reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 24 - WORK FIRST NEW JERSEY/GENERAL ASSISTANCE CLAIMS PROCESSING › Section 10:49-24.1 - Introduction

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Effective for
				services rendered on or after February 1, 1997, consistent with N.J.A.C.
				10:90-13, the Division's fiscal agent shall process Work First New
				Jersey/General Assistance (WFNJ/GA) claims.
				10:49-24.3 describes the covered
				services that shall be processed by the fiscal agent.
				10:49-24.4 describes services that
				shall not be processed by the fiscal agent.
				10:49-24.5 indicates that payment
				for services shall be made using existing Medicaid reimbursement
				methodology.
(b) The information in
				this subsection is provided to assist providers in identifying a WFNJ/GA
				beneficiary. Consistent with
				10:90-13.3, each municipal welfare
				department (MWD) or county welfare agency (CWA) provides an HBID card or HBID
				Emergency Services letter for each client, which is used to obtain medical
				services.
(c) Providers may contact
				the local MWD/CWA that assists the WFNJ/GA client if there are questions
				regarding eligibility. Questions regarding WFNJ/GA requirements or coverage of
				services should be directed to DMAHS. Only questions related to claim
				processing should be directed to the fiscal agent.
(d) Dispute resolution requirements related
				to a client's eligibility for WFNJ/GA are contained in N.J.A.C. 10:90-9.
				Individuals shall contact the county or municipal agency to resolve any
				questions, consistent with the requirements contained in N.J.A.C.
				10:90-9.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 24 - WORK FIRST NEW JERSEY/GENERAL ASSISTANCE CLAIMS PROCESSING › Section 10:49-24.2 - Administrative provisions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any provider of
				services shall meet Medicaid requirements and be enrolled as a Medicaid
				provider. Requirements regarding enrollment and provision of service are set
				forth in the appropriate chapters of the New Jersey Administrative
				Code.
(b) The administrative
				requirements of the Medicaid program shall apply to these claims. The
				requirements contained in this chapter include, but are not limited to,
				N.J.A.C. 10:49-1, General Provisions; N.J.A.C. 10:49-3, Provider Participation;
				N.J.A.C. 10:49-4, Providers' Role in a Shared Health Care Facility;
				10:49-5.5, Services not covered by
				the Medicaid or NJ FamilyCare-Plan A program; N.J.A.C. 10:49-6, Authorizations
				Required by Medicaid and NJ FamilyCare Programs; N.J.A.C. 10:49-7, Submitting
				Claims for Payment (Policies and Regulations); N.J.A.C. 10:49-8, Payment for
				Services Provided; N.J.A.C. 10:49-11, Exclusion from Participation in the New
				Jersey Medicaid and NJ FamilyCare Programs (Suspension, Debarment, and
				Disqualification); N.J.A.C. 10:49-12, Provider Reinstatement; N.J.A.C.
				10:49-13, Program Controls;
				10:49-14.2, Sanctions--Special
				Status Program;
				10:49-14.3, Authority to adjust,
				compromise, settle or waive claims, liens and certificates of debt; and
				10:49-14.5, Administrative
				charges/service fees.
1. WFNJ/GA claims
				processed by the Division's fiscal agent are not subject to the fair hearing
				processes described at
				10:49-9.14.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 24 - WORK FIRST NEW JERSEY/GENERAL ASSISTANCE CLAIMS PROCESSING › Section 10:49-24.5 - Basis for reimbursement

Current through Register Vol. 56, No. 14, July 15, 2024
Except as noted under
				  10:49-24.3(a)16 
				  ii, payment for services shall be based upon the Medicaid reimbursement
				  methodology for the respective service. (See specific provider chapter(s) for
				  reimbursement methodology and requirements.)
According to the Paperwork Reduction Act of 1995, no persons
				  are required to repsond to a collection of information unless it displays a
				  valid OMB control number. The valid OMB control number for this information
				  collection is 0938-0086. Ths time required to complete this information
				  collection is estimated to average 30 minutes per response, including the time
				  to review instructions, search existing data resources gather the data needed,
				  and complete and review the information collection. If you have any comments
				  concerning the accuracy of the time estimate(s) or suggestions for improving
				  this form, please write to CMS, 7500 Security Boulevard, N2-14-26, Baltimore,
				  Maryland 21244-1850.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Appendix - APPENDIX

Current through Register Vol. 56, No. 14, July 15, 2024
Health Benefits Identification (HBID) Card
Form #1
HBID Emergency Services Letter
Form #1A
Medically Needy Claim Transmittal (FD-311)
Form #2
Public Assistance Inquiry (PA-1C)
Form #3
One Page NJ FamilyCare Presumptive Eligibility
Form #4
Application
One-Page NJ FamilyCare Application
Form #5
Retroactive Eligibility Application
Form #6
Validation of Eligibility (FD-34)
Form #7
Provider Application (FD-20)
Form #8
One Time Enrollment Application (FD-20A)
Form #8A
Provider Agreement (FD-62)
Form #9
Disclosure of Ownership and Control Interest
Form #10
Statement (CMS-1513)
Patient Certification Form (FD-197)
Form #11
Notice to All Applicants and Providers
Form #12
Medical Assistance Customer Centers Directory
Form #13
New Jersey County Welfare Agencies
Form #14
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New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49A - NURSING FACILITY PATIENT CARE RATIO REQUIREMENTS › Subchapter 1 - GENERAL INFORMATION › Section 10:49A-1.1 - Scope and purpose

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This
				chapter shall apply to all nursing facilities providing services to Medicaid/NJ
				FamilyCare beneficiaries.
(b) This
				chapter establishes the requirements for defined nursing facilities to report
				information concerning certain revenues and the use of those revenues for the
				care of the residents.
(c) This
				chapter describes how this information will be used to determine, with respect
				to each patient care ratio (PCR) reporting year, whether the amount of reported
				revenue expended by the facility on permitted costs meets, or exceeds, the
				percentage established pursuant to
				P.L.
				2020, c. 89, addresses
				requirements for calculating any rebate amounts that may be due in the event
				that a facility did not meet the PCR standard during the reporting year, and
				specifies administrative requirements of the program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49A - NURSING FACILITY PATIENT CARE RATIO REQUIREMENTS › Subchapter 1 - GENERAL INFORMATION › Section 10:49A-1.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, as used in this chapter, shall
				  have the following meanings, unless the context clearly indicates
				  otherwise.
"Department" means the New Jersey Department of Human
				  Services.
"Facility" means a Class I (private), Class II (county), or
				  Class III (special care) nursing facility identified by both a unique
				  Medicaid/NJ FamilyCare provider number and a unique daily payment rate. A
				  facility may be a specific unit co-located with other services (for example, a
				  special care nursing facility floor sharing space with a nursing facility shall
				  be considered a separate facility, if it has a separate Medicaid/NJ FamilyCare
				  provider number and daily rate).
"GAAP" means the U.S. Generally Accepted Accounting
				  Principles, a common set of accounting principles, standards, and procedures
				  issued by the national Financial Accounting Standards Board (FASB). GAAP aims
				  to improve the clarity, consistency, and comparability of the communication of
				  financial information. Any financial concept, measure, metric, or other
				  financial reference used in this chapter, or to meet the requirements of this
				  chapter, must follow U.S. Generally Accepted Accounting Principles.
"Patient care ratio" (PCR) means the percentage of a
				  facility's Medicaid revenue expended on resident care, services, and support
				  that is calculated.
"Patient care ratio (PCR) reporting year" means a calendar
				  year from January 1 through December 31, during which Medicaid/NJ
				  FamilyCare-covered services are provided by a facility.
"Related party" means a person or entity that is related to
				  the reporting facility. A related party relationship includes, but is not
				  limited to, relationships between:
(1) divisions of an organization;
(2) organizations under common control through common
				  officers, directors, or members;
(3) an organization and its director, trustee, officer, or
				  key employee, or an immediate family member of those individuals, any of whom
				  holds a controlling interest in the organization either directly or through
				  corporations, trusts, or similar arrangements; and
(4) any parties that enable one to control or substantially
				  influence the actions of the other.
"Resident" means an individual who resides at the facility
				  for at least one night at any time during a PCR reporting year.
"Revenue" means all recognized income received from, or on
				  behalf of, a resident as a condition of receiving services from the facility,
				  including any fees or other contributions the facility may require as part of a
				  resident reserving, securing, or receiving services.
"State audit entity" means the Department, the New Jersey
				  Department of Law and Public Safety, the New Jersey Office of the State
				  Comptroller, or any authorized agents of those entities.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49A - NURSING FACILITY PATIENT CARE RATIO REQUIREMENTS › Subchapter 2 - DISCLOSURE AND REPORTING REQUIREMENTS › Section 10:49A-2.1 - General requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For
				each PCR reporting year, a facility must submit, to the Department, a report,
				that complies, in all respects, with the requirements of this chapter
				concerning revenue and expenses related to the services that it provided.
1. The report must be submitted to the
				Department by the first day of the sixth month following the end of a PCR
				reporting year and must contain the information set forth in this
				section.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49A - NURSING FACILITY PATIENT CARE RATIO REQUIREMENTS › Subchapter 2 - DISCLOSURE AND REPORTING REQUIREMENTS › Section 10:49A-2.2 - Revenue reporting requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A facility must report to the Department
				its revenue in accordance with GAAP, as defined by the Financial Standards
				Accounting Board for the reporting year.
1.
				All revenue for services provided by one facility that is later assumed by
				another facility must be reported by the assuming facility for the entire PCR
				reporting year during which the services were provided.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49A - NURSING FACILITY PATIENT CARE RATIO REQUIREMENTS › Subchapter 2 - DISCLOSURE AND REPORTING REQUIREMENTS › Section 10:49A-2.3 - Required reported expenses: personnel and facility management

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A facility must
				report gross salaries, wages, consultant fees, fringe benefits, workers'
				compensation insurance, other compensation, and employer taxes paid or accrued
				during the PCR reporting year in order to operate the facility and provide
				services to residents. Amounts must be reported in the aggregate for each of
				the following distinct categories:
1. A
				single aggregate amount must be reported for all Certified Nurse Aide (CNA)
				compensation paid during the PCR reporting year;
2. A single aggregate amount must be reported
				for all Non-CNA Direct Care compensation paid during the PCR reporting year.
				Non-CNA Direct Care compensation means the amount paid to registered
				professional nurses and licensed practical nurses, as well as other individuals
				who, over the course of a PCR reporting year, primarily provide hands-on care
				to residents as part of their daily job duties;
3. A single aggregate amount must be reported
				for all Other Resident Care and Support compensation paid during the PCR
				reporting year. Resident Care and Support compensation means the entire amount
				paid to individuals who provide resident care oversight, planning, quality
				assurance, support services, and other functions, including, but not limited
				to, activities, food service, housekeeping, infection control, maintenance,
				medical services, medical recordkeeping, social services, and
				transportation;
4. A single
				aggregate amount must be reported for all other compensation paid to
				individuals who have general and administrative functions that are common to
				most businesses, including, but not limited to, administrative, executive,
				finance, human resources and legal staff, and similar staff that are necessary
				to ensure safe operation and compliance with all general business laws, rules,
				and regulations;
5. A single
				aggregate amount may be reported for all management fees paid, only if the
				management fee is apportioned or charged to the facility in the same manner
				that it is charged to all other facilities that the management entity serves
				and is allocated using a method based on one or more of the following:
i. A measure of service level;
ii. Actual hours of services
				delivered;
iii. The number of staff
				per facility;
iv. The number of
				residents per facility;
v. Pricing
				of actual services delivered; or
vi. The proportion of total bed days;
				and
6. No amount shall
				be reported for all other compensation or management fees paid during the PCR
				reporting year.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49A - NURSING FACILITY PATIENT CARE RATIO REQUIREMENTS › Subchapter 2 - DISCLOSURE AND REPORTING REQUIREMENTS › Section 10:49A-2.4 - Required reported expenses: materials and supplies

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A facility must report amounts paid or
				accrued during the PCR reporting year for materials and supplies needed in
				order to operate the facility and provide services to residents. Amounts must
				be reported in the aggregate for each of the following distinct categories.
1. A single aggregate amount must be reported
				for all direct care materials and supplies. Direct care materials and supplies
				means items used by, or for, residents, such as those used for services and
				other functions, including, but not limited to: activities, food service,
				housekeeping, infection control, maintenance, medical services, medical
				recordkeeping, social services, and transportation; and
2. A single aggregate amount is reported for
				all other materials and supplies. Other materials and supplies means general
				and administrative items common to most businesses, such as those corresponding
				to the staff, provided at N.J.A.C. 10:49A-2.3(a)4.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49A - NURSING FACILITY PATIENT CARE RATIO REQUIREMENTS › Subchapter 2 - DISCLOSURE AND REPORTING REQUIREMENTS › Section 10:49A-2.5 - Required reported expenses: facility operating expenses

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A facility must report amounts paid, or
				accrued, during the PCR reporting year in order to secure facility space and
				maintain it in habitable and licensable condition. Amounts must be reported in
				the aggregate for each of the following distinct categories:
1. A single aggregate amount must be reported
				for all equipment, maintenance, telecommunications, and utility expenses
				attributable to buildings and equipment used for resident living, activities,
				services, and support functions, including, but not limited to, food service
				and transportation. If administrative offices are attached to these buildings,
				expenses for similar items may be included in this total if they are dedicated
				solely to the operations of the reporting facility. Expenses for areas that are
				not used solely by, or for, residents may only be reported in this category if
				the amount is allocated on a pro rata basis, based on the proportion of actual
				resident use, as calculated over the course of the PCR reporting
				year;
2. A single aggregate amount
				must be reported for all depreciation and rent expenses attributable to
				property, plant, and equipment (PP&E) used for resident living, activities,
				services, and support functions, such as food service and transportation.
				PP&E that are not used solely by, or for, residents may only be reported in
				this category if the amount is allocated on a pro rata basis, based on the
				proportion of actual resident use, as calculated over the course of the PCR
				reporting year;
3. Depreciation
				must match the amount that would be recognized on a facility's income statement
				in accordance with GAAP, as defined by the Financial Standards Accounting Board
				for the reporting year. Facilities may not report the total cash outlay or
				balance sheet asset generated by a capitalized expenditure. Facilities shall
				not report accelerated depreciation used for internal reporting or tax filing;
				and
4. No amount shall be reported
				for all other facility operating expenses. Other facility operating expenses
				means amounts not allowable under any other category.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49A - NURSING FACILITY PATIENT CARE RATIO REQUIREMENTS › Subchapter 2 - DISCLOSURE AND REPORTING REQUIREMENTS › Section 10:49A-2.6 - Required reported expenses: other operating expenses

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A facility must report amounts paid, or
				accrued, during the PCR reporting year in order to support operations. Amounts
				shall be reported in the aggregate for each of the following distinct
				categories.
1. A single aggregate amount must
				be reported for all staff training;
2. A single aggregate amount must be reported
				for all insurance policies , except for workers' compensation insurance, which
				is reported as part of staff compensation;
3. A single aggregate amount must be reported
				for all interest on depreciable property, plant, and equipment (PP&E) used
				for resident living, activities, services, and support functions, such as food
				service and transportation. PP&E that are not used solely by, or for,
				residents may only be reported in this category if the amount is allocated on a
				pro rata basis, based on the proportion of actual resident use, as calculated
				over the course of the PCR reporting year; and
4. A single aggregate amount must be reported
				for all other non-PPE interest payments. Interest on borrowings for expenses
				that are not used solely by, or for, residents may only be reported in this
				category if the amount is allocated on a pro rata basis, based on the
				proportion of actual resident use, as calculated over the course of the PCR
				reporting year.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49A - NURSING FACILITY PATIENT CARE RATIO REQUIREMENTS › Subchapter 2 - DISCLOSURE AND REPORTING REQUIREMENTS › Section 10:49A-2.7 - Allocation of expenses

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each
				expense must be reported under only one type of expense, unless a cost incurred
				by the facility aggregates amounts that must be reported in different
				categories, in which case the expense must be allocated between expense
				reporting categories.
(b)
				Allocation to each category must be based on a generally accepted accounting
				method consistent with GAAP that is expected to yield the most accurate
				results. If expenses are allocated, the report must include a detailed
				description of the methods used to allocate expenses, including how each
				specific expense meets the criteria for the several categories assigned and why
				this is more accurate than specific identification with a single
				category.
(c) Facilities operating
				within a group where personnel and physical locations are shared, including
				expenses under the terms of a management contract, must be allocated among the
				facilities incurring the expense in accordance with the above standards.
				Expenses that relate solely to the operations of a reporting facility must be
				borne solely by the reporting entity and shall not be allocated to other
				entities within a group.
(d) The
				facility must maintain, and make available to the Department upon request, the
				data used to allocate expenses reported, along with all supporting information
				required to determine that the methods identified and reported were accurately
				implemented in preparing the report.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49A - NURSING FACILITY PATIENT CARE RATIO REQUIREMENTS › Subchapter 3 - REBATE AND AUDIT REQUIREMENTS › Section 10:49A-3.1 - Calculating and providing the rebate

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A facility must provide a rebate to the
				Department if the facility has a PCR of less than 90 percent.
1. For the sole purpose of determining if the
				facility has a PCR of less than 90 percent, the Department is entitled to
				receive a rebate pursuant to this subchapter, the term "payer" means the
				Department, as the administrator of the New Jersey Medicaid/NJ FamilyCare
				fee-for-service and Managed Care programs.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49A - NURSING FACILITY PATIENT CARE RATIO REQUIREMENTS › Subchapter 3 - REBATE AND AUDIT REQUIREMENTS › Section 10:49A-3.2 - Audits of a facility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The
				Department will provide 30 days' advance notice of its intent to conduct an
				audit of a facility, either by Department staff or by authorized
				representatives of the Department.
1. All
				audits will include an entrance conference at which the scope of the audit will
				be presented and an exit conference at which the audit findings will be
				discussed.
2. The Department will
				share its preliminary audit findings with the facility, which will then have 30
				days to respond to such findings. The Department may extend, for good cause,
				the time for a facility to submit such a response.
3. If the facility does not dispute the
				preliminary findings, the audit findings will become final. Alternatively, if
				the facility responds to the preliminary findings, the Department will review
				and consider such response and finalize the audit findings.
4. The Department will send the facility a
				copy of the final audit findings, including any recommendations the facility
				must implement as a result of the audit findings. A plan of corrective actions
				must be submitted to the Department within 90 days of the issuance of the final
				report.
5. If the Department
				determines, as the result of an audit, that a facility has failed to pay
				rebates it is obligated to pay pursuant to this chapter, the Department may
				order the facility to pay those rebates in accordance with this
				chapter.
6. If another entity
				conducts an audit of a facility's PCR reporting and rebate obligations, the
				Department may, in the exercise of its discretion, accept the findings of that
				audit if the Department determines the following:
i. The entity's audit reports on the validity
				of the data regarding expenses and revenue that the facility reported to the
				Department, including the appropriateness of the allocations of expenses used
				in such reporting; and
ii. The
				entity submits final audit reports to the Department within 30 days of
				finalization.
7. If the
				Department accepts an audit conducted by another entity, and if the facility
				makes additional rebate payments as a result of the audit, then the Department
				shall accept those payments as satisfying the facility's obligation to pay
				rebates pursuant to this chapter.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49A - NURSING FACILITY PATIENT CARE RATIO REQUIREMENTS › Subchapter 3 - REBATE AND AUDIT REQUIREMENTS › Section 10:49A-3.3 - Access to facilities

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each
				facility subject to the reporting requirements of this chapter must allow
				access and entry to its premises, facilities, and records, including computer
				and other electronic systems, to the Department, the New Jersey Department of
				Law and Public Safety, the New Jersey Office of the State Comptroller, or any
				authorized agents of those entities to evaluate, through inspection, audit, or
				other means, compliance with the requirements for reporting and calculation of
				data submitted to the Department, and the timeliness and accuracy of rebate
				payments made pursuant to this chapter.
(b) Each facility must allow the same access
				and entry to the facilities and records, including computer and other
				electronic systems, of its parent organization, subsidiaries, related parties,
				contractors, subcontractors, agents, or a transferee, that pertain to any
				aspect of the data reported to the Department or to rebate payments calculated
				and made pursuant to this chapter. To the extent that the facility does not
				control access to the facilities and records of its parent organization,
				related parties, or third parties, it is the responsibility of the facility to
				contractually obligate any such parent organization, related parties, or third
				parties to grant said access.
(c)
				Unless a longer period is required by applicable law, State audit entities may
				inspect or audit a facility at any time up to three years from the date,
				determined by the timestamped confirmation that the Department provides, of the
				facility's filing of a report required by this chapter. The Department may also
				inspect or audit a facility at any time up to three years after the completion
				of an audit and for such longer period as set forth in this subsection,
				provided that any of the following occur:
1.
				An entity determines there is a special need to retain a particular record, or
				group of records, for a longer period and notifies the facility at least 30
				days before the record retention disposition date;
2. There has been a dispute or allegation of
				fraud or similar action by the facility, in which case the retention may be
				extended to six years from the date of any resulting final resolution of the
				dispute, fraud, or similar fault; or
3. The entity determines that there is a
				reasonable possibility of fraud or similar fault, in which case the entity may
				inspect, evaluate, and audit the facility at any time.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49A - NURSING FACILITY PATIENT CARE RATIO REQUIREMENTS › Subchapter 3 - REBATE AND AUDIT REQUIREMENTS › Section 10:49A-3.4 - Recordkeeping

Current through Register Vol. 56, No. 14, July 15, 2024
Each facility subject to the requirements of this chapter
				  must maintain all documents and other evidence necessary to enable the
				  Department to verify that the data required to be submitted in accordance with
				  this chapter comply with the definitions and criteria set forth in this
				  chapter, and that the PCR is calculated and any rebates owing are calculated
				  and provided in accordance with this chapter. This requirement includes, but is
				  not limited to, all administrative and financial books and records used in
				  compiling data reported, and rebates provided, pursuant to this chapter and in
				  determining what data to report and rebates to provide under this chapter,
				  electronically stored information, and evidence of accounting procedures and
				  practices. This requirement also includes all administrative and financial
				  books and records used by others in assisting a facility with its obligations
				  pursuant to this chapter.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 50 - TRANSPORTATION SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:50-1.1 - Scope

Current through Register Vol. 56, No. 14, July 15, 2024
This chapter describes the policies and procedures of the New
				  Jersey Medicaid/NJ FamilyCare program regarding transportation services.
				  Questions about this chapter may be directed to the Transportation Coordinator,
				  Division of Medical Assistance and Health Services, PO Box 712, Trenton, New
				  Jersey 08625-0712.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 50 - TRANSPORTATION SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:50-1.3 - General policies for participation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The approval
				process for becoming an independent transportation service provider is as
				follows:
1. Each independent transportation
				provider must be individually approved for each type of service provided. The
				Division of Medical Assistance and Health Services, Department of Human
				Services, in conjunction with the Fiscal Agent for the New Jersey Medicaid/NJ
				FamilyCare program, must approve each provider before reimbursement can be made
				to that provider for a transportation service.
i. A transportation broker under contract
				with the Department of Human Services to provide nonemergency transportation
				shall require that all transportation professionals contracted with the broker
				be approved by the Division of Medical Assistance and Health
				Services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 50 - TRANSPORTATION SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:50-1.4 - Services covered by the New Jersey Medicaid/NJ FamilyCare program

Current through Register Vol. 56, No. 14, July 15, 2024
(a)
				All non-emergency medical transportation services shall be provided by an
				independent transportation broker under contract with the Department of Human
				Services. These services may include, but are not limited to:
1. Ground ambulance service
				(non-emergency);
2. Mobility
				assistance vehicle service;
3.
				Livery services, including modified livery services;
4. All lower-mode transportation services,
				including arranging for transportation by taxi, train, bus, plane, other public
				conveyance, or mileage reimbursement for the use of an individual's vehicle;
				and
5. Fixed wing air
				transportation services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 50 - TRANSPORTATION SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:50-1.5 - Authorization for air ambulance services

Current through Register Vol. 56, No. 14, July 15, 2024
(a)
				Authorization from the Division of Medical Assistance and Health Services'
				contracted transportation broker is required for all fixed wing air ambulance
				services.
1. The use of a rotary wing air
				ambulance is retroactively authorized and includes the approval for
				fee-for-service reimbursement of a set rate plus mileage costs per loaded
				mile.
2. For Medicaid/NJ FamilyCare
				beneficiaries enrolled in a managed care organization (MCO), the reimbursement
				of the rotary wing air ambulance, as well as its associated loaded mileage,
				shall be the responsibility of the MCO.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 50 - TRANSPORTATION SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:50-1.6 - Reimbursement policy for emergency transportation services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The
				least expensive mode of emergency transportation suitable to the Medicaid/NJ
				FamilyCare fee-for-service beneficiary's needs shall be used.
(b) Mileage for ground ambulance service
				shall be measured by odometer from the point at which the Medicaid/NJ
				FamilyCare fee-for-service beneficiary enters the vehicle to the point at which
				he or she exits the vehicle.
1. Medicaid/NJ
				FamilyCare fee-for-service beneficiaries shall be transported in a manner that
				results in the accrual of the least number of miles.
2. There may be instances in which a driver
				takes a faster-but-longer route to avoid traffic congestion or road
				construction. Mileage based on the faster-but-longer route shall be acceptable
				if the reason for the route is fully documented on the Transportation
				Certification Form.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 50 - TRANSPORTATION SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:50-1.7 - Transportation certification for emergency services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The
				Fiscal Agent Billing Supplement contains a sample transportation certification
				form and instructions for the form's proper completion. The elements appearing
				on the sample transportation certification form shall appear on all
				certification forms furnished and prepared by the independent transportation
				provider. In addition to the elements appearing on the sample transportation
				certification form in the Fiscal Agent Billing Supplement, a provider's
				transportation certification form for emergency ground ambulance service shall
				contain the following documentation:
1.
				Beginning and ending mileage amounts for each trip as measured by the vehicle's
				odometer. Mileage amounts shall accurately reflect the point at which the
				Medicaid or NJ FamilyCare fee-for-service beneficiary enters the vehicle and
				the point at which he or she exits the vehicle; and
2. The seven-digit Provider Billing Number of
				the provider at the place of destination.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 50 - TRANSPORTATION SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:50-1.9 - Insurance requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An independent
				transportation provider shall have the following insurance, upon initial
				application to enroll, and shall fully maintain that insurance, in order to
				participate in the Medicaid/NJ FamilyCare program:
1. Workers compensation, in amounts as
				required by law, including
				34:15-1 et seq.;
2. General liability coverage for ambulance
				providers shall comply with the professional liability requirements for such
				providers contained at
				N.J.A.C.
				8:40-3.3;
3. Automobile liability coverage, for each
				vehicle, which for ambulance service, shall comply with the automobile
				liability requirements for such providers contained at
				N.J.A.C.
				8:40-3.3; and
4. For ambulance providers, professional
				liability insurance coverage, which shall comply with the professional
				liability requirements for such providers contained in
				8:40-3.3, as amended and
				supplemented.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 50 - TRANSPORTATION SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:50-1.14 - Recordkeeping

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each independent transportation provider
				shall prepare daily log sheets which shall be maintained for a period of at
				least five years from the date the service was rendered to the Medicaid/NJ
				FamilyCare beneficiary.
(b) The
				daily log sheets shall be made available for immediate review if requested by
				the Division.
(c) If a daily log
				sheet is not on file for each service, or does not contain all the required
				elements as indicated in this section, Medicaid/NJ FamilyCare payment for the
				service may be denied or subject to recoupment in accordance with N.J.A.C.
				10:49 or this chapter.
(d) The
				daily log sheet shall contain, at a minimum, the following information:
1. The date;
2. The name of each Medicaid/NJ FamilyCare
				beneficiary;
3. The beneficiary's
				Health Benefits Identification (HBID) number;
4. The place of origin (address);
5. The destination (name of facility and
				address); and
6. A description of
				the emergency condition of the beneficiary.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 50 - TRANSPORTATION SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:50-1.15 - Complaint log

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An independent transportation provider
				shall implement a complaint/grievance procedure.
(b) An independent transportation provider
				shall prepare and maintain a complaint log, containing all complaints and/or
				grievances from beneficiaries or their representatives.
(c) An independent transportation provider
				shall make all complaint logs available for immediate review upon the request
				of any representative(s) of the Division, for a period of at least five years
				from the date of service involved.
(d) An independent transportation provider
				shall enter the following information into the complaint log:
1. The name and address of the Medicaid/NJ
				FamilyCare beneficiary involved;
2.
				The beneficiary's Health Benefits Identification (HBID) number;
3. The telephone number of the
				beneficiary;
4. Complete details
				about the nature of the complaint; and
5. Complete details of the resolution of the
				complaint and any corrective action taken by the provider.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 50 - TRANSPORTATION SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:50-1.16 - Program integrity

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An independent transportation provider
				shall comply with the following requirements:
1. Each claim, certification form, and daily
				log sheet entry shall correspond to an actual trip provided to a Medicaid/NJ
				FamilyCare beneficiary;
2. No
				remuneration, compensation, or other consideration shall be solicited or
				accepted from any Medicaid/NJ FamilyCare-eligible beneficiary for services
				delivered;
3. An independent
				transportation provider shall not use any marketing material that includes any
				reference to Medicaid/NJ FamilyCare coverage unless that material has been
				approved by the Division prior to its use;
4. An independent transportation provider
				shall report immediately to the Office of the State Comptroller, Medicaid Fraud
				Division, any evidence of fraud or abuse related to Medicaid/NJ FamilyCare
				services or beneficiaries. The Medicaid Fraud Division Hotline, 1-888-937-2835,
				is available to report allegations of fraud and abuse. Suspected fraud and
				abuse can also be reported on the New Jersey State Comptroller's website:
www.state.nj.us/comptroller/divisions/medicaid
.
				The provider shall cooperate with any investigation that may result;
5. An independent transportation provider
				shall abide by the provisions of
				N.J.A.C.
				10:49-7.4 and 7.5, concerning the use of
				factors, service bureaus, and management agencies;
6. An independent transportation provider
				shall abide by the provisions of N.J.A.C. 10:49-11 and 12, concerning exclusion
				from participation in the New Jersey Medicaid/NJ FamilyCare program and
				provider reinstatement; and
7. An
				independent transportation provider shall not release any data pertaining to
				transportation services without the prior written approval of authorized
				personnel of the Division or other authorized agency of the State of New
				Jersey. Data shall be released only in accordance with the explicit written
				instructions from the Division or other authorized agency. No results of the
				program shall be released without the prior written approval of the Division or
				other authorized agency of the State of New Jersey, and such results shall be
				released only to persons designated in that written approval.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 50 - TRANSPORTATION SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:50-1.17 - Auditing

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division may review and evaluate the
				care and services provided to Medicaid/NJ FamilyCare beneficiaries to ensure
				that independent transportation providers comply with the provisions of their
				contracts with the Division and with applicable Federal and State laws, rules,
				and regulations. Post-service reviews may be on a pre-payment or post-payment
				basis.
(b) A provider shall comply
				with a request by the Division for any documentation within three business
				days. Such documentation shall include, but shall not be limited to:
				photocopies of licenses, registrations, insurance documents, prior
				authorization forms, claims, transportation certification forms, complaint
				logs, and daily log sheets.
(c) At
				the Division's request, vehicle service and maintenance records shall be made
				available for immediate on-site inspection by any representative(s) of the
				Division.
(d) An independent
				transportation provider shall permit spot checks and on-site inspections for
				the purpose of monitoring and evaluating the work performed.
(e) An independent transportation provider
				and its drivers and attendants shall cooperate fully during any spot checks and
				on-site inspections conducted by representatives of the State of New Jersey for
				the purpose of inspecting, investigating, monitoring, or otherwise evaluating
				the work performed under the terms of the Provider Agreement.
(f) The Division, the U.S. Department of
				Health and Human Services, the General Accounting Office (GAO), the New Jersey
				Department of Law and Public Safety, and any other Federal, State, county, or
				local agency with appropriate jurisdiction, or their authorized
				representative(s), shall, at reasonable times, have the right to enter an
				independent transportation provider's premises, or such other places where
				duties under the contract are being performed, to inspect, investigate,
				monitor, or otherwise evaluate the work being performed and all related
				financial records.
(g) A
				transportation provider shall provide reasonable access to all facilities and
				shall cooperate with any Federal, State, county, and local representative(s)
				conducting spot checks, on-site inspection visits, audits, and
				investigations.
(h) Independent
				transportation providers that provide modified livery transport services shall
				provide monthly reports to the Division which shall include the following
				information regarding each modified livery transport service provided:
1. The beneficiary's HBID number;
2. The beneficiary's name;
3. The beneficiary's destination (name of
				facility and address);
4. The fleet
				number of the vehicle used;
5. The
				date and hours of service;
6. The
				provider-supplied attendant's name; and
7. The driver's name.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 50 - TRANSPORTATION SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:50-1.18 - Performance standards; termination of services, privileges and/or provider agreement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An independent transportation provider
				shall ensure that each Medicaid/NJ FamilyCare beneficiary is picked up without
				delay and is transported by a safe driver, in a safe manner, and in accordance
				with the requirements of all State and Federal laws, rules, and
				regulations.
(b) The following
				shall result in the Division's immediate termination of the Provider Agreement
				and immediate termination of service from the provider, and may also result in
				denial, or recoupment, of payment to the provider:
1. Failure to maintain a business location
				and a telephone dispatch service, as required under this chapter;
2. Failure to provide to the Division, within
				five working days, notice of any change of address, telephone number, or
				cessation of service;
3. Failure to
				provide door-through-door escort services, if required by a beneficiary;
				and
4. Any violation of any
				provision of any State or Federal law, rule, or regulation that affects, or
				threatens to affect, the life, health, or safety of any Medicaid/NJ FamilyCare
				beneficiary or any representative of the State.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 50 - TRANSPORTATION SERVICES MANUAL › Subchapter 2 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:50-2.1 - Introduction

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey Medicaid/NJ FamilyCare
				program adopted the Federal Centers for Medicare & Medicaid Services' (CMS)
				Healthcare Common Procedure Coding System (HCPCS) codes for 2006, established
				and maintained by CMS in accordance with 42 CFR 424, incorporated herein by
				reference, as amended and supplemented and published by PMIC, 4727 Wilshire
				Blvd., Suite 300, Los Angeles, CA 90010. Revisions to the Healthcare Common
				Procedure Coding System (code additions and deletions, and replacement codes)
				will be reflected in this subchapter through publication of a notice of
				administrative change in the New Jersey Register. Revisions to existing
				reimbursement amounts specified by the Division and specification of new
				reimbursement amounts for new codes will be made in accordance with the
				Administrative Procedure Act,
				N.J.S.A.
				52:14B-1 et seq. The HCPCS codes as listed in
				this subchapter are relevant to Medicaid/NJ FamilyCare fee-for-services
				transportation services and must be used when filing a claim. An updated copy
				of the HCPCS codes may be obtained by accessing
www.njmmis.com
.
1. The responsibility of the transportation
				services provider when rendering services and requesting reimbursement is
				listed in Subchapter 1 and Subchapter 2 of this manual.
2. The column titled Maximum Fee Allowance
				indicates the amount of reimbursement or the symbol B.R.:
i. "B.R." (By Report) is listed instead of a
				dollar amount. It means that additional information will be required in order
				to properly evaluate the service. Attach a copy of the report to the MC-12
				claim form.