reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 2 - PHARMACEUTICAL SERVICES TO MEDICAID OR NJ FAMILYCARE FEE-FOR-SERVICES BENEFICIARIES IN A NURSING FACILITY › Section 10:51-2.7 - Prescription dispensing fee (capitation)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey Medicaid and NJ FamilyCare programs capitate the dispensing fee for each prescription for beneficiaries in Medicaid approved nursing facilities in accordance with the total number of Medicaid and NJ FamilyCare fee-for-service beneficiary days in the facility(ies) serviced by the pharmacy. Additional dispensing fees (add-ons) per prescription shall be given to pharmacy providers who provide the following levels of services: Pharmacies with institutional permits shall be reimbursed as defined in (a) above, except that the daily per beneficiary capitation fee shall be 75 percent of the fee for pharmacies with retail permits.
1. Twenty-Four Hour Unit Dose Service: Pharmacies with retail permits dispensing medication in a dispensing system in which a 24-hour supply of unit dose oral medication, both solid (for example, tablets, capsules) and liquid formulations, is delivered for each beneficiary daily, shall be reimbursed the cost of all reimbursable legend medication plus a fee of $ 0.656 per beneficiary day.
i. Exception: Certain liquid medications that are supplied in concentrate form only and are administered by drop dosage cannot be supplied in a 24-hour dose.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 2 - PHARMACEUTICAL SERVICES TO MEDICAID OR NJ FAMILYCARE FEE-FOR-SERVICES BENEFICIARIES IN A NURSING FACILITY › Section 10:51-2.8 - Compounded prescriptions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Compounded prescriptions may be reimbursed by the Medicaid or NJ FamilyCare program. Compounded prescriptions are extemporaneously prepared mixtures of an active ingredient or ingredients and/or a pharmaceutical excipient or excipients and are dispensed by approved providers.
1. Acceptable pharmaceutical excipients which do not contribute therapeutically to a compound include, but are not limited to hydrophilic ointment, petrolatum, aquaphor, eucerin cream, phenol, menthol, resorcinol, caffeine, talc, simple syrup, aromatic elixir distilled water, and glycerin.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 2 - PHARMACEUTICAL SERVICES TO MEDICAID OR NJ FAMILYCARE FEE-FOR-SERVICES BENEFICIARIES IN A NURSING FACILITY › Section 10:51-2.9 - Non-proprietary or generic dispensing

Current through Register Vol. 56, No. 14, July 15, 2024
When medication is prescribed by its non-proprietary or generic name, the pharmacist shall dispense the least expensive, therapeutically effective equivalent product available, preferably one listed in N.J.A.C. 8:71. The labeler code and drug product code of the actual product dispensed must be reported on the claim form. The package size code reported may differ from the stock package size used to fill the prescription.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 2 - PHARMACEUTICAL SERVICES TO MEDICAID OR NJ FAMILYCARE FEE-FOR-SERVICES BENEFICIARIES IN A NURSING FACILITY › Section 10:51-2.10 - Covered pharmaceutical services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All covered pharmaceutical services shall be provided within the scope of N.J.A.C. 10:49 (Administration) and this Chapter, and billed to the fiscal agent on the claim form or other approved billing method. (See Appendix, Fiscal Agent Billing Supplement).
(b) Covered pharmaceutical services include:
1. Prescribed legend drugs (for their medically accepted indication) as defined in Section 1927(k)(6) of Social Security Act. "Legend drugs" mean those drugs whose labels include the legend statement "Caution: Federal Law Prohibits Dispensing Without a Prescription."
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 2 - PHARMACEUTICAL SERVICES TO MEDICAID OR NJ FAMILYCARE FEE-FOR-SERVICES BENEFICIARIES IN A NURSING FACILITY › Section 10:51-2.11 - Non-covered pharmaceutical services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following classes of prescription drugs or conditions shall not be covered under the New Jersey Medicaid or NJ FamilyCare program:
1. Prescriptions which are not for medically accepted indications as defined in Section 1927(k)(6) of the Social Security Act;
2. Antiobesics and anorexiants when used in treatment of obesity;
3. Drug products for which adequate and accurate information is not readily available, such as, but not limited to, product literature, package inserts and price catalogues;
4. Experimental drugs;
i. Exception: Drugs available only for treatment through an Investigational New Drug (IND) application may be prior authorized;
5. Medication furnished by a prescriber or an employee of a prescriber;
6. Medication prescribed for hospital inpatients;
7. Non-legend drugs;
8. Prescriptions and in-patient medication orders written and/or dispensed with nonspecific directions;
9. Food supplements, milk modifiers, infant formulas, therapeutic diets, special liquid or powdered diets used in the treatment of obesity;
10. Methadone in any form (tablets, capsules, liquid, injectables, or powder) when used for drug detoxification or addiction maintenance;
11. Drug products for which final orders have been published by the Food and Drug Administration, withdrawing the approval of their new drug application (NDA);
12. Drugs or drug products not approved by the Food and Drug Administration, when such approval is required by Federal law and/or regulation;
13. Radiopaque contrast materials (for example, Telepaque);
14. Drug Efficacy Study Implementation (DESI) drugs and identical, similar and related drugs (see 10:51-2.18 );
15. Drugs not covered by rebate agreements as defined in Section 4401 of OBRA '90 and Section 1927(a) of the Social Security Act (see 10:51-1.22 );
16. Erectile dysfunction drugs for individuals who are registered on New Jersey's Sex Offender Registry;
17. Any bundled drug service (see 10:51-2.20 ); and
18. Preventive vaccines, biologicals, and therapeutic drugs distributed to hospital clinics and/or community health centers by the New Jersey Department of Health.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 2 - PHARMACEUTICAL SERVICES TO MEDICAID OR NJ FAMILYCARE FEE-FOR-SERVICES BENEFICIARIES IN A NURSING FACILITY › Section 10:51-2.12 - Quantity of medication

Current through Register Vol. 56, No. 14, July 15, 2024
When the quantity of a drug or medication is not indicated in writing by the prescriber, the pharmacy provider shall dispense an appropriate quantity of medication not to exceed a one month supply (see 10:51-2.16, Prescription Refill).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 2 - PHARMACEUTICAL SERVICES TO MEDICAID OR NJ FAMILYCARE FEE-FOR-SERVICES BENEFICIARIES IN A NURSING FACILITY › Section 10:51-2.13 - Dosage and directions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Dosage and directions for use shall be included as part of all prescriptions or in-patient medication orders. Prescriptions or inpatient medication orders written and dispensed with no specific directions, such as "prn," "as directed" or "ad lib," etc. are not eligible for reimbursement. Specific directions such as "1 tablet 4 times a day PRN" are required.
1. Exceptions:
i. Topical preparations including ophthalmic and otic drops and ointments;
ii. Aerosol inhalers; and
iii. Nitroglycerin.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 2 - PHARMACEUTICAL SERVICES TO MEDICAID OR NJ FAMILYCARE FEE-FOR-SERVICES BENEFICIARIES IN A NURSING FACILITY › Section 10:51-2.14 - Prescriptions and in-patient medication orders rendered by telephone or technological devices

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Telephone rendered and/or technologically transmitted (for example: Fax) original prescriptions shall be permitted in accordance with all applicable Federal and State laws and regulations.
(b) For purposes of reimbursement, a telephone rendered and/or a technologically transmitted authorization to refill an original prescription is considered a new prescription or in-patient medication order and requires a new prescription number. Stamping or writing a new number on the original prescription or in-patient medication order does not constitute a new prescription under the Medicaid or NJ FamilyCare program.
(c) When a prescriber chooses not to allow product interchange on a telephone rendered original prescription or in-patient medication order, the statement "Substitution not permitted by prescriber-telephoned Rx" plus the pharmacist's full signature next to or below the statement, shall appear on the medication order. A rubber stamp bearing the statement is acceptable.
(d) When a prescriber chooses to certify "Brand Medically Necessary" on a telephone rendered original prescription or in-patient medication order for a product included on the Federal MAC list, a written signed prescription or in-patient medication order containing the certification, shall be sent to the pharmacist within seven days of the date of the telephone order. The written in-patient medication order shall be retained by the pharmacist as the original prescription. Failure to comply will result in the payment for that prescription being reduced to the MAC reimbursement level.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 2 - PHARMACEUTICAL SERVICES TO MEDICAID OR NJ FAMILYCARE FEE-FOR-SERVICES BENEFICIARIES IN A NURSING FACILITY › Section 10:51-2.15 - Changes or additions to the original prescription or in-patient medication order

Current through Register Vol. 56, No. 14, July 15, 2024
Changes or additions to the original prescription or in-patient medication order, when approved by the prescriber, shall be clearly indicated (including date and time) and signed by the dispensing pharmacist. No changes (for example, dosage, quantity, number of refills, days supply, etc.) are permitted on the original prescription order after the claim is submitted for payment.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 2 - PHARMACEUTICAL SERVICES TO MEDICAID OR NJ FAMILYCARE FEE-FOR-SERVICES BENEFICIARIES IN A NURSING FACILITY › Section 10:51-2.16 - Prescription refill

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Refills are not allowed.
(b) For purposes of reimbursement, an order for continuation of medication shall be considered a new prescription requiring a new written prescription and new prescription number.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 2 - PHARMACEUTICAL SERVICES TO MEDICAID OR NJ FAMILYCARE FEE-FOR-SERVICES BENEFICIARIES IN A NURSING FACILITY › Section 10:51-2.17 - Prescription Drug Price and Quality Stabilization Act

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Prescription Drug Price and Quality Stabilization Act,
24:6E-1
et seq., shall apply to the Medicaid and NJ FamilyCare programs. This law requires that every prescription blank contain the statements "Substitution Permissible" and "Do Not Substitute." The prescriber shall initial one of the statements in addition to signing the prescription blank.
1. When the prescriber does not initial "Substitution Permissible" or the "Do Not Substitute" statement on a prescription or in-patient medication order for a drug product listed in the DURC Formulary, the pharmacist shall substitute from the list of interchangeable products and bill Medicaid or NJ FamilyCare accordingly.
2. When the prescriber initials "Substitution Permissible," the pharmacist shall dispense and bill Medicaid or NJ FamilyCare for one of the less expensive products listed in the DURC Formulary as interchangeable with the brand name prescribed. The Medicaid or NJ FamilyCare fee-for-service beneficiary must accept the interchangeable product unless the beneficiary is willing to pay the pharmacy's full, usual, and customary price. If that occurs, the pharmacist shall so note on the prescription blank and no claim shall be submitted to Medicaid or NJ FamilyCare.
3. When a prescriber authorizes, in accordance with (b) below, the dispensing of a brand MAC drug, the pharmacist shall indicate the prescriber's preference by indicating "Medical Certification" on the claim form or the similar field in the EMC claim format and shall dispense and bill Medicaid or NJ FamilyCare, as appropriate, for the prescribed product. Reimbursement will be the estimated acquisition cost (EAC) (see 10:51-2.5 ) plus applicable dispensing fee or the usual and customary charge, whichever is less for that product (see Appendix D, Fiscal Agent Billing Supplement for instructions about the claim form and Appendix E regarding the proper EMC claim format).
4. When the prescriber orders by the generic name, N.J.A.C. 8:71 (see 10:51-2.4 ) does not apply. The pharmacist shall dispense the least expensive, therapeutically effective product available to him or her at the time of dispensing. The product need not necessarily be from the list of interchangeable products.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 2 - PHARMACEUTICAL SERVICES TO MEDICAID OR NJ FAMILYCARE FEE-FOR-SERVICES BENEFICIARIES IN A NURSING FACILITY › Section 10:51-2.18 - Drug Efficacy Study Implementation (DESI)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) "Less than effective drugs" are subject to a Notice of Opportunity for Hearing (NOOH) by the Food and Drug Administration (FDA).
1. Reimbursement is not available for the purchase or administration of any drug product that meets all of the following conditions:
i. The drug product was approved by the Food and Drug Administration (FDA) before October 10, 1962;
ii. The drug product is available only through prescription;
iii. The drug product is the subject of a NOOH issued under Section 505(e) of the Federal Food, Drug, and Cosmetic Act and published in the Federal Register on a proposed order of FDA to withdraw its approval for the drug product because it has determined that the product is less than effective for all its labeled indications; and
iv. The drug product is at present the subject of an efficacy review study performed by FDA (see 21 CFR 310.6 including all subsequent amendments and supplements). The FDA efficacy review potentially can determine justification for a drug product's medical need. If a drug product fails this review, the product is classified as a DESI drug.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 2 - PHARMACEUTICAL SERVICES TO MEDICAID OR NJ FAMILYCARE FEE-FOR-SERVICES BENEFICIARIES IN A NURSING FACILITY › Section 10:51-2.19 - Drug manufacturers' rebate agreement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order for legend drug products to be reimbursed by the New Jersey Medicaid or NJ FamilyCare program, manufacturers must have in effect a rebate agreement pursuant to Section 4401 of OBRA 1990 and Section 1927 et seq. of the Social Security Act.
(b) Price information is supplied from a reference drug file subcontracted for this purpose by the fiscal agent and accepted by the Division as the primary source of pricing information for the New Jersey Medicaid Management Information System (NJMMIS). The calculated price shall not exceed the lower of the average wholesale price (AWP) or the Federal Fund Participation Upper Limit (FFPUL) as supplied by the reference drug file contractor.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 2 - PHARMACEUTICAL SERVICES TO MEDICAID OR NJ FAMILYCARE FEE-FOR-SERVICES BENEFICIARIES IN A NURSING FACILITY › Section 10:51-2.20 - Bundled drug service

Current through Register Vol. 56, No. 14, July 15, 2024
(a) "Bundled drug service" means a drug or service that is marketed or distributed by the manufacturer or distributor as a combined package which includes in the cost the drug product and ancillary services such as, but not limited to, case management services and laboratory testing.
(b) Bundled drug service shall not be eligible for reimbursement by the Medicaid or NJ FamilyCare program.
1. This provision may be waived at the discretion of the Commissioner if the Commissioner determines that a bundled drug service is less than or equal to the total cost of the unbundled components if reimbursed separately; or
2. The Commissioner may waive the provisions for reasons of medical necessity for a bundled drug or in accordance with terms approved by the Department as follows:
i. Those instances where discontinuation, withdrawal, or elimination of the use of the bundled drug by someone who has been receiving a bundled drug would result in the deprivation of the lifesaving or life prolonging benefits of the drug or would cause potential harm or serious exacerbation of the illness being treated; or
ii. Those instances where use of the bundled drug has shown marked improvement in the beneficiary's clinical status reflected in alleviation of symptoms, and elevation of level of function and independence.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 2 - PHARMACEUTICAL SERVICES TO MEDICAID OR NJ FAMILYCARE FEE-FOR-SERVICES BENEFICIARIES IN A NURSING FACILITY › Section 10:51-2.21 - Claims submission

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Based on the level of service provided by an approved pharmacy to a nursing facility, a provider may choose to:
1. Submit a properly completed hard copy pharmacy claim form approved by the New Jersey Division of Medical Assistance and Health Services (DMAHS).
2. Submit an electronic media claim (EMC) by modem, diskette, or magnetic tape in an approved electronic format that complies with the National Council Prescription Drug Program (NCPDP) standards Version 5.1 and Version 1.1, incorporated herein by reference, as amended and supplemented. The Council's address is 4201 North 24th Street, Suite 365, Phoenix, Arizona 85016.
i. In order for a pharmacy provider to be eligible to submit an EMC claim to the Medicaid NJ FamilyCare programs, a pharmacy provider or vendor of EMC services shall complete the "New Jersey Medicaid Provider Electronic Billing Agreement."
ii. The completed agreement shall be submitted to the fiscal agent and approved by the Division.
iii. The pharmacy provider or vendor of EMC services shall submit electronic media claims under an approved submitter identification number and comply with EMC requirements contained in the EMC Manual, Appendix E, incorporated herein by reference.
iv. For the purposes of this subchapter, all electronically submitted claims, including POS claims, shall commonly be referred to as EMC claims.
3. Enter into an agreement with a point-of-sale (POS) intermediary or directly provide a similar telecommunication network approved by DMAHS to submit claims to the fiscal agent for adjudication. POS claims require an approved electronic format which complies with the National Council Prescription Drug Program standards, Version 5.1 and 1.1 as amended and supplemented, incorporated herein by reference. The Council's address is 4201 North 24th Street, Suite 365, Phoenix, Arizona 85016.
i. The approved POS intermediary or provider established network shall enter into an agreement with the State of New Jersey to provide on-line telecommunication services, including transmission of pharmacy claim detail data, access to the fiscal agent's POS computer and return of adjudicated claim data to the provider.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 2 - PHARMACEUTICAL SERVICES TO MEDICAID OR NJ FAMILYCARE FEE-FOR-SERVICES BENEFICIARIES IN A NURSING FACILITY › Section 10:51-2.22 - Point-of-sale (POS) claims adjudication system

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Pharmacies providing traditional pharmacy services, as described in 10:51-2.7, to nursing facilities may be submitted through a POS system and adjudicated by the State's fiscal agent on-line and in real-time. The POS system is an alternative to other methods of claim submission, including magnetic tape, diskette and paper claims. The pharmacist would be required to enter pharmacy claim detail data into a computer or POS device and transmit this data to the fiscal agent over a dedicated telephone line. Regardless of the method of claim submission, all claims will go through all New Jersey Medicaid Management Information System (NJMMIS) claims processing edits and the claims will be processed to determine their payment disposition (for example, paid or denied).
1. Pharmacy services provided to nursing facility and residential care residents utilizing 24 hour unit-dose or modified unit-dose drug delivery systems are precluded from the POS system.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 2 - PHARMACEUTICAL SERVICES TO MEDICAID OR NJ FAMILYCARE FEE-FOR-SERVICES BENEFICIARIES IN A NURSING FACILITY › Section 10:51-2.23 - Prospective drug utilization review (PDUR) program

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division of Medical Assistance and Health Services has established a prospective drug utilization review (PDUR) program to assist pharmacy providers with monitoring drug utilization by Medicaid and NJ FamilyCare beneficiaries. As a component of the Medicaid and NJ FamilyCare point-of-sale (POS) claims adjudication system, the State's fiscal agent will review drug utilization based on claims submitted on-line and provide pharmacists with responses in real-time regarding utilization within PDUR standards recommended by the New Jersey Drug Utilization Review (DUR) Board. Similar responses related to EMC or paper claims processed by the New Jersey Medicaid Management Information System (NJMMIS) shall be received by pharmacies on the Remittance Advice statement.
1. PDUR standards approved by the New Jersey DUR Board shall be based on standards established by First Data Bank (FDB) as part of the FDB DUR information system. The FDB standards are incorporated herein by reference and may be obtained from First Data Bank, The Hearst Corp., 1111 Bayhill Dr., San Bruno, CA 94066.
2. PDUR standards adopted by the New Jersey Drug Utilization Review (DUR) Board shall be applied to all Medicaid and NJ FamilyCare pharmacy claims resulting from traditional pharmacy services provided in nursing facilities, regardless of the mode of claim submission.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 3 - CONSULTANT PHARMACIST SERVICES › Section 10:51-3.1 - Introduction

Current through Register Vol. 56, No. 14, July 15, 2024
All services required of a consultant pharmacist in nursing facilities as stipulated in Federal and State statutes, rules and regulations, including, but not limited to, those listed in this subchapter, shall be provided.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 3 - CONSULTANT PHARMACIST SERVICES › Section 10:51-3.2 - Definition of consultant pharmacist

Current through Register Vol. 56, No. 14, July 15, 2024
The term "consultant pharmacist" shall mean a pharmacist licensed by the New Jersey State Board of Pharmacy, and who meets the qualifications in 10:51-3.3.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 3 - CONSULTANT PHARMACIST SERVICES › Section 10:51-3.3 - Qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
Qualifications shall include holding a valid license as a registered pharmacist issued by the New Jersey State Board of Pharmacy.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Appendix A

Current through Register Vol. 56, No. 14, July 15, 2024
DRUG EFFICACY STUDY IMPLEMENTATION (DESI)
(Update of Drug Products and Known Related Drug Products that Lack Substantial Evidence of Effectiveness)
Appendix A is a list of drugs that the Food and Drug Administration (FDA) has proposed to withdraw from the market. The list is updated periodically by the Centers for Medicare and Medicaid Services subsequent to published listing changes in the Federal Register, in accordance with
21 CFR 310.6
.
AGENCY NOTE: Appendix A is filed as a part of this chapter/manual, but is not reproduced in the New Jersey Administrative Code. When revisions are made to Appendix A, replacement pages will be distributed to providers, placed on the website at
www.njmmis.com
and copies will be filed with the Office of Administrative Law.
For a copy of Appendix A, 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 51 - PHARMACEUTICAL SERVICES MANUAL › Appendix B

Current through Register Vol. 56, No. 14, July 15, 2024
UPPER PAYMENT LIMITS FOR MAXIMUM ALLOWABLE COST (MAC) DRUGS
Appendix B lists the multiple source drugs which meet the criteria set forth in 42 CFR Part 447, Subpart I, which is updated periodically by the Centers for Medicare and Medicaid Services subsequent to published listing changes in the Federal Register.
AGENCY NOTE: Appendix B is filed as a part of this chapter/manual but is not reproduced in the New Jersey Administrative Code. When revisions are made to Appendix B, replacement pages will be distributed to providers, placed on the website at
www.njmmis.com
and copies will be filed with the Office of Administrative Law.
For a copy of Appendix B, 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 51 - PHARMACEUTICAL SERVICES MANUAL › Appendix D

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. When revisions are made to the Fiscal Agent Billing Supplement, replacement pages will be distributed to providers, placed on the website at
www.njmmis.com
and copies will be filed with the Office of Administrative Law.
For 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 51 - PHARMACEUTICAL SERVICES MANUAL › Appendix E

Current through Register Vol. 56, No. 14, July 15, 2024
ELECTRONIC MEDIA CLAIMS (EMC) MANUAL
AGENCY NOTE: The Electronic Media Claims (EMC) Manual is filed as an incorporated Appendix of this chapter/manual, but is not reproduced in the New Jersey Administrative Code. When revisions are made to the EMC Manual, replacement pages will be distributed to providers, placed on the website at
www.njmmis.com
and copies will be filed with the Office of Administrative Law.
For a copy of the EMC Manual, write to:
Molina Medicaid Solutions
PO Box 4801
Trenton, New Jersey 08650-4801
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Appendix F

Current through Register Vol. 56, No. 14, July 15, 2024
MEDICAID REBATE PROGRAM MANUFACTURERS' LABELER CODE LIST
Appendix F is a list of drug manufacturers, identified by labeler code, whose drug products are covered by the Medicaid and NJ FamilyCare fee-for-service programs. These drug manufacturers have in effect a rebate agreement pursuant to
42 U.S.C. 1396
-r-8(a), (b) and (c). This list is updated periodically by the Centers for Medicare and Medicaid Services subsequent to published listing changes in the Federal Register.
AGENCY NOTE: Appendix F is filed as a part of this chapter/manual but is not reproduced in the New Jersey Administrative Code. When revisions are made to Appendix F, replacement pages will be distributed to providers, placed on the website at
www.njmmis.com
and copies will be filed with the Office of Administrative Law.
For a copy of Appendix F, 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 52 - HOSPITAL SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:52-1.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This chapter outlines the policies and procedures of the Division for the provision of inpatient and outpatient (including emergency room) hospital services to Medicaid/NJ FamilyCare fee-for service beneficiaries. These policies and procedures apply to general hospitals, special hospitals, rehabilitation hospitals, and psychiatric hospitals, unless specifically indicated otherwise.
(b) Unless otherwise stated, the rules of this chapter apply to Medicaid/NJ FamilyCare fee-for-service beneficiaries and to Medicaid/NJ FamilyCare fee-for-service services that are not the responsibility of the managed care organization with which the beneficiary is enrolled. Hospital services that are to be provided by the beneficiary's selected managed care organization (MCO) are governed and administered by that MCO in accordance with the Division's rules for MCOs at N.J.A.C. 10:74, the MCO's policies and procedures, and the MCO's provider contract with the State, and all amendments thereto.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:52-1.3 - Criteria for participation: outpatient hospital services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division shall reimburse approved hospitals to provide covered outpatient hospital services, where applicable, in accordance with all the provisions of this chapter. In order to be approved and reimbursed as an outpatient hospital service, effective in accordance with the dates in (c) below, each site that provides an outpatient hospital service for which the hospital bills the Medicaid/NJ FamilyCare fee-for-service program as an outpatient hospital service shall have been approved by the Division in accordance with this rule. Such approval shall include sites located in the main inpatient hospital, and both the contiguous and non-contiguous sites.
(b) Each site shall meet all of the following criteria prior to receiving reimbursement from the Medicaid/NJ FamilyCare fee-for-service program as an outpatient hospital service, effective in accordance with the dates in (c) below:
1. The entity shall be physically located in close proximity to the hospital, and both the entity and the hospital shall service the same patient population (such as from the same service or catchment area);
i. In determining close proximity, the following factors will be considered:
(A) The distance between the entity and the inpatient hospital facility;
(B) The physical location (inner-city, urban, suburban or rural area) of the inpatient hospital facility and the entity; and
(C) The availability of other inpatient hospital facilities providing the same services located closer to the entity than the hospital requesting the outpatient designation.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:52-1.5 - Eligibility of beneficiary for hospital services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Hospital services shall not be reimbursed by the Medicaid/NJ FamilyCare fee-for-service program when hospital services were rendered prior to or after the period of beneficiary eligibility, as determined in accordance with N.J.A.C. 10:49-2.7; except that, when a Medicaid/NJ FamilyCare beneficiary in an acute care general hospital loses eligibility during an inpatient hospital stay, but was eligible on the date of admission, eligibility shall continue for hospital inpatient services for the entire length of that hospital stay.
(b) When a patient is admitted to a hospital and is determined Medicaid/NJ FamilyCare eligible subsequent to the date of admission, charges incurred during the ineligible period of the hospital stay shall not be reimbursable, unless coverage is pursued and approved under retroactive eligibility.
(c) For coverage of services rendered prior to date of application for Medicaid/NJ FamilyCare, the beneficiary shall apply for retroactive eligibility, in accordance with N.J.A.C. 10:49-1.1.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:52-1.6 - Covered services (inpatient and outpatient)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division will cover those inpatient services ordinarily furnished by an approved hospital maintained for the treatment and care of patients, and provided to any Medicaid/NJ FamilyCare fee-for-service beneficiary, for whom professionally developed criteria and standards of care were used to determine that the beneficiary warranted an appropriate hospital level of care for a given diagnosis or problem.
1. Inpatient psychiatric services in approved beds in a general hospital for patients of any age shall be covered services.
2. Inpatient room and board service shall be provided in a semi-private accommodation. Accommodations other than semi-private require certification of medical necessity or lack of availability of semi-private accommodations.
3. Inpatient services in an acute general hospital rendered the day after acute care is no longer medically necessary shall be covered only under specified conditions. (See Social Necessity Days in 10:52-1.14 and Administrative Days in 10:52-1.9.)
4. Non-physician services, supplies, and equipment supplied by an outside vendor to Medicaid/NJ FamilyCare beneficiaries who are receiving inpatient acute care hospital services shall be covered directly under the hospital reimbursement system. Vendor claims for these services are the responsibility of the acute care hospital where the beneficiary is a patient and shall not be billed directly to the Medicaid/NJ FamilyCare fiscal agent.
5. For beneficiaries in the Medically Needy Program, inpatient hospital services shall be available only to pregnant women. For information on how to identify a Medicaid beneficiary in the Medically Needy Program, refer to 10:49-2.3(c), Administration.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:52-1.7 - Offset of disproportionate share hospital payments

Current through Register Vol. 56, No. 14, July 15, 2024
The Division shall, upon receipt of documentation from the Department of Health, apply an offset to a hospital's disproportionate share hospital Medicaid/NJ FamilyCare payments to collect delinquent statutory and regulatory debts owed by the hospital to the State arising under the Health Care Facilities Planning Act, N.J.S.A. 26:2H-1et seq., and the implementing regulations.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:52-1.8 - Non-covered services (inpatient and outpatient)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following non-covered services (inpatient and outpatient) shall not be eligible for payment by the Division:
1. Hospital admissions of the following description:
i. Admission for any condition for which hospitalization is not medically necessary;
ii. Admission primarily for rest cure, custodial care, convalescent care or diet therapy for exogenous obesity;
iii. Admission for illnesses which, according to generally accepted professional standards, are not amenable to favorable modification. However, psychiatric services in a general hospital shall be covered for the purpose of determining that such disorders or illness (such as senility) are not amenable to favorable modification;
iv. Admission for diagnostic procedures which may be done on an out-of-hospital basis including, but not limited to, laboratory tests, electrocardiograms and diagnostic radiological services;
v. Admission or extension of hospital stay solely for research or teaching studies;
vi. Admission for inpatient services provided in an approved private psychiatric hospital unless:
(1) The Medicaid beneficiary is age 65 or over;
(2) The Medicaid beneficiary has not attained age 21, except that a beneficiary who is receiving such services immediately preceding the date on which he or she attained age 21 will continue to be covered until the date the individual no longer requires such services or the date the individual reaches age 22, whichever occurs first;
(3) The NJ FamilyCare-Plan A beneficiary has not attained the age of 21; or
(4) The FamilyCare-Children's Program-Plan B, C or D beneficiary has not attained the age of 19; and
vii. Admission of beneficiaries in the Medically Needy Program, except for pregnant women. For information on how to identify a Medically Needy beneficiary, see 10:49-2.3(c), Administration.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:52-1.9 - Administrative days (nursing facility level of care)-general, special (Classification A & B) and private psychiatric hospitals

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For a patient who is no longer in need of inpatient acute level of care and who is awaiting placement in a nursing facility, payment shall be made for "administrative days" if the general, special, rehabilitation, or the private psychiatric hospital is able to demonstrate the following:
1. All other possible health insurance benefits have been utilized;
2. Discharge planning was initiated upon admission of the patient to the hospital and was reviewed and updated regularly;
3. Within one working day of identifying a Medicaid/NJ FamilyCare-Plan A beneficiary as being at risk for nursing facility placement, the hospital notified the Medical Assistance Customer Center (MACC), CWA, and the Office of Community Choice Options (OCCO). See N.J.A.C. 10:52-1.11, Preadmission screening for nursing facility placement; and
4. The care and services provided are medically necessary, that is, the attending physician wrote a discharge order from acute care or made a written entry in the medical record that the patient could be transferred to a nursing facility (NF), a Preadmission Screening Evaluation (PAS) confirmed the necessity for nursing facility services and placement could not be made in a NF, as substantiated by documentation of timely and continuous contact (at a minimum, twice a week) with family members, nursing facilities (NFs), and placement agencies.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:52-1.12 - Recordkeeping

Current through Register Vol. 56, No. 14, July 15, 2024
Hospitals shall be required to keep 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. This information shall be available upon the request of the Division or its agents.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:52-1.13 - Second opinion program for elective surgical procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A second opinion shall be obtained for any elective surgical procedures listed under (b) below. The outcome of the second opinion shall have no bearing on reimbursement. Once the second opinion is rendered, the beneficiary shall retain the right to decide whether or not to proceed with the surgery; however, failure to obtain a second opinion for these procedures shall result in a denial of the hospital claim.
1. If the operating physician determines that the need for surgery is urgent or is an emergency, no second opinion shall be required. "Urgent" or "emergency" includes any situation in which a delay in performing surgery in order to meet the second opinion requirement could result in a significant threat to the patient's health or life.
i. Reimbursement for urgent or emergency surgery shall be made only if a specific statement is attached to the claim form by the operating physician certifying that the second opinion requirement was not met and substantiating the urgent or emergency nature of the surgery.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:52-1.14 - Social Necessity Days

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Payment for "Social Necessity Days" shall be made to hospitals for a maximum of 12 calendar days per hospitalization for a Medicaid/NJ FamilyCare-Children's Program fee-for-service beneficiary child admitted with the diagnosis of child abuse or suspected child abuse, if special circumstances (social necessity) prevent the discharge or transfer of the patient and the hospital has taken effective action to initiate discharge or transfer of the patient.
1. For these cases, it is not necessary for the day of admission to be at the acute level of care.
2. Effective action is defined as telephone notification to the county welfare agency (CWA), or Division of Child Protection and Permanency *(CP&P) local* office, or other responsible officials as may be designated, within 48 hours of the time that the stay is determined to be no longer medically necessary. This telephone contact *then* shall be confirmed in writing within three working days. A copy of the written notification shall be submitted with all claims for which reimbursement is claimed for special circumstances (social necessity).
3. Medicaid/NJ FamilyCare-Children's Program reimbursement for social necessity shall be made to hospitals paid in accordance with the DRG rate setting methodology in N.J.A.C. 10:52-5 through 7 and 9 prior to August 3, 2009, and in accordance with N.J.A.C. 10:52-14on or after August 3, 2009.
i. Payment for Social Necessity Days will be made at the Statewide average per diem rate paid to Medicaid participating nursing facilities (NF) as determined on January 1 of each calendar year.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:52-1.16 - Utilization control: inpatient psychiatric services for beneficiaries under 21 years of age in private psychiatric hospitals

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This section specifies the unique requirements for certification of the need for inpatient psychiatric services provided to beneficiaries under 21 years of age in private psychiatric hospitals. In accordance with Section 1905(a)16 and (h) of the Social Security Act, a team, consisting of physicians and other qualified personnel, shall determine that inpatient services are necessary and can reasonably be expected to improve the beneficiary's condition. This section also includes general requirements; certification of the need for services, which involves "active treatment" as defined in (c) below; requirements for the team certifying the need for services; and requirement for an individual plan of care. These requirements do not apply to an admission to a psychiatric unit of a general hospital. See 10:52-1.15 for requirements on utilization control in an acute care general hospital.
(b) This rule applies only to inpatient psychiatric services in an approved private psychiatric hospital for the treatment of children and youths before NJ FamilyCare-Children's Program beneficiaries reach age 19 and before the Medicaid beneficiary reaches age 21 or, if the Medicaid beneficiary was receiving the services immediately before he reached age 21, before the earlier of the following:
1. The date the beneficiary no longer requires the services; or
2. The date the beneficiary reaches age 22. (See 42 CFR 441.151 ).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:52-1.17 - Utilization control; outpatient psychiatric services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following requirements in this rule were developed to help ensure the appropriate utilization of outpatient psychiatric services. These include the role of the evaluation team in relation to the patient's treatment regimen, with emphasis placed on intake evaluation, development of a plan of care, performance of periodic reviews for evaluation purposes, and supportive documentation for services rendered. Outpatient psychiatric services include the initial evaluation; individual psychotherapy; group psychotherapy; family therapy; family conference; partial hospitalization (see 10:52-2.10 ); psychological testing; and medication management.
(b) The intake evaluation shall be performed as follows:
1. An intake evaluation shall be performed within 14 days or by the third outpatient visit, whichever is later, for each Medicaid beneficiary being considered for continued treatment, and shall consist of a written assessment that:
i. Evaluates the beneficiary's mental condition; and
ii. Determines whether treatment in the program is appropriate, based on the patient's diagnosis; and,
iii. Includes certification (signed statement) by the evaluation team that the program is appropriate to meet the patient's treatment needs; and,
iv. Is made part of the patient's records.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:52-1.18 - Advance directives

Current through Register Vol. 56, No. 14, July 15, 2024
All hospitals participating in the New Jersey Medicaid/NJ FamilyCare program are subject to the provisions of State and Federal statutes regarding advance directives including, but not limited to, appropriate notification to patients of their rights, development of policies and practices and communication to, and education of, staff, community and interested parties. See 10:49-9.15, and sections 1902(a)(58), and 1902(w)(1) of the Social Security Act ( 42 U.S.C. §§
										1396a(a)(58) and 1396a(w) ) for detailed information.