reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 2 - POLICIES AND PROCEDURES RELATED TO SPECIFIC SERVICES › Section 10:52-2.1 - Ambulatory Surgical Center (ASC)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An Ambulatory Surgical Center (ASC) shall be any distinct entity that operates for the purpose of providing surgical services to patients not requiring hospitalization which has an agreement with the Centers for Medicare & Medicaid Services (CMS) to participate in the Medicare program and meets the specific conditions for coverage set forth in Federal regulations in 42 CFR Part 416.
(b) An ASC, as described in N.J.A.C. 10:66-5, may be operated by a hospital that is under common ownership or control of a hospital.
1. An ASC operated by a hospital shall be a separately identifiable entity physically and administratively and shall be financially independent and distinct from other operations of the hospital.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 2 - POLICIES AND PROCEDURES RELATED TO SPECIFIC SERVICES › Section 10:52-2.2 - Blood and blood products

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Reimbursement may be made for blood provided to an inpatient or an outpatient of an approved hospital when prescribed and supervised by a licensed physician.
(b) Whole blood and derivatives, and necessary processing and administration thereof, may be reimbursed with the following limitations:
1. Efforts should be made by the family or the provider to arrange for the replacement of blood. This can be done by the contribution of a blood donor or by using a blood replacement plan in which the Medicaid/NJ FamilyCare fee-for-service eligible beneficiary is a beneficiary of the blood replacement plan (if available).
2. The cost of donated blood or blood products (including autologous donation) received through a replacement plan shall not be reimbursable. However, the charge for phlebotomy, cross-matching, indexing, storage and transfusing shall be reimbursable.
3. In order to obtain Medicaid/NJ FamilyCare reimbursement, the hospital shall submit a certification that a voluntary blood donation cannot be obtained.
i. When arrangements for payment for the replacement of blood are not accomplished, reimbursement to the hospital shall be 100 per cent of the "add-on" charge.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 2 - POLICIES AND PROCEDURES RELATED TO SPECIFIC SERVICES › Section 10:52-2.3 - Dental services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Dental services in the outpatient department shall be provided in accordance with the requirements contained in N.J.A.C. 10:56, Dental Services. The outpatient dental department shall be subject to the same policies and procedures that apply to the Medicaid/NJ FamilyCare fee-for-service provider of dental services in the community, with the following exceptions:
1. Emergency dental care provided under special circumstances in a hospital emergency room; or
2. Outpatient dental services provided to NJ Medicaid/NJ FamilyCare fee-for-service beneficiaries with chronic medical conditions and/or developmental disabilities resulting in special healthcare needs.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 2 - POLICIES AND PROCEDURES RELATED TO SPECIFIC SERVICES › Section 10:52-2.4 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is a Federally-mandated comprehensive and preventive child health program for Medicaid/NJ FamilyCare-Children's Program fee-for-service beneficiaries from birth through 20 years of age (see 42 CFR 441 Subpart B). The goal of the program is to assess the beneficiary's health needs through initial and periodic examinations (screenings); to provide health education and guidance; and to assure that health problems are prevented, diagnosed, and treated at the earliest possible time.
1. As a condition of participation in Medicaid/NJ FamilyCare, all ambulatory care facilities (including hospital outpatient departments) providing primary care to children and adolescents from birth through 20 years of age, shall participate in the EPSDT program and shall provide, at a minimum, the required EPSDT screening services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 2 - POLICIES AND PROCEDURES RELATED TO SPECIFIC SERVICES › Section 10:52-2.5 - Family planning services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Family planning services shall include medical history and physical examination (including pelvis and breast), diagnostic and laboratory tests, drugs and biologicals, medical supplies and devices, counseling, continuing medical supervision, continuity of care and genetic counseling.
(b) Services provided primarily for the diagnosis and treatment of infertility, including sterilization reversals, and related medical visits, drugs, laboratory, radiological and diagnostic services and surgical procedures shall not be covered services, except:
1. When a service is provided that is ordinarily considered an infertility service, but is provided for another purpose, then the hospital shall submit the claim with supporting documentation for medical review and approval of payment to the Division of Medical Assistance and Health Services, Office of Provider Relations, PO Box 712, Mail Code #27, Trenton, New Jersey 08625-0712.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 2 - POLICIES AND PROCEDURES RELATED TO SPECIFIC SERVICES › Section 10:52-2.6 - Home health agencies; hospital-based

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A home health agency (hospital-based) shall be licensed by the New Jersey State Department of Health, certified as a home health agency under Title XVIII (Medicare), possess a valid and current provider agreement from the Division, and be an identifiable part of a hospital.
(b) The provision of home health care services can range from a complex concentrated professional program (for acute care cases) which would require the services of a public health nurse, registered professional nurse, a licensed practical nurse, physical therapist, occupational therapist, speech pathologist, medical social worker, and homemaker/home health aide to a less complex program (as in chronic care cases) involving a homemaker/ home health aide, personal care assistant and/or therapist and minimal visits by a registered nurse. The types of services provided, the frequency and the duration of these services are determined by the needs of each beneficiary. Only medically necessary home health services shall be reimbursed by the Division.
(c) Division requirements for Home Health Agencies (Hospital-based) are located in N.J.A.C. 10:60, Home Care Services. A hospital wishing to become a provider of home health services should contact Molina Medicaid Solutions Provider Enrollment, PO Box 4804, Trenton, NJ 08650, or the website
www.njmmis.com
and click on the Provider Enrollment Application. The application can be completed online or downloaded and mailed or faxed to Molina Medicaid Solutions at (609) 584-1192.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 2 - POLICIES AND PROCEDURES RELATED TO SPECIFIC SERVICES › Section 10:52-2.7 - Medical day care centers; hospital affiliated

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An adult or pediatric day health services facility shall be affiliated and identified as part of a hospital which is licensed by the New Jersey State Department of Health, in accordance with its Manual of Standards for Licensure of Adult and Pediatric Day Health Services and shall possess a valid and current provider agreement from the Division.
(b) Adult Day Health Services is a program of medically supervised, health-related services provided in a hospital affiliated ambulatory care setting to persons who are non-residents of the facility, who do not require 24-hour inpatient institutional care but, due to their physical or mental impairment, need health maintenance and restorative services to live in the community. Pediatric Day Health Services is a program which provides additional health-related services in order to provide for the needs of technology-dependent or medically unstable children.
(c) The Department of Health administers the Medicaid/NJ FamilyCare fee-for-service Adult Day Health Services and Pediatric Day Health Services programs. For program requirements, see N.J.A.C. 8:86.
1. Medical day care transportation services shall not be reimbursed by the fiscal agent as a separate service.
2. All direct and indirect costs associated with hospital-affiliated medical day care centers shall be reported separately on New Jersey State Department of Health cost filings for payment purposes and shall not be considered an allowable cost under the DRG reimbursement system.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 2 - POLICIES AND PROCEDURES RELATED TO SPECIFIC SERVICES › Section 10:52-2.8 - Substance use disorder treatment facilities; free- standing

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Division requirements for substance use disorder treatment facilities are located in N.J.A.C. 10:66, Independent Clinic Services. Services provided to a Medicaid/NJ FamilyCare fee-for-service beneficiary by a free standing hospital-affiliated substance use disorder treatment facility shall be covered only if those services are eligible for Federal Financial Participation under the Medicaid Program (Title XIX of the Social Security Act) or the NJ FamilyCare program (Title XXI of the Social Security Act) and the following conditions are met:
1. The treatment is prescribed or certified by a physician or an advance practice nurse (APN); and
2. The treatment is provided in a substance use disorder treatment facility licensed or approved by the New Jersey State Department of Health pursuant to N.J.S.A. 26:2G-21et seq., and N.J.A.C. 10:161A for residential services, N.J.A.C. 10:161B for outpatient services, and/or N.J.A.C. 10:161B-11for opioid treatment services, as applicable; and
3. The staff of the treatment facility includes a medical director.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 2 - POLICIES AND PROCEDURES RELATED TO SPECIFIC SERVICES › Section 10:52-2.9 - Organ procurement and transplantation services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division shall reimburse for medically necessary transplantation services, including organ procurement, except those transplants categorized as experimental. (See (d) below for further information on organ procurement and transplantation.)
1. Claims for transplant services and organ procurement services rendered to or items dispensed or furnished to an organ donor shall be submitted using the Health Benefits Identification Number of the Medicaid/NJ FamilyCare beneficiary who is receiving the transplant.
2. The organ donor's claim will be paid by the Medicaid/NJ FamilyCare program whether the claim is from the same hospital where the transplant service was provided to the Medicaid/NJ FamilyCare patient or from a different hospital.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 2 - POLICIES AND PROCEDURES RELATED TO SPECIFIC SERVICES › Section 10:52-2.10 - Psychiatric services; partial hospitalization

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Partial hospitalization (PH) means a psychiatric service whose primary purpose is to maximize the client's independence and community living skills in order to reduce unnecessary hospitalization. It is directed toward the acute and chronically disabled individual. A PH program shall provide, as listed below, a full system of services necessary to meet the comprehensive needs of the individual Medicaid/NJ FamilyCare fee-for-service beneficiary. These services shall include:
1. Assessment and evaluation;
2. Service procurement;
3. Therapy;
4. Information and referral;
5. Counseling;
6. Daily living education;
7. Community organization;
8. Pre-vocational therapy;
9. Recreational therapy; and,
10. Health-related services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 2 - POLICIES AND PROCEDURES RELATED TO SPECIFIC SERVICES › Section 10:52-2.12 - Renal dialysis services for end-stage renal disease (ESRD)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A hospital outpatient renal dialysis center shall be approved by the New Jersey State Department of Health to provide renal dialysis treatment for ESRD.
(b) At the beginning of a maintenance course of renal dialysis treatment for ESRD, renal dialysis centers should direct their Medicaid/NJ FamilyCare fee-for-service beneficiary to the Social Security Administration District Office to file an application for Medicare benefits, if applicable.
(c) Renal dialysis services for ESRD and Medicare approved "add-on" costs shall be reimbursable by Medicaid/NJ FamilyCare fee-for-service only when the individual is a Medicaid/NJ FamilyCare fee-for-service beneficiary and not a Medicare beneficiary, or during the time frame when ESRD services are not Medicare reimbursable.
1. Medicare coverage usually begins with the first day of the third month after the month in which a maintenance course of renal dialysis services begins. Claims from that date on shall be submitted to Medicare, unless the Medicaid/NJ FamilyCare fee-for-service beneficiary has been denied eligibility for Medicare.
i. Exception: Medicare coverage may begin earlier than the time frame stated above if the individual receives renal transplantation services or participates in a self-dialysis training program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 2 - POLICIES AND PROCEDURES RELATED TO SPECIFIC SERVICES › Section 10:52-2.13 - Sterilization

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division covers sterilization procedures performed on Medicaid/NJ FamilyCare fee-for-service beneficiaries based on Federal regulations ( 42 CFR 441.250 through 441.258 ) and related requirements outlined in this section and in the billing instructions contained in the Fiscal Agent Billing Supplement. For sterilization policy and procedures, see (b) through (e) below.
(b) "Sterilization" means any medical procedure, treatment, or operation, performed for the purpose of rendering an individual permanently incapable of reproducing. Surgical sterilization procedures are considered to be those whose primary purpose is to render an individual incapable of reproducing. Such procedures require the completion of the Federal "Consent Form" for sterilization.
(c) "Consent Form"--(Pursuant to 42 CFR 441.258 --Appendix to Subpart F--Specific Requirements for Use) requirements, including time frames to be met and/or documented on the "Consent Form" prior to the sterilization of an individual, follow:
1. The individual shall be at least 21 years of age at the time the consent is obtained;
2. The individual shall not be mentally incompetent. A "mentally incompetent individual" means an individual who has been declared mentally incompetent by a Federal, state, or local court of competent jurisdiction for any purpose, unless the individual has been declared competent for purposes which include the ability to consent to sterilization;
3. The individual shall not be institutionalized. An "institutionalized individual" means an individual who is:
i. Involuntarily confined or detained, under a civil or criminal statute, in a correctional or rehabilitative facility, including a mental hospital or other facility for the care and treatment of mental illness; or,
ii. Confined, under a voluntary commitment, in a mental hospital or other facility for the care and treatment of mental illness;
4. The individual shall have voluntarily given informed consent;
5. At least 30 days, but not more than 180 days, shall have passed between the date of informed consent and the date of sterilization, except in the case of emergency abdominal surgery or premature delivery;
i. In the case of emergency abdominal surgery, at least 72 hours shall have passed between the date he or she gave informed consent and date of sterilization;
ii. In the case of premature delivery, informed consent shall have been given at least 30 days before the expected date of delivery and at least 72 hours have passed between the date of informed consent and the date of premature delivery.
6. In the case where a patient desires to be sterilized at the time of delivery, the "Consent Form" shall be signed by the patient no earlier than the 5th month of pregnancy to minimize the possibility of exceeding the 180 day limit.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 2 - POLICIES AND PROCEDURES RELATED TO SPECIFIC SERVICES › Section 10:52-2.14 - Hysterectomy

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division covers hysterectomy procedures performed on Medicaid/NJ FamilyCare fee-for-service beneficiaries based on Federal regulations ( 42 CFR 441.250 through 441.258 ) and related requirements outlined in this section and in the billing instructions. For hysterectomy requirements see (b) through (d) below. In addition, see N.J.A.C. 10:52-1.13for the requirements for a Second Surgical Opinion for performing a hysterectomy.
(b) "Hysterectomy" means an operation for the purpose of removing the uterus.
1. A hysterectomy shall not be performed solely for the purpose of rendering an individual permanently incapable of reproducing. A hysterectomy shall be covered as a surgical procedure if performed primarily for the purpose of removing a pathological organ.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 2 - POLICIES AND PROCEDURES RELATED TO SPECIFIC SERVICES › Section 10:52-2.15 - Termination of pregnancy

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division shall reimburse for medically necessary termination of pregnancy procedures on Medicaid/NJ FamilyCare beneficiaries when performed by a physician in accordance with N.J.A.C. 13:35-4.2. These services are reimbursed fee-for-service for all beneficiaries, including individuals enrolled in an MCO.
(b) A physician may take the following factors into consideration in determining whether a termination of pregnancy is medically necessary:
1. The termination of the pregnancy is necessary to save the life of the mother;
2. The pregnancy was the result of an act of rape;
3. The pregnancy was the result of an act of incest; or
4. In the physician's professional judgment, the termination was medically necessary, consistent with the following factors:
i. Physical, emotional, and psychological factors;
ii. Family reasons; and
iii. The age of the mother.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 2 - POLICIES AND PROCEDURES RELATED TO SPECIFIC SERVICES › Section 10:52-2.16 - Transportation services; hospital-based

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Transportation shall be recognized by the Division as a covered outpatient hospital service under the following conditions:
1. Hospital-based emergency ambulance service for inpatient admission or outpatient services. For the definition of "emergency conditions", see 10:49-6.1, Administration, Prior and Retroactive Authorization.
2. When a hospital is under contract with a municipality, county, or other government unit, to provide "911" or rescue squad ambulance service, reimbursement shall only be permitted on a fee-for-service basis under the policies and procedures as defined in 10:50-1.2, Transportation Services.
3. Each hospital providing ambulance service to Medicaid/NJ FamilyCare fee-for-service beneficiaries shall possess all of the following:
i. An approved certificate of need for ambulance service from the New Jersey State Department of Health; and
ii. A provider license and vehicle license(s) for ambulance service from the New Jersey State Department of Health.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 3 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:52-3.1 - Purpose

Current through Register Vol. 56, No. 14, July 15, 2024
The purpose of HealthStart shall be to provide comprehensive maternity care services to pregnant Medicaid/NJ FamilyCare fee-for-service beneficiaries, (including those determined to be presumptively eligible) and preventive child health care services for Medicaid/NJ FamilyCare fee-for-service beneficiaries up to the age of two.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 3 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:52-3.2 - Scope of services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) HealthStart maternity care services provided by a HealthStart-certified provider shall be obstetrical care services provided in accordance with the recommendations of the American College of Obstetricians and Gynecologists and a program of support services provided in accordance with the New Jersey Department of Health's "HealthStart Comprehensive Maternity Care Services Program Guidelines," dated 1997, available from the Department of Health.
(b) HealthStart comprehensive maternity care includes both medical maternity care services and health support services, which are described in (b)1 and 2 below:
1. Medical maternity care services shall include, but shall not be limited to:
i. Ambulatory prenatal services;
ii. Admission arrangements for delivery;
iii. Obstetrical delivery services; and
iv. Postpartum medical services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 3 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:52-3.3 - HealthStart provider participation criteria

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following Medicaid/NJ FamilyCare fee-for-service-enrolled provider types shall be eligible to participate as HealthStart providers:
1. Independent clinics;
2. Federally qualified health centers;
3. Hospital outpatient departments;
4. Local health departments;
5. Physician groups; and
6. Certified nurse midwives meeting the New Jersey Department of Health's Improved Pregnancy Outcome criteria.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 3 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:52-3.4 - Termination of HealthStart Comprehensive Maternity Provider Certificate

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey State Department of Health shall enforce its requirements for HealthStart Comprehensive Maternity Provider Certificates and for evaluation and enforcement of its requirements within the standards and guidelines for HealthStart providers.
(b) Failure to comply with HealthStart standards shall be cause for termination of the HealthStart Comprehensive Maternity Provider Certificate by the New Jersey State Department of Health.
1. A HealthStart Comprehensive Maternity Provider Certificate shall be time-limited. Failure to complete the recertification process shall result in termination of the provider's HealthStart provider status by the New Jersey State Department of Health.
2. Termination of the HealthStart Comprehensive Maternity Provider Certificate shall result in the termination of the HealthStart Provider Agreement with the Medicaid NJ FamilyCare fee-for-service program. Providers who are terminated shall have the right to request a hearing in accordance with N.J.A.C. 10:49-10.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 3 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:52-3.5 - Standards for a HealthStart Comprehensive Maternity Care Provider Certificate

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Comprehensive maternity care services shall be integrated and coordinated.
(b) HealthStart maternity care providers, excluding physicians and nurse midwives who are in private practice, shall provide comprehensive maternity care services within the following organizational requirements:
1. Providers shall provide directly or through an approved agreement, at one contiguous site, the following services: ambulatory prenatal and postpartum care; case coordination services; nutrition assessment; guidance and counseling services; health education assessment and instruction; and social-psychological assessment, guidance and counseling;
2. Providers shall provide or arrange for the admission of patients to the appropriate level of care facility for obstetrical care delivery services;
3. Providers shall provide or arrange for all necessary laboratory services;
4. Providers shall provide one or more prenatal home visits for each high risk patient;
5. Providers shall provide at least one postpartum home visit for each high risk patient;
6. Providers shall adopt policies and procedures to assure the delivery of coordinated, integrated and comprehensive care; and
7. Providers shall provide referral and follow-up services, which shall include, but shall not be limited to: referral for specialized evaluations, counseling and treatment for extensive social, psychological, nutritional and medical needs.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 3 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:52-3.6 - Access to services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All HealthStart services shall be accessible to patients.
(b) HealthStart maternity care providers shall facilitate patient access to services by scheduling an initial medical visit appointment within two weeks of the patient's first request for services.
(c) HealthStart maternity care providers shall provide or arrange for 24-hour access to case coordination and medical services for emergency situations.
(d) HealthStart maternity care providers shall arrange for language translation or interpretation services.
(e) HealthStart maternity care providers may implement presumptive eligibility processing if so approved by the Division of Medical Assistance and Health Services.
(f) HealthStart maternity care providers shall undertake community outreach activities to encourage women to seek early prenatal care and increase awareness of the availability of maternity care services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 3 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:52-3.7 - Plan of care

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A plan of care shall be developed and maintained by the case coordinator for each patient.
(b) A plan of care shall be based on the medical, nutritional, social-psychological and health education assessments.
(c) A plan of care shall include, but shall not be limited to: identification of risk conditions and problems, prioritization of needs, outcome objectives, planned interventions, time frames, referrals, follow-up activities and identification of staff responsible for the services.
(d) The plan of care shall be developed and revised in consultation with the patient and staff providing services to the patient.
(e) The initial plan of care shall be completed after a case conference and no later than one month after the initial registration visit.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 3 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:52-3.8 - Maternity medical care services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Maternity medical care services shall include antepartum, intrapartum, and postpartum care provided by the obstetrical care practitioner(s) in accordance with New Jersey State Department of Health's HealthStart Comprehensive Maternity Care Services Program Guidelines.
(b) Prenatal services shall be as follows:
1. Frequency of prenatal visits for an uncomplicated pregnancy shall be every four weeks during the first 28 weeks; then every two weeks until 36 weeks; and weekly thereafter. Prenatal visits for complications shall be scheduled as needed.
2. Initial prenatal visit content shall include, but not be limited to:
i. History;
ii. Review of systems;
iii. Comprehensive physical examination;
iv. Risk assessment;
v. Patient counseling;
vi. Routine laboratory tests;
vii. Development of the plan of care; and
viii. Special tests and/or procedures as medically indicated.
3. Subsequent prenatal visit content shall include, but not be limited to:
i. Review and revision of the patient plan of care;
ii. Interim history;
iii. Physical examination;
iv. Patient counseling and treatment;
v. Laboratory tests;
vi. Special tests and/or procedures which are medically indicated;
vii. Identification of new or developing problems; and
viii. Management, including transfers, of any new or persistent problems.
4. Transfer of prenatal records to the hospital of delivery shall occur no later than 34 weeks gestation.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 3 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:52-3.9 - Health support services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Case coordination services shall facilitate the delivery of continuous, coordinated, and comprehensive services for each patient in accordance with the New Jersey State Department of Health's "HealthStart Comprehensive Maternity Care Services Program Guidelines," as follows:
1. A permanent case coordinator shall be assigned to each patient no later than two weeks after the HealthStart enrollment visit.
2. Prenatal case coordination activities shall include, but shall not be limited to:
i. Orienting the patient to all services;
ii. Developing, maintaining and coordinating the plan of care in consultation with the patient;
iii. Coordinating and monitoring the delivery of all services and referrals;
iv. Monitoring and facilitating the patient entry into and continuation with maternity services;
v. Facilitating and providing advocacy for obtaining referral services;
vi. Reinforcing health teachings and providing support;
vii. Providing vigorous follow-up for missed appointments and referrals;
viii. Arranging home visits;
ix. Meeting with the patient and coordinating patient care conferences; and
x. Reviewing, monitoring and updating the patient's complete record.
3. Postpartum case coordination activities shall include, but shall not be limited to, the following:
i. Arranging and coordinating the postpartum visit and any home visit;
ii. Arranging with the obstetrical care provider to obtain the labor, delivery and postpartum hospital summary record information no later than two weeks after delivery;
iii. Linking the patient to appropriate service agencies including: the Special Supplemental Food Program for Women, Infants and Children Program (WIC), pediatric care, future family planning, Special Child Health Services, the County-Based Special Child Health and Early Intervention Services Case Management Units, early intervention services for infants with disabilities and other health and social agencies, if needed;
iv. Arranging for the transfer of pertinent information or records to the pediatric care and/or future family planning service providers;
v. Coordinating referrals and following up on missed appointments and referrals; and
vi. Reinforcing health instruction for mother and baby.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 3 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:52-3.10 - Professional staff requirements for HealthStart Comprehensive Maternity Care services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All HealthStart comprehensive maternity care services shall be delivered through a team approach by qualified professionals.
(b) Physicians and certified nurse midwives shall be Medicaid/NJ FamilyCare fee-for-service providers and have obstetrical admitting privileges at a licensed maternity care facility.
(c) Case coordinators shall have, at a minimum, a license as a registered nurse; or a Bachelor's degree in social work, health or a behavioral science.
(d) Health professionals shall have a valid license to practice their professions, as required by the State of New Jersey.
(e) All other professionals, for whom no license to practice is required, shall meet generally accepted professional standards for qualification.
(f) Paraprofessionals shall be familiar with the local community, have knowledge or skills in maternal and child health services and shall be supervised by a health professional.
(g) Prenatal, delivery, and postpartum medical services shall be delivered by a physician or a certified nurse midwife.
(h) Nutrition, social-psychological and health education assessments and development of the plan of care shall be provided by appropriate professionals in each of the specialty areas, or by case coordinators or medical care professionals. If the nutrition or social-psychological assessment portion of the plan of care is provided by a case coordinator or medical care professional, then these portions shall be reviewed by a nutritionist or social worker, respectively.
(i) Nutrition and social-psychological basic counseling shall be provided by a case coordinator with at least one year of experience in providing services to maternity patients or by the appropriate specialist in each of the areas or by a registered nurse or obstetrical care provider.
(j) Short term specialized social-psychological and nutrition counseling services shall be provided by a social worker and nutritionist, respectively. The social worker and nutritionist shall be available on site during patient visits.
(k) There shall be adequate professional, paraprofessional and clerical staff to provide, in a timely manner, maternity care services as described herein which meet the needs of the patients.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 3 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:52-3.11 - Records; documentation, confidentiality, and informed consent requirements for HealthStart maternity care providers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) HealthStart maternity care providers shall have policies which protect patient confidentiality, provide for informed consent and document prenatal, labor, delivery, and postpartum services in accordance with the Department of Health's "HealthStart Comprehensive Maternity Care Services Program Guidelines."
(b) An individual record shall be maintained for each patient throughout the pregnancy.
(c) Each record shall be confidential and shall include at least the following: history and physical examination findings assessment, a plan of care, treatment services, laboratory reports, counseling and health instructions provided and documentation of referral and follow-up services.
(d) There shall be policies and procedures for appropriate informed consent for all HealthStart services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 3 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:52-3.12 - Standards for HealthStart pediatric care

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Pediatric care services shall be comprehensive, integrated and coordinated.
(b) HealthStart pediatric care providers shall be Medicaid/NJ FamilyCare fee-for-service providers and shall:
1. Directly provide preventive child health care, maintenance of complete patient history, outreach for preventive care, initiation of referrals for appropriate medical, educational, social, psychological and nutrition services, and follow-up of referrals and sick care;
2. Directly provide or arrange for non emergency room-based, 24-hour physician telephone access for eligible patients; and
3. Directly provide or arrange for sick care and emergency care.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 3 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:52-3.13 - Professional requirements for HealthStart pediatric care providers

Current through Register Vol. 56, No. 14, July 15, 2024
All HealthStart pediatric care providers shall be pediatricians or have a physician on staff who possesses a knowledge of pediatrics. This may be demonstrated by eligibility for board certification by the American Academy of Pediatrics, the American Osteopathic Board of Pediatrics, or by hospital admitting privileges in pediatrics.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 3 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:52-3.14 - Preventive care services provided by HealthStart pediatric care providers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) HealthStart pediatric care providers shall provide preventive health visits in accordance with the recommended guidelines of the American Academy of Pediatrics. The schedule shall include a two-to four-week visit, two-month visit, four-month visit, six-month visit, nine-month visit, 12-month visit, 15-month visit, 18-month visit and 23-to 24-month visit. Each visit shall include, at a minimum, medical, family and social history, unclothed physical examination, developmental and nutritional assessment, vision and hearing screening, dental assessment, assessment of behavior and social environment, anticipatory guidance, age appropriate laboratory examinations, and immunizations. Referrals shall be made as appropriate.
(b) Each provider shall provide or arrange for sick care and 24-hour telephone physician access during non-office hours. If not directly provided by the HealthStart provider, sick care and 24-hour telephone access shall be provided for each child by a single designated provider via a documented agreement. Information on care given shall be communicated to the primary HealthStart pediatric care provider. Telephone access provided exclusively via emergency room staff shall not be permitted. Referral to the emergency room should occur only for emergency medical care or urgent care.
(c) Case coordination outreach and follow-up services shall include letter or telephone call reminders to the child's parent or guardian for preventive well-child visits and letter or telephone follow-up of missed appointments. Referrals for home visit services for follow-up shall be made when appropriate. For all referrals and follow-up visits, the provider shall document the completion of such referrals or visits. If the referral is not completed, a letter or phone call to the child's parent or guardian and to the referred agency shall be sent or made, encouraging the follow through of the referral. All of the activity shall be recorded on the patient's chart.
(d) All HealthStart pediatric care providers shall make provision for consultation for specialized health and other pediatric services. Services shall include medical services, as well as social, psychological, educational, and nutrition services. This may include, but shall not be limited to: the Special Supplemental Food Program for Women, Infants and Children Program (WIC), the Division of Child Protection and Permanency, Special Child Health Services Case Management Units' Child Evaluation Centers, early intervention programs, county welfare agencies, certified home health agencies, community mental health centers, and local and county health departments.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 3 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:52-3.15 - Records; documentation, confidentiality and informed consent for HealthStart pediatric care providers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) HealthStart pediatric care providers shall have policies which protect patient confidentiality, provide for informed consent and document comprehensive care services.
(b) An individual record shall be maintained for each patient.
(c) Each record shall be confidential and shall include at least the following: history and physical examination, results of required assessments, plan of care, treatment services, laboratory reports, counseling and health instruction provided and documentation of referral and follow-up services.
(d) There shall be policies and procedures for appropriate informed consent for all HealthStart pediatric services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 3 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:52-3.16 - Reimbursement for HealthStart providers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The HealthStart HCPCS procedure codes listed in this subchapter are governed by the same rules that appear in the HCPCS subchapter of each non-institutional provider services manual (Independent Clinic, Physician and the Nurse Midwifery Services Chapters). The maximum fee allowance schedule and reimbursement requirements for HCPCS HealthStart Maternity Codes (Medical Care and Health Support Services) and HCPCS HealthStart Pediatric Codes are listed under N.J.A.C. 10:66-6.
(b) A hospital outpatient department (OPD) which is a HealthStart Provider shall use the procedure for OPD billing (UB-92 claim form), contained in this chapter; except for the following services:
1. HealthStart Health Support Services (W9040 through W9043), which shall be billed on the CMS 1500 claim form, using the Independent Clinic billing number; and
2. HealthStart pediatric continuity of care services (W9070), which shall be billed on the MC-19 form, EPSDT Referral Report.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 3 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:52-3.17 - HealthStart Maternity Care billing code requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) HealthStart Maternity Care billing code requirements shall be as follows:
1. Separate reimbursement shall be available for maternity medical care services and maternity health support services.
2. Maternity medical care services shall be billed as a total obstetrical package, when applicable, but may be billed as separate procedures.
3. The enhanced reimbursement for the delivery and postpartum care may be claimed only for a patient who had received at least one antepartum HealthStart maternity medical or health support service.
4. The modifier "WM" in the HCPCS lists of codes (W9025 through W9030) refers to those services provided by certified nurse midwives who shall include the modifier at the end of each code. HCPCS codes for health support services do not require the "WM" modifier on HCPCS codes W9040 and W9043.
5. Laboratory and other diagnostic procedures and all necessary medical consultations shall be eligible for separate reimbursement.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 4 - BASIS OF PAYMENT FOR HOSPITAL SERVICES › Section 10:52-4.1 - Basis of payment; acute general hospitals reimbursed under the Diagnosis Related Groups (DRG) system-inpatient services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For inpatient services with discharge dates prior to August 3, 2009, the Division will reimburse acute care general hospitals for inpatient services based upon rates determined under N.J.A.C. 10:52-5 through 7 and 9, except for distinct units of acute care general hospitals. For reimbursement methodology for distinct units of acute care general hospitals, see 10:52-4.2(e).
(b) For inpatient services with discharge dates on or after August 3, 2009, the Division will reimburse acute care general hospitals for inpatient services based upon rates determined under N.J.A.C. 10:52-14. However, the reimbursement methodology for distinct units of acute care general hospitals is not changed on or after that date. See 10:52-4.2(e).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 4 - BASIS OF PAYMENT FOR HOSPITAL SERVICES › Section 10:52-4.4 - Basis of payment; hospital capital project adjustment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any qualifying hospital that has completed a capital facilities construction project with an approved certificate of need from the New Jersey Department of Health, which meet both conditions in (a)1 below will be eligible for increased payments for capital project funding related to its Medicaid/NJ FamilyCare-Plan A managed care utilization.
1. The conditions required in (a) above are:
i. The approval is for a single capital project in excess of $ 20 million, which is for replacement beds, which reduce the number of hospital beds available in the State as of September 15, 1997; and
ii. The hospital has a 1995 percentage of low income revenue greater than 50 percent. The low income revenue percentage shall be based on revenue data as reported on the submitted 1995 New Jersey Hospital Cost Report, after desk audit. The low income revenue percentage shall be based on the sum of the Medicaid revenue as reported on Forms E-5 and E-6, line 1, column E, plus the Charity Care revenue as reported on Forms E-5 and E-6, line 1, column J, divided by the sum of the total revenue as reported on Forms E-5 and E-6, line 1, column M.