reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 5 - SERVICES COVERED BY MEDICAID AND THE NJ FAMILYCARE PROGRAMS › Section 10:49-5.2 - Services available to beneficiaries eligible for, or children who are presumptively eligible for, the regular Medicaid and NJ FamilyCare-Plan A programs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The services
				listed below shall be provided under the managed care program:
1. Advanced practice nurse
				services;
2. Chiropractic
				services;
3. Clinic services in an
				independent outpatient health care facility, other than hospital, that provides
				Family Planning, Dental, Optometric, Ambulatory Surgery services, or
				FQHCs;
4. Dental
				services;
5. Early and Periodic
				Screening, Diagnosis, and Treatment for beneficiaries under age 21 (EPSDT): A
				preventative health care program for beneficiaries under age 21 designed for
				early detection, diagnosis and treatment of correctable abnormalities. This
				program supplements the general medical services otherwise available;
6. Family planning services including medical
				history and physical examination (including pelvic and breast), diagnostic and
				laboratory tests, drugs and biologicals, medical supplies and devices,
				counseling, continuing medical supervision, continuity of care and genetic
				counseling.
i. Services provided primarily for
				the diagnosis and treatment of infertility, including sterilization reversals,
				and related office (medical and clinic) visits, drugs, laboratory services,
				radiological and diagnostic services and surgical procedures are not covered by
				the New Jersey Medicaid or NJ FamilyCare-Plan A program.
7. Hearing aid services;
8. Home care services (home health care
				except for the Aged, Blind and Disabled population (ABD));
9. Hospice services including room and board
				services in a nursing facility (available to dually eligible Medicare/Medicaid
				or dually eligible Medicare/NJ FamilyCare-Plan A beneficiaries);
10. Hospital services--inpatient:
i. General acute care hospitals;
ii. Special hospitals; and
iii. Rehabilitation hospitals;
11. Hospital
				services--outpatient;
12.
				Laboratory (clinical);
13. Medical
				supplies and durable medical equipment;
14. Mental health and substance abuse
				services for clients of the Division of Developmental Disabilities (DDD),
				excluding partial care and partial hospitalization services;
15. Nurse-midwifery services;
16. Optometric services;
17. Optical appliances;
18. Prescription drugs (except for ABD and
				all other dual eligible beneficiaries);
19. Physician services;
20. Podiatric services;
21. Prosthetic and orthotic
				devices;
22. Radiological
				services;
23. Non-lower mode
				transportation services, which include ambulance, mobility assistance vehicle,
				and mobile intensive care units;
24. Audiology services;
25. Organ transplants, recipient and donor
				costs;
26. Emergency medical care;
				and
27. Treatment for conditions
				categorized as altering the mental status of an individual and that are organic
				in nature.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 5 - SERVICES COVERED BY MEDICAID AND THE NJ FAMILYCARE PROGRAMS › Section 10:49-5.3 - Services available to beneficiaries eligible for the Medically Needy program

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Regular
				Medicaid services are available to Medically Needy beneficiaries except for the
				following services, which are not available or are only available to certain
				eligible Medically Needy groups: Group A--pregnant women, Group B--needy
				children, and Group C--aged, blind and disabled.
1. Chiropractic services are available only
				to pregnant women (Group A).
2.
				EPSDT services are not available to any Medically Needy group.
3. Hospital services (inpatient) are
				available only to pregnant women (Group A).
4. Nursing facility services are available to
				Medically Needy beneficiaries. For purposes of the Medically Needy program,
				nursing facility services include pharmacy services under Title XIX.
5. Medical day care services are available
				only to pregnant women, the aged, the blind and the disabled (Groups A and
				C).
6. Pharmaceutical services are
				available only to pregnant women and needy children (Groups A and B); and aged,
				blind or disabled beneficiaries who reside in Medicaid participating nursing
				facilities (see
				10:51-2.10 ). Pharmaceutical
				services are not available to other aged, blind and disabled beneficiaries
				(Group C).
7. Podiatric services
				are available only to pregnant women, the aged, the blind and the disabled
				(Groups A and C).
8. Rehabilitative
				services are not available for reimbursement when provided through a hospital
				or nursing facility, except to pregnant women as part of their inpatient
				hospital services.
9. Case
				management services for the mentally ill are available to Medically Needy
				pregnant women only.
10. Services
				provided primarily for the diagnosis and treatment of infertility, including
				sterilization reversals, and related office visits (medical or clinic), drugs,
				laboratory services, radiological and diagnostic services and surgical
				procedures are not available to the Medically Needy group.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 5 - SERVICES COVERED BY MEDICAID AND THE NJ FAMILYCARE PROGRAMS › Section 10:49-5.4 - Emergency medical services for aliens and prenatal care for specified pregnant alien women

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Most legal
				aliens who entered the United States on or after August 22, 1996 are restricted
				in their entitlement to emergency services for five years from their date of
				entry. Undocumented aliens and temporarily documented aliens, that is visitors,
				workers, and students, are also restricted in their entitlement to emergency
				services. These emergency medical services are only available to individuals
				who, except for their alien status, would be eligible for Medicaid, Medically
				Needy, New Jersey Care ... Special Medicaid Programs, AFDC-related Medicaid, or
				NJ FamilyCare-Plan A. Applicants who would otherwise be eligible for NJ
				FamilyCare-Plans B, C and D are not eligible for these emergency medical
				services for aliens.
1. Except as noted in
				(a)2 below, emergency services are defined as care provided in an acute care
				general hospital (emergency outpatient services and/or inpatient services) for
				a medical condition (including labor and delivery) manifesting itself by acute
				symptoms of sufficient severity (including severe pain) such that the absence
				of immediate medical attention could reasonably be expected to result in:
i. Placing the patient's health in serious
				jeopardy;
ii. Serious impairment to
				bodily functions; or
iii. Serious
				dysfunction of any bodily organ or part.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 5 - SERVICES COVERED BY MEDICAID AND THE NJ FAMILYCARE PROGRAMS › Section 10:49-5.6 - Services available and unavailable to beneficiaries eligible for, or who are presumptively eligible for, NJ FamilyCare-Plan B or C

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Except for the
				exceptions at
				10:79-6.5, which concern services
				for newborns enrolling into NJ FamilyCare-Plan C, the services listed below are
				available to beneficiaries eligible for NJ FamilyCare-Plan B or C, through an
				HMO selected by the NJ FamilyCare-Plan B or C beneficiary.
1. Advance practice nurse services;
2. Audiology services;
3. Chiropractic services;
4. Clinic services (services in an
				independent outpatient health care facility, other than hospital, that provides
				services such as, dental, optometric, ambulatory surgery, etc.);
5. Clinical nurse specialist
				services;
6. Dental
				services;
7. Durable medical
				equipment;
8. Early and periodic
				screening, and diagnosis medical examinations, dental, vision and hearing
				services, and lead screening services. Includes only those treatment services
				identified through the examination that are available under the HMO contract or
				covered fee-for-service program;
9.
				Emergency room services;
10. Family
				planning services including medical history and physical examination (including
				pelvic and breast), diagnostic and laboratory tests, drugs and biologicals,
				medical supplies and devices, counseling, continuing medical supervision,
				continuity of care and genetic counseling;
i.
				Services provided primarily for the diagnosis and treatment of infertility,
				including sterilization reversals, and related office (medical and clinic)
				visits, drugs, laboratory services, radiological and diagnostic services and
				surgical procedures are not covered by the New Jersey Medicaid or NJ FamilyCare
				program.
11. Federally
				qualified health center primary care services;
12. Hearing aid services;
13. Home health care services;
i. Exception: personal care assistant
				services;
14. Hospice
				services;
15. Hospital
				services--inpatient:
i. General
				hospitals;
ii. Special hospitals;
				and
iii. Rehabilitation
				hospitals;
16. Hospital
				services--outpatient;
17.
				Laboratory (clinical);
18. Medical
				supplies and equipment;
19.
				Nurse-midwifery services;
20.
				Optometric services;
21. Optical
				appliances;
22. Organ transplant
				services, donor and recipient costs;
23. Prescription drug services;
24. Physician services;
25. Podiatric services;
26. Prosthetic and orthotic
				devices;
27. Private duty
				nursing;
28. Radiological services;
				and
29. Transportation services,
				limited to ambulance, MICU's and invalid coach.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 5 - SERVICES COVERED BY MEDICAID AND THE NJ FAMILYCARE PROGRAMS › Section 10:49-5.8 - Services available for beneficiaries eligible for NJ FamilyCare-Plan H

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Effective for
				dates of service on or after July 1, 2007, all beneficiaries previously covered
				under Plan H are covered under NJ FamilyCare Plan D. The information in (b)
				through (g) below applies only to claims for former NJ FamilyCare Plan H
				beneficiaries with dates of service prior to July 1, 2007.
(b) Childless adults whose income is below
				100 percent of the Federal poverty level and who do not qualify for WFNJ/GA and
				who were enrolled in NJ FamilyCare on July 1, 2002 shall be eligible to receive
				the NJ FamilyCare Plan H service package.
(c) Restricted alien parents who are enrolled
				in NJ FamilyCare on November 1, 2003, shall receive the Plan H service
				package.
(d) Out-of-plan
				community-based mental health services shall be limited to 60 service days per
				calendar year and shall be eligible for payment on a fee-for-service basis.
1. Adult mental health rehabilitation
				services provided in/by community residence programs (see N.J.A.C. 10:77A)
				shall not be eligible for payment under NJ FamilyCare-Plan H.
2. NJ FamilyCare-Plan H beneficiaries under
				age 21 who are receiving services under the Division of Child Behavioral Health
				Services may secure additional mental health services if the services are
				authorized by the Contracted Systems Administrator or other agent authorized by
				the Department of Human Services and included in a plan of care.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 5 - SERVICES COVERED BY MEDICAID AND THE NJ FAMILYCARE PROGRAMS › Section 10:49-5.9 - Services available for beneficiaries eligible for NJ FamilyCare-Plan G

Current through Register Vol. 56, No. 14, July 15, 2024
(a) General
				assistance-eligible individuals shall receive Plan G services, which shall be
				those services delineated at
				10:49-24.3.
(b) The mental health and mental health
				rehabilitation services listed below may be available to beneficiaries under 21
				years of age who are eligible for NJ FamilyCare-Plan G if they are also
				receiving services from the Division of Child Behavioral Health Services. All
				services shall first be authorized by the Contracted Systems Administrator, the
				Division of Medical Assistance and Health Services or other agent authorized by
				the Department of Human Services and shall be included in an approved plan of
				care.
1. Care coordination by a care
				management organization (CMO) (see N.J.A.C. 10:73);
2. Psychiatric services provided in an
				inpatient psychiatric hospital setting (see N.J.A.C. 10:52);
3. Mental health rehabilitation services
				provided in residential childcare facilities (as defined in N.J.A.C. 10:127 and
				licensed by DHS/DYFS), children's group homes (as defined in N.J.A.C. 10:128
				and licensed by DHS/DYFS), or psychiatric community residences for youth (as
				defined in N.J.A.C. 10:37B and licensed by DHS/DMHS);
4. Behavioral assistance services for
				children, youth or young adults (see N.J.A.C. 10:77-4 );
5. Mobil response and stabilization
				management services for children, youth or young adults under EPSDT (see
				N.J.A.C. 10:77-6 ); and
6.
				Intensive in-community mental health rehabilitation services for children,
				youth or young adults under EPSDT (see N.J.A.C. 10:77-5 ).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 6 - AUTHORIZATIONS REQUIRED BY MEDICAID AND THE NJ FAMILYCARE PROGRAMS › Section 10:49-6.1 - Prior and retroactive authorization (general)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Under the
				Programs, payment for certain services shall require prior authorization except
				in an emergency. It is the responsibility of the provider to obtain prior
				authorization before furnishing or rendering a service. Specific instructions
				are detailed in the appropriate Provider Services chapter.
1. Prior authorization should not be
				construed as a guarantee that a person is eligible for the New Jersey Medicaid
				or NJ FamilyCare program. At the time the service is to be provided, it is the
				provider's responsibility to verify eligibility.
2. "Medical emergency" means a critical
				illness or injury status for which prompt medical care may be crucial to saving
				life and limb or sparing the beneficiary significant or intractable pain.
				Services provided for a medical emergency are exempt from prior authorization.
				Any service classified as a medical emergency that would have been subject to
				prior authorization had it not been so classified, must be supported by a
				practitioner's statement which describes the nature of the emergency, including
				relevant clinical information, and must state why the emergency services
				rendered were considered to be immediately necessary. To simply state that an
				emergency did exist is not sufficient.
3. In addition to services that must be prior
				authorized under the previous subsections, a provider may be required to submit
				some or all services for prior authorization if in the judgment of the Medicaid
				Agent or DMAHS the provider has engaged in conduct which would constitute good
				cause for suspension, debarment or disqualification under
				10:49-11.1(d).
				Prior authorization under this subsection may be imposed prior to a hearing
				under the same conditions applicable to suspensions under
				10:49-11.1(j),
				except that the approval of the Attorney General shall not be
				necessary.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 6 - AUTHORIZATIONS REQUIRED BY MEDICAID AND THE NJ FAMILYCARE PROGRAMS › Section 10:49-6.2 - Out-of-State medical care and services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any covered
				service that requires prior authorization as a prerequisite for reimbursement
				to New Jersey Medicaid providers shall also require prior authorization if it
				is to be provided in any other state.
1.
				Services which require prior authorization are described in the specific
				Medicaid Provider Services Manual.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 7 - SUBMITTING CLAIMS FOR PAYMENT POLICIES AND REGULATIONS › Section 10:49-7.1 - General provisions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following
				information outlines the policies and regulations of the New Jersey Medicaid/NJ
				FamilyCare program that the provider shall adhere to when submitting a claim
				and requesting payment for services provided to a New Jersey Medicaid/NJ
				FamilyCare beneficiary. (To identify a Medicaid/NJ FamilyCare beneficiary, see
				N.J.A.C. 10:49-2.)
1. Each Provider Services
				Manual has information relevant to the basis of payment for services and items
				of payment provided that is usually found in the second chapter of each
				manual.
2. For requirements of the
				Division of Medical Assistance and Health Services and the New Jersey State
				Department of Health and Senior Services when submitting a claim to be
				considered for the charity care component of the disproportionate share
				subsidies for hospital services and other rules regarding eligibility for these
				services, see N.J.A.C. 10:52-11, 12 and 13.
3. The rules of this subchapter shall also
				apply when submitting a claim for services provided to Medicaid/NJ FamilyCare
				beneficiaries who are enrolled in managed care programs but who are provided
				certain services through the regular Medicaid program. See N.J.A.C. 10:49-5 for
				a list of services that are eligible to be reimbursed on a fee-for-service
				basis when provided to Medicaid/NJ FamilyCare beneficiaries enrolled in managed
				care programs.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 7 - SUBMITTING CLAIMS FOR PAYMENT POLICIES AND REGULATIONS › Section 10:49-7.2 - Timeliness and method of Medicaid claim or other claim submission

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A Medicaid
				claim is defined as a request for payment from the New Jersey Medicaid program
				for a Medicaid reimbursable service provided to a Medicaid recipient.
1. A Medicaid claim or any other provider
				claim submitted for payment from or through the Division of Medical Assistance
				and Health Services shall be submitted by means of an approved method of
				automated data exchange unless an attachment to the claim is required, in which
				case the claim for payment instead shall be submitted using an approved hard
				copy claim form.
2. It is the
				responsibility of each provider to ensure that each Medicaid/NJ FamilyCare-Plan
				A claim submitted by that provider is received by the New Jersey Medicaid/NJ
				FamilyCare program's Fiscal Agent within the time periods indicated in this
				section. Providers shall reconcile their claims submission records with the
				Remittance Advice they receive from the Division's Fiscal Agent in order to
				verify that the Division's Fiscal Agent has received their claims. Providers
				shall resubmit any claims for reimbursement, which the provider determines have
				been submitted previously, but which do not appear on the Remittance Advice.
i. The New Jersey Medicaid program shall not
				reimburse for a claim received outside the prescribed time periods. This policy
				also applies to inquiries concerning a claim or claim related information
				received outside the prescribed time periods.
ii. For retroactive eligibility cases, a
				claim associated with a retroactive eligibility application will be considered
				as received on the date of receipt of the application at the appropriate
				eligibility determination agency on behalf of the applicant. For information
				about retroactive eligibility, see
				10:49-2.9.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 7 - SUBMITTING CLAIMS FOR PAYMENT POLICIES AND REGULATIONS › Section 10:49-7.3 - Third-party liability (TPL) benefits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Third-party
				liability (TPL) exists when any person, institution, corporation, insurance
				company, health insurer, self-insured plan, group health plan as defined in
				section 607(1) of the Federal Employee Retirement and Income Security Act of
				1974,
				29 U.S.C. §
										1167(1), service benefit
				plan, managed care organization or other prepaid health plan, pharmacy benefits
				manager, third-party administrator as defined in
				17B:27B-1, absent parent,
				Medicare program, or any other public, private, or governmental entity or party
				is or may be liable in contract, agreement, tort, or otherwise by law or equity
				to pay all or part of the cost of medical assistance payable by the Medicaid or
				NJ FamilyCare program.
1. It is a violation of
				section 1902(a)(25)(D) of the Federal Social Security Act to refuse to furnish
				covered services to any Medicaid beneficiary because of a third party's
				potential liability to pay for services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 7 - SUBMITTING CLAIMS FOR PAYMENT POLICIES AND REGULATIONS › Section 10:49-7.4 - Prohibition of payment to factors

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A "factor"
				means an individual or an organization, such as a collection agency or service
				bureau, that advances money to a provider for accounts receivable that the
				provider has assigned, sold or transferred to the individual organization for
				an added fee or deduction of a portion of the accounts receivable.
(b) Payment for any covered services
				furnished to any Medicaid or NJ FamilyCare beneficiary by an approved provider
				may not be made to or through a factor, either directly or by
				power-of-attorney.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 7 - SUBMITTING CLAIMS FOR PAYMENT POLICIES AND REGULATIONS › Section 10:49-7.5 - Use of service bureau and/or management agency

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Payment may be
				made to a business agent, such as a billing service or an accounting firm, that
				furnishes statements and receives payment in the name of the provider if the
				agent's compensation for this service is:
1.
				Related to the cost of processing the billing;
2. Not related on a percentage or other basis
				to the amount that is billed or collected; and
3. Not dependent upon the collection of the
				payment.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 7 - SUBMITTING CLAIMS FOR PAYMENT POLICIES AND REGULATIONS › Section 10:49-7.6 - Timeliness of charity care claim submission

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A charity care
				claim is defined as a request for the New Jersey charity care program to price
				the hospital services rendered and consider those services when determining the
				amount of the charity care component of the disproportionate share subsidies of
				the Health Care Trust Fund to be allocated to each New Jersey disproportionate
				share hospital.
(b) In order to be
				priced by the Fiscal Agent, the charity care claim must be a clean charity care
				claim, as defined in
				10:52-12.1.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 8 - PAYMENT FOR SERVICES PROVIDED › Section 10:49-8.1 - Fiscal Agent

Current through Register Vol. 56, No. 14, July 15, 2024
The State of New Jersey uses a fiscal agent for the
				  processing of Medicaid claims, the pricing of charity care claims, and payment
				  to providers.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 8 - PAYMENT FOR SERVICES PROVIDED › Section 10:49-8.2 - Medicaid claims payment and charity care claims pricing

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Fiscal
				Agency will process Medicaid claims daily and produce provider payments and
				associated Remittance Advice (RA) statements once each week. The RA is the
				provider's account statement and reflects the status of all Medicaid claims
				currently entered into the Medicaid Management Information System. Provider
				payments in the form of checks and electronic funds transfers will be released
				following approval by the New Jersey Medicaid program. For charity care claims
				pricing information, see N.J.A.C. 10:52-11, 12 and 13.
1. The Remittance Advice (RA) is the major
				vehicle for communicating to the provider the status of all Medicaid claims
				received by the fiscal agent. All of the provider's claims are processed and
				supporting records are updated during each payment cycle. RA statements are
				generated as a result of a payment cycle. All claims processed (entered into
				the Medicaid Management Information System) fall into one of three
				classifications: paid; in process; or denied.
i. A claim that is correctly completed for a
				covered service provided to a Medicaid beneficiary by an approved provider will
				be paid. The claim will appear on the RA Claims Status page, or pages, along
				with all other claims for which a provider is being paid in that payment cycle.
				If the amount differs from the billed charges, an explanation will appear on
				the RA.
ii. In process claims or
				processed but unpaid claims are those claims held for prepayment review by the
				Division or by the Fiscal Agent. The review will result in a claim or group of
				claims being paid, denied, or additional information being requested. If
				additional information is required, a letter and/or a Claim Correction Form
				(CCF) will be forwarded to the provider. (Additional billing information is
				provided in the Fiscal Agent Billing Supplement following the second chapter of
				each Provider Services Manual).
iii. Reasons for denial of a claim will be
				provided on the RA in the form of an error/edit code.
(1) Messages explaining all codes reflected
				on the Remittance Advice will be printed on a separate page.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 8 - PAYMENT FOR SERVICES PROVIDED › Section 10:49-8.3 - Adjustments following payment of claims

Current through Register Vol. 56, No. 14, July 15, 2024
(a) If a claim is
				incorrectly paid, so that the provider receives an overpayment or underpayment,
				within 60 days of such receipt, the provider shall correctly adjust the claim
				by utilizing the web-based claims resolution process or another approved method
				of automated data exchange, unless an attachment to the claim is required, in
				which case the provider shall instead use an MMIS Claim Adjustment Request
				Form, (FD-999). (For the procedure to follow, see Fiscal Agent Billing
				Supplement following the second chapter of each Provider Services Manual).
				However, a provider shall immediately adjust all incorrectly overpaid claims
				that are discovered subsequent to the expiration of the 60-day deadline, also
				utilizing the web-based claims resolution process or another approved method of
				automated data exchange, unless an attachment to the claim is required, in
				which case the provider shall instead use an MMIS Claim Adjustment Request Form
				(FD-999).
(b) On occasion, a claim
				will be paid that should not have been paid. If a claim is paid in error,
				within 60 days of such receipt, the provider shall utilize the web-based claims
				resolution process or another approved method of automated data exchange to
				void the claim. (For the procedure to follow, see the Fiscal Agent Billing
				Supplement following the second chapter of each Provider Services Manual.)
				However, a provider shall immediately void all claims paid in error that are
				discovered subsequent to the expiration of the 60-day deadline, also utilizing
				the web-based claims resolution process or another approved method of automated
				data exchange.
(c) Any adjustment
				made by Medicare will not cross over to Medicaid. If Medicare makes an
				adjustment that results in an overpayment or underpayment by Medicaid, within
				60 days of receipt of any such overpayment or under payment, the provider shall
				notify the Fiscal Agent. (For the procedure to follow, see the Fiscal Agent
				Billing Supplement following the second chapter of each Provider Services
				Manual).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 8 - PAYMENT FOR SERVICES PROVIDED › Section 10:49-8.4 - Claims payment by direct deposit (electronic funds transfer or EFT)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each provider
				or other entity receiving reimbursement from or through the Division, except
				those enrolled for a specified limited period of time pursuant to
				10:49-3.5, will receive claims
				payment automatically as a direct deposit to the provider's or entity's
				checking account through electronic funds transfer (EFT). (However, the
				Division and its agent may temporarily use paper checks to provide
				reimbursement to new providers prior to confirmation of direct deposit
				information.) All providers and entities shall apply for EFT in order to
				receive payment.
1. To enroll in the EFT
				payment program, the provider must complete an EFT Enrollment
				Request/Authorization form. A voided check displaying the provider's account
				number must accompany the complete authorization form. The enrollment form must
				be signed by the provider or an authorized official such as the business
				manager, owner, or facility administrator. Any change to the EFT information
				(for example, a change of account number, ownership, or authorized official)
				requires the completion of a new EFT Enrollment Request/Authorization form.
				(For detailed instructions about enrollment in the EFT payment program, see the
				Fiscal Agent Billing Supplement following the second chapter of each Provider
				Services Manual.)
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 8 - PAYMENT FOR SERVICES PROVIDED › Section 10:49-8.5 - Outstanding checks

Current through Register Vol. 56, No. 14, July 15, 2024
(a) After Medicaid
				checks are outstanding for a period of six months, a follow-up letter shall be
				sent to the payee. This procedure shall only apply to checks of $ 5.00 or
				more.
(b) All Medicaid checks
				remaining outstanding after 12 months shall be cancelled in monthly lots rather
				than check by check. Listings of cancelled checks shall be in sufficient detail
				to identify providers and amounts of payment. These records shall be retained
				for audit.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 9 - PROVIDER AND BENEFICIARY'S RIGHTS AND RESPONSIBILITIES; ADMINISTRATIVE PROCESS › Section 10:49-9.2 - NJ FamilyCare-Plans C and D-premiums

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For children in
				families with income at or below 150 percent of the Federal poverty limit,
				there shall be no premiums under NJ FamilyCare-Plan B.
(b) For families with gross income above 150
				percent and at or below 200 percent of the Federal poverty level (NJ FamilyCare
				Plan C), a monthly premium shall be required to be paid, for enrollment, of $
				33.50 for the first parent/caretaker and $ 14.00 for the second
				parent/caretaker.
(c) Under NJ
				FamilyCare-Plan D, effective July 1, 2009, the following premiums shall apply:
1. For children in families with gross income
				above 200 percent and at or below 250 percent of the Federal poverty level, a
				single monthly premium of $ 40.00 per family per month that applies to all
				families, regardless of the number of children in the family.
2. For children in families with gross income
				above 250 percent and at or below 300 percent of the Federal poverty level, a
				single monthly premium of $ 79.00 per family per month that applies to all
				families, regardless of the number of children in the family.
3. For children in families with gross income
				above 300 percent and at or below 350 percent of the Federal poverty level, a
				single monthly premium of $ 133.00 per family per month that applies to all
				families, regardless of the number of children in the family.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 9 - PROVIDER AND BENEFICIARY'S RIGHTS AND RESPONSIBILITIES; ADMINISTRATIVE PROCESS › Section 10:49-9.3 - Limitation on cost sharing-Plan C

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be
				a family limit on cost-sharing equal to 5 percent of household income for Plan
				C beneficiaries.
(b) The
				cost-sharing limit shall be calculated annually starting with the date of
				initial enrollment of any children in the family or the annual reenrollment
				date. For ease of administration, the annual premium should be calculated by
				the Statewide eligibility determination agency and used to reduce the family
				cost from the first day of enrollment.
(c) Once the limits have been met, the
				Statewide eligibility determination agency shall issue a certification
				indicating that the Plan C member has met their cost share limit, and the
				provider shall not collect a personal contribution to care until further
				notice.
(d) No cost sharing shall
				be imposed on children who are American Indians/Alaska Natives. Proof of
				Federally recognized AI/AN tribal status shall be provided in the form of a
				tribal card or letter, in accordance with 42 C.F.R. 36a.16.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 9 - PROVIDER AND BENEFICIARY'S RIGHTS AND RESPONSIBILITIES; ADMINISTRATIVE PROCESS › Section 10:49-9.4 - Civil rights

Current through Register Vol. 56, No. 14, July 15, 2024
Federal regulations require that services provided to any
				  Medicaid beneficiary shall be given without discrimination on the basis of
				  race, color, national origin, or handicap. Therefore, payments shall be limited
				  to providers of service who are in compliance with the nondiscrimination
				  requirements of Title VI of the Civil Rights Act and Section 504 of the
				  Rehabilitation Act of 1973.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 9 - PROVIDER AND BENEFICIARY'S RIGHTS AND RESPONSIBILITIES; ADMINISTRATIVE PROCESS › Section 10:49-9.5 - Observance of religious belief

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Nothing in the
				Medicaid program shall be construed to require any beneficiary to undergo any
				medical screening, examination, diagnosis, or treatment, or to accept any other
				health care or services provided under the program for any purpose (other than
				for the purpose of discovering and preventing the spread of infection or
				contagious disease or for the purpose of protecting environmental health) if
				such person or his or her parent or guardian objects thereto on religious
				grounds, except as specified in (b) below.
(b) If a physical examination is necessary to
				establish eligibility based on disability or blindness, the Medicaid Program
				may not find an individual eligible for Medicaid unless he or she undergoes the
				examination.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 9 - PROVIDER AND BENEFICIARY'S RIGHTS AND RESPONSIBILITIES; ADMINISTRATIVE PROCESS › Section 10:49-9.6 - Free choice by beneficiary and provider

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The concept of
				freedom of choice shall apply to both provider and beneficiary.
1. A Medicaid fee-for-service beneficiary
				shall be free to choose providers of service who meet program standards and who
				elect to participate in the Medicaid program. The MACC shall assist any
				beneficiary in obtaining services if the beneficiary cannot locate a provider.
				Exception: See
				10:49-14.2, Special Status
				programs.
2. A Medicaid provider
				who accepts a Medicaid beneficiary as a patient under the Medicaid program
				shall accept the program's policies and reimbursement for all covered services
				and/or items provided or delivered during that period when, by mutual
				agreement, the beneficiary is under the provider's care. In the provision of
				professional services, the provider shall be bound by the code of ethics
				governing his or her profession.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 9 - PROVIDER AND BENEFICIARY'S RIGHTS AND RESPONSIBILITIES; ADMINISTRATIVE PROCESS › Section 10:49-9.7 - Confidentiality of records

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All information
				concerning applicants and beneficiaries acquired under this program shall be
				confidential and shall not be released without the written consent of the
				individual or his or her authorized representative. If, because of an emergency
				situation, time does not permit obtaining consent before release, the program
				shall notify the individual, his or her family, or authorized representative,
				immediately after releasing the information.
(b) The restriction on the disclosure of
				information shall not preclude the release of statistical or summary data or
				information in which applicants or beneficiaries are not, and cannot be,
				identified; nor shall it preclude the exchange of information among providers
				furnishing services, Fiscal Agent of the program, and State or local government
				agencies, for purposes directly connected with administration of the program.
				Disclosure without the consent of the applicant or beneficiary shall be limited
				to purposes directly connected with the administration of the program in
				accordance with Federal and State law and regulations.
1. Purposes directly connected with the
				administration of the program shall include but are not limited to:
i. Establishing eligibility;
ii. Determining the amount of medical
				assistance;
iii. Providing services
				for beneficiaries; and
iv.
				Conducting or assisting an investigation, prosecution, or civil or criminal
				proceeding related to the administration of the program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 9 - PROVIDER AND BENEFICIARY'S RIGHTS AND RESPONSIBILITIES; ADMINISTRATIVE PROCESS › Section 10:49-9.8 - Provider certification and recordkeeping

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All program
				providers, except institutional, pharmaceutical, and transportation providers,
				shall be required to certify that the services billed on any claim were
				rendered by or under his or her supervision (as defined and permitted by
				program regulations); and all providers shall certify that the information
				furnished on the claim is true, accurate, and complete.
1. All claims for covered services must be
				personally signed by the provider or by an authorized representative of the
				provider (for example, hospital, home health agency, independent clinic) unless
				the provider is approved for electronic media claims (EMC) submission by the
				Fiscal Agent. The provider must apply to the Fiscal Agent for EMC approval and
				sign an electronic billing certificate.
i.
				The following signature types are unacceptable:
(1) Initials instead of signature;
(2) Stamped signature; and
(3) Automated (machine-generated)
				signature.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 9 - PROVIDER AND BENEFICIARY'S RIGHTS AND RESPONSIBILITIES; ADMINISTRATIVE PROCESS › Section 10:49-9.10 - Withholding of provider payments

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When the
				Division, in accordance with
				42 C.F.R.
				455.23, receives reliable evidence of fraud
				or willful misrepresentation by a provider, including an HMO, as well as a
				practitioner or entity participating in an HMO's network (whether or not the
				HMO practitioner or entity is also enrolled as a Medicaid or NJ FamilyCare
				provider), the Medicaid Agent or the Division shall withhold Program payments,
				in whole or in part, upon approval by the Division Director or the Assistant
				Director, Office of Program Integrity Administration, or their designee.
				Further, a practitioner or entity participating in an HMO's network subject to
				a withholding action under this section shall have any payments for services
				rendered to Medicaid and NJ FamilyCare beneficiaries withheld by the
				HMO.
(b) "Reliable evidence" shall
				include, but not necessarily be limited to:
1. Receipt of information from a Division
				unit or from the Department of Health and Senior Services, Department of
				Banking and Insurance or a law enforcement, investigatory, or prosecutorial
				agency that indicates fraud or willful misrepresentation has occurred or is
				occurring;
2. Information from any
				other local, county, State or Federal agency indicating fraud or willful
				misrepresentation has occurred or is occurring; or
3. Indications that a violation of those
				subsections of
				10:49-11.1 that pertain to fraud
				or willful misrepresentation may have occurred or is occurring, including, but
				not necessarily limited to, overutilization or misutilization; any unexplained
				increase in the number of claims rejected by the claims processing system; or
				any other reliable grounds to believe that fraud or willful misrepresentation
				may have occurred or is occurring.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 9 - PROVIDER AND BENEFICIARY'S RIGHTS AND RESPONSIBILITIES; ADMINISTRATIVE PROCESS › Section 10:49-9.11 - Integrity of the Medicaid and NJ FamilyCare programs; gifts/gratuities prohibited

Current through Register Vol. 56, No. 14, July 15, 2024
The Division, in order to maintain the integrity of the
				  programs it administers in whole or in part, strictly prohibits its employees,
				  or representatives of its contractors, subcontractors or fiscal agents, from
				  accepting gifts or gratuities of any kind and of any value from representatives
				  of providers or provider-related individuals, entities, organizations or
				  institutions if receipt of such gifts or gratuities would violate the rules of
				  the New Jersey Executive Commission on Ethical Standards (N.J.A.C. 19:61), the
				  New Jersey Conflicts of Interest Law (52:13D-12 et seq.), Executive
				  Order No. 189 (July 20, 1988), and/or Executive Order No. 2 (January 18, 1994).
				  This includes the prohibition of offers of special employment, consultation
				  fees and all other gratuities by a provider, individual or facility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 9 - PROVIDER AND BENEFICIARY'S RIGHTS AND RESPONSIBILITIES; ADMINISTRATIVE PROCESS › Section 10:49-9.12 - Fraud and abuse

Current through Register Vol. 56, No. 14, July 15, 2024
The New Jersey Medicaid and NJ FamilyCare programs shall
				  employ methods to identify situations in which a question of fraud and/or abuse
				  in the program may exist. The Division shall refer to law enforcement officials
				  situations in which there is valid reason to suspect that fraud has or may have
				  been committed.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 9 - PROVIDER AND BENEFICIARY'S RIGHTS AND RESPONSIBILITIES; ADMINISTRATIVE PROCESS › Section 10:49-9.13 - Informing individuals of their rights

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All Medicaid
				and NJ FamilyCare-Plan A claimants and NJ FamilyCare Plan D parents with
				incomes up to 133 percent of the Federal poverty level shall be informed of the
				following, in writing, at the time of application and at the time of any action
				affecting their claim:
1. Of their right to a
				fair hearing;
2. Of the method by
				which they may obtain a hearing;
3.
				That they may be represented by legal counsel or by a relative, friend, or
				other spokesperson, or they may represent themselves; and
4. Of legal services within the community
				from which they may receive legal aid.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 9 - PROVIDER AND BENEFICIARY'S RIGHTS AND RESPONSIBILITIES; ADMINISTRATIVE PROCESS › Section 10:49-9.14 - Provisions for appeals; fair hearings

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Pursuant to
				N.J.A.C. 10:49-10, Notices, Appeals, and Fair Hearings, providers, Medicaid
				beneficiaries and NJ FamilyCare-Plan A beneficiaries and NJ FamilyCare Plan D
				parents with incomes up to 133 percent of the Federal poverty level shall have
				the right to file for fair hearings.
(b) A provider may be granted a hearing
				because of the denial of a prior authorization request or issues involving the
				provider's status; for example, termination, debarment, suspension, and so
				forth, as described in
				10:49-11.1, or issues arising out
				of the claims payment process.
(c)
				A Medicaid or NJ FamilyCare-Plan A beneficiary and NJ FamilyCare Plan D parents
				with incomes up to 133 percent of the Federal poverty level may be granted a
				fair hearing in accordance with N.J.A.C. 10:49-10 if his or her claim for
				medical assistance is denied or is not acted upon with reasonable promptness,
				or because the beneficiary is aggrieved by any other agency action resulting in
				non-eligibility, denial, termination, reduction or suspension of such
				assistance. NJ FamilyCare-Plan B, C and all other Plan D beneficiaries shall be
				afforded the opportunity for grievance review in accordance with N.J.A.C.
				10:78-8.
(d) In order to obtain a
				fair hearing, the provider or the beneficiary shall submit a request in writing
				to the Medicaid Agent at the address as specified in the notice.
(e) Any nursing facility whose certification
				or Medicaid Provider Agreement is denied, terminated, or not renewed, may
				request a hearing in accordance with the appeals procedure described in the
				Nursing Facilities Services chapter.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 10 - NOTICES, APPEALS AND FAIR HEARINGS › Section 10:49-10.1 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this subchapter,
				  shall have the following meanings unless the context clearly indicates
				  otherwise.
"Applicant" means any person who has made application for
				  purpose of becoming a "qualified applicant."
"Claimant," when used within these rules, means applicant,
				  qualified applicant or beneficiary as defined in this section.
"Notice" means an announcement of a policy decision by the
				  Title XIX or Title XXI agency that may adversely affect the Medicaid or NJ
				  FamilyCare-Plan A beneficiary or an NJ FamilyCare Plan D beneficiary who is a
				  parent with an income level of up to 133 percent of the Federal poverty
				  level.
"Qualified applicant" means any person who is determined to
				  be eligible to receive benefits in accordance with
				  30:4D-1 et seq., as amended and
				  supplemented.