, incorporated herein by
				reference as the chapter Appendix) required for coverage of these services by
				the Medicaid/NJ FamilyCare program shall include, but shall not be limited to,
				the following:
1. The Nursing Facility
				Hearing Aid Screening form (FD-257);
2. The Audiologic and Hearing Aid
				Examinations form (FD-36); and
3.
				The Follow-up to Hearing Aid Examination form (FD-244).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 64 - HEARING AID SERVICES › Subchapter 2 - PROVISIONS OF SERVICES › Section 10:64-2.3 - Dispensing of a hearing aid; repairs and replacement of parts

Current through Register Vol. 56, No. 14, July 15, 2024
(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
				tubing, or cord and receiver;
4.
				Issue a one month's supply of batteries;
5. Issue a garment bag, if applicable, and
				any other accessories normally supplied with the type of hearing aid
				provided;
6. Issue the
				manufacturer's User Instructional Brochure for the particular instrument
				provided;
7. Instruct in the use
				and care of the hearing aid and earmold, including specific instruction on
				insertion of the earmold; and
8.
				Explain the need for a follow-up visit and complete a copy of the Notice of
				Requirement for Hearing Aid Follow-up Visit, unless the aid is a replacement
				aid and no hearing aid examination was performed.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 64 - HEARING AID SERVICES › Subchapter 2 - PROVISIONS OF SERVICES › Section 10:64-2.4 - Provider's responsibilities

Current through Register Vol. 56, No. 14, July 15, 2024
(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 beneficiary's condition permits;
2. Assume liability for material defects and
				unconditionally guarantee material and workmanship for one year from date of
				delivery for a new hearing aid, except that:
i. Cords and bone-conduction receivers shall
				be excluded from this liability; and
ii. The provider shall not be responsible for
				damage to an aid due to accident, misuse or alteration;
3. Provide appropriate repair services for a
				period of at least one year after delivery of the aid, including a loaner
				instrument of comparable performance in good working order;
4. Provide appropriate maintenance services
				for a period of at least one year after delivery of the aid, which shall
				include:
i. Cleaning of the
				earmold;
ii. Replacing
				tubing;
iii. Cleaning contacts;
				and
iv. Spraying for volume wheel
				noise;
5. Accept return
				of an instrument or part thereof within 30 days of delivery to the beneficiary
				when the audiologist, otologist, or Medicaid/NJ FamilyCare staff member, after
				the follow-up visit, determines that the instrument does not conform to the
				prescription, does not fit properly, is not of acceptable quality and comfort
				consistent with the condition of the beneficiary, or has failed to produce the
				benefit anticipated during the nursing facility hearing aid screening or the
				hearing aid examination, as follows:
i. If it
				is found that material or workmanship are defective, then the provider shall be
				allowed a reasonable opportunity to make such adjustments, corrections or
				replacement that may be necessary to allow for acceptance of the instrument
				and/or earmold, without additional charges to the program except that the
				provider's responsibility shall not apply to corrections necessitated by the
				beneficiary's misuse or abuse of the instrument;
6. Make services, supplies, and parts
				reasonably accessible and available during regular business hours in an
				identifiable and fixed place of business, which shall include a public entrance
				directly into the provider's place of business;
7. Assure that the hearing aid candidacy
				requirements described in
				10:64-2.1(b)  are
				met prior to dispensing an aid and that all required procedures are followed;
				and
8. Provide auxiliary aids, such
				as qualified sign language interpreters, to beneficiaries who need such an aid
				to facilitate communication with the provider during the service delivery
				process.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 64 - HEARING AID SERVICES › Subchapter 2 - PROVISIONS OF SERVICES › Section 10:64-2.5 - Policies on replacement of a hearing aid

Current through Register Vol. 56, No. 14, July 15, 2024
(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 cost of
				repairing the aid is 50 percent or more of its replacement cost to the
				Medicaid/NJ FamilyCare program; or
3. The hearing loss for which the original
				aid was prescribed has changed such that the original aid no longer is
				appropriate and the examinations prescribed in
				10:64-2.1(b) 
				have determined that a new aid should be prescribed.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 64 - HEARING AID SERVICES › Subchapter 2 - PROVISIONS OF SERVICES › Section 10:64-2.6 - Hearing aid follow-up visit

Current through Register Vol. 56, No. 14, July 15, 2024
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 of the
				  amplification provided.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 64 - HEARING AID SERVICES › Subchapter 2 - PROVISIONS OF SERVICES › Section 10:64-2.7 - Policies on repairs, replacement earmolds, and replacement parts

Current through Register Vol. 56, No. 14, July 15, 2024
(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.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 64 - HEARING AID SERVICES › Subchapter 2 - PROVISIONS OF SERVICES › Section 10:64-2.8 - Standards for environment and equipment used for audiologic and hearing aid testing

Current through Register Vol. 56, No. 14, July 15, 2024
(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 reference, as amended and supplemented.
1. Standards for the test environment may be
				waived in the rare case when a good hearing aid candidate cannot be moved due
				to severe health problems. In these situations, dispensers shall test the
				candidate within the environment available, approximate, to the extent
				possible, the standards described in (a) above, and document the testing
				conditions in the beneficiary's record.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 64 - HEARING AID SERVICES › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:64-3.1 - Introduction to the HCPCS procedure code system

Current through Register Vol. 56, No. 14, July 15, 2024
(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,
				42
				U.S.C. §
										1320d et seq., and incorporated
				herein by reference, as amended and supplemented, and published by PMIC, 4727
				Wilshire Blvd., Suite 300, Los Angeles, CA 90010. Revisions to the Healthcare
				Common Procedure Coding System made by CMS (code additions, code deletions, and
				replacement codes) will be reflected in this chapter through publication of a
				notice of administrative change in the New Jersey Register. Revisions to
				existing reimbursement amounts specified by the Department and specification of
				new reimbursement amounts for new codes will be made by rulemaking in
				accordance with the Administrative Procedure Act,
				N.J.S.A.
				52:14B-1et seq.
(b) HCPCS has been developed as a three-level
				coding system, as follows:
1. Level I codes:
				Narratives for these codes are found in the CPT, which is incorporated herein
				by reference, as amended and supplemented. The codes are adapted from the CPT
				for use primarily by physicians, podiatrists, optometrists, certified
				nurse-midwives, certified nurse practitioners and clinical nurse specialists,
				independent clinics and independent laboratories. Level I procedure codes are
				not applicable to hearing aid services.
2. Level II codes: These codes are assigned
				by CMS for physician and non-physician services which are not in the CPT.
				Narratives for these codes, and the fees for each, can be found at
				N.J.A.C.
				10:64-3.2.
3. Level III codes: Level III codes identify
				services unique to the New Jersey Medicaid program. These codes are assigned by
				the Department to be used for those services not identified by CPT codes or
				CMS-assigned codes. Narratives for these codes, and the fees paid for each, can
				be found at
				N.J.A.C.
				10:64-3.3.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 64 - HEARING AID SERVICES › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:64-3.2 - HCPCS Procedure codes and maximum fee allowance schedule for Level II codes and narratives

Current through Register Vol. 56, No. 14, July 15, 2024
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
Glasses, Air Conduction
B.R.
V5080
Glasses, Bone
						  Conduction
B.R.
V5090
Dispensing Fee, Unspecified
(LT or RT)
Hearing Aid
175.00
NOTE: Monaural.
Specify LT = left or RT = right.
V5100
Hearing Aid, Bilateral,
						  Body
B.R.
Worn
NOTE: One unit, withY-cord or
bilateral cords.
V5110
Dispensing Fee,
						  Bilateral
175.00
V5120
Binaural, Body
B.R.
V5130
Binaural, In The Ear
B.R.
V5140
Binaural, Behind The
						  Ear
B.R.
V5150
Binaural, Glasses
B.R.
V5160
Dispensing Fee,
						  Binaural
280.00
V5170
Hearing Aid, CROS,In The
						  Ear
B.R.
V5180
Hearing Aid, CROS,Behind The
						  Ear
B.R.
V5190
Hearing Aid,
						  CROS,Glasses
B.R.
V5200
Dispensing Fee, CROS
175.00
V5210
Hearing Aid, BICROS,In The
						  Ear
B.R.
V5220
Hearing Aid, BICROS,Behind
						  The
B.R.
Ear
V5230
Hearing Aid, BICROS,
						  Glasses
B.R.
V5240
Dispensing Fee,
						  BICROS
175.00
V5299
Hearing
						  service,miscellaneous
B.R.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 64 - HEARING AID SERVICES › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:64-3.3 - HCPCS Procedure codes and maximum fee allowance schedule for Level III codes and narratives

Current through Register Vol. 56, No. 14, July 15, 2024
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 Service
						  Fee
10.00
V5266
Battery for Hearing Aids (Per
						  Battery)
B.R.
Y4410
Replacement Hook, Door, or
						  Volume
B.R.
Control
Y4510
Cord, Replacement part for Hearing
						  Aid
B.R.
Y4520
Receiver, Replacement part for
						  Hearing
B.R.
Aid
Y4530
Tubing, Associated with Hearing
						  Aid
B.R.
Repair
Y4540
Garment Bag, Associated with
						  Hearing
B.R.
Aid
Y4550
Bone Conductor, Used with Hearing
						  Aid
B.R.
Y4560
Headband, Used with Hearing
						  Aid
B.R.
Y4620
Use of Electric Test Box to
						  Test
B.R.
Electroacoustic Performance of Hearing
Aid
Y4630
Hearing Aid, Monaural, in the
						  Canal
B.R.
Y4640
Hearing Aid, Binaural, in the
						  Canal
B.R.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 64 - HEARING AID SERVICES › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:64-3.4 - HCPCS Procedure codes with qualifiers for hearing aid services

Current through Register Vol. 56, No. 14, July 15, 2024
(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 will also
						  serve
for minor in-office repair.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 64 - HEARING AID SERVICES › Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Appendix - APPENDIX

Current through Register Vol. 56, No. 14, July 15, 2024
FISCAL AGENT BILLING SUPPLEMENT
AGENCY NOTE: The Fiscal Agent Billing Supplement is appended
				  as a part of this manual but is not reproduced in the New Jersey Administrative
				  Code. When revisions are made to the Fiscal Agent Billing Supplement,
				  replacement pages will be distributed to providers and copies will be filed
				  with the Office of Administrative Law. For a copy of the Fiscal Agent Billing
				  Supplement, access
www.njmmis.com
or write
				  to:
Gainwell Technologies
PO Box 4801
Trenton, New Jersey 08650-4801
or contact:
Office of Administrative Law
Quakerbridge Plaza, Building 9
PO Box 049
Trenton, New Jersey 08625-0049
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:66-1.3 - Provisions for provider participation

Current through Register Vol. 56, No. 14, July 15, 2024
(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 from the New Jersey Medicaid and NJ FamilyCare
				fee-for-service programs shall be obtained before reimbursement for the
				service(s) may be claimed. For additional details, see the Administration
				chapter, 10:49-3.2, Enrollment process, and
				10:49-3.3, Providers with
				multi-locations.
1. All clinical
				practitioners directly affiliated with the clinic shall enroll in the New
				Jersey Medicaid and NJ FamilyCare fee-for-service programs, as indicated in the
				Administration chapter at
				10:49-3.4, in order to obtain an
				individual Medicaid and NJ FamilyCare fee-for-service Provider
				Number(s).
2.
(Reserved)
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:66-1.4 - Prior authorization (PA)

Current through Register Vol. 56, No. 14, July 15, 2024
(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 required for out-of-State
				clinics for specified dental, mental health, substance use disorder, and vision
				care services in accordance with N.J.A.C. 10:49-6 and in accordance with
				specific provider chapters. Prior authorization requirements by the Primary
				Care Provider (PCP) for persons participating in managed health care programs
				are located at
				N.J.A.C.
				10:49-21.4(c).
(b) Dental services shall be prior authorized
				as indicated in the New Jersey Medicaid and NJ FamilyCare fee-for-service
				programs' Dental Services chapter,
				10:56-1.4.
(c) In addition to the other requirements of
				this section, mental health and substance use disorder outpatient
				rehabilitative services, including individual psychotherapy, group therapy,
				family consultation, and family therapy, provided to each Medicaid or NJ
				FamilyCare fee-for-service beneficiary require prior authorization when payment
				to an independent clinic exceeds $ 6,000 for that Medicaid or NJ FamilyCare
				fee-for-service beneficiary in any 12-month period, commencing with the
				beneficiary's initial visit.
1. The maximum
				period of authorization shall not exceed 12 months for all mental health
				services. Additional authorizations may be requested.
i. The maximum period of authorization for
				partial care shall not exceed six months.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:66-1.5 - Basis for reimbursement

Current through Register Vol. 56, No. 14, July 15, 2024
(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 of Medicaid/NJ FamilyCare fee-for-service-participating
				practitioners in "private" (independent) practice. Reimbursement is made
				directly to the clinic.
1. An independent
				clinic shall charge for services to all patients, except as provided by
				legislation. No charge will be made directly to the Medicaid/NJ FamilyCare
				fee-for-service beneficiary, and the charge to the New Jersey Medicaid/NJ
				FamilyCare fee-for-service program may not exceed the charge by the clinic for
				identical services to other groups or individuals in the community.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:66-1.6 - Recordkeeping

Current through Register Vol. 56, No. 14, July 15, 2024
(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
				beneficiary's record shall include a progress note for each visit which
				supports the procedure code(s) billed, except where specified
				otherwise.
(c) Additional
				requirements governing medical records in an ambulatory surgical center are
				located in N.J.A.C. 10:66-5.
(d)
				The information described in this subsection shall be made available to the New
				Jersey Medicaid and NJ FamilyCare fee-for-service programs or is agents upon
				request.