reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:66-1.7 - Personal contribution to care requirements for NJ FamilyCare-Plan C and copayments for NJ FamilyCare-Plan D

Current through Register Vol. 56, No. 14, July 15, 2024
(a) General
				policies regarding the collection of personal contribution to care for NJ
				FamilyCare-Plan C and copayments for NJ FamilyCare-Plan D fee-for-service are
				set forth at N.J.A.C. 10:49-9.
(b)
				Personal contribution to care for NJ FamilyCare-Plan C services is $ 5.00 a
				visit for clinic visits, except when the service is provided as indicated in
				(e) below.
1. A clinic visit is defined as a
				face-to-face contact with a medical professional under the direction of a
				physician or dentist, which meets the documentation requirements of this
				chapter.
2. Clinic visits include
				medical professional services provided in the office, patient's home, or any
				other site, excluding a hospital, where the beneficiary may have been examined
				by the clinic staff. Generally, these procedure codes are in the 90000 HCPCS
				series of reimbursable codes at N.J.A.C. 10:66-6.
3. Clinic services which do not meet the
				requirements of a clinic visit as defined in this chapter, such as surgical
				services, immunizations, laboratory or x-ray services, do not require a
				personal contribution to care.
4.
				Encounter procedure codes billed by Federally Qualified Health Centers do not
				require a personal contribution to care.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:66-1.8 - Medical exception process (MEP)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For pharmacy
				claims that exceed Prospective Drug Utilization Review (PDUR) standards
				recommended by the New Jersey DUR Board and approved by the Commissioners of
				DHS and DOH, the Division of Medical Assistance and Health Services has
				established a Medical Exception Process (MEP).
(b) The medical exception process (MEP) shall
				be administered by a contractor, referred to as the MEP contractor, under
				contract with the Department of Human Services.
(c) The medical exception process shall apply
				to all pharmacy claims, regardless of claim media, unless there is a
				recommended exemption by the New Jersey DUR Board that has been approved by the
				Commissioners of DHS and DOH, in accordance with the rules of those
				Departments.
(d) The medical
				exception process is as follows:
1. The MEP
				contractor shall contact prescribers of conflicting drug therapies or drug
				therapies that exceed established PDUR standards to request written
				justification to determine medical necessity for continued drug utilization.
i. The MEP contractor shall send a Prescriber
				Notification Letter, which includes, but may not be limited to, the beneficiary
				name, Medicaid/NJ FamilyCare eligibility identification number, dispense date,
				drug quantity, and drug description. The prescriber shall be requested to
				provide the reason for medical exception, diagnosis, expected duration of
				therapy, and expiration date for medical exception.
ii. The prescriber shall provide information
				requested on the Prescriber Notification to the MEP contractor.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:66-2.1 - Introduction

Current through Register Vol. 56, No. 14, July 15, 2024
This subchapter describes the New Jersey Medicaid and NJ
				  FamilyCare fee-for-service programs' policies and procedures for the provision
				  of Medicaid-covered and NJ FamilyCare fee-for-service covered services in an
				  independent clinic setting. Services, as described in N.J.A.C. 10:49-5, are
				  separately identified and discussed only where unique characteristics or
				  requirements exist. Unless indicated otherwise, reimbursement requirements are
				  located in
				  10:66-1.5, Basis for
				  reimbursement.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:66-2.2 - Dental services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All diagnostic,
				preventive or corrective dental procedures shall be administered by, or under,
				the direct supervision of a dentist enrolled in the New Jersey Medicaid and NJ
				FamilyCare fee-for-service program.
(b) Dental services provided in an
				independent clinic shall follow the policies and procedures outlined in the New
				Jersey Medicaid and NJ FamilyCare fee-for-service programs' Dental Services
				chapter, N.J.A.C. 10:56.
(c) The
				New Jersey Medicaid and NJ FamilyCare fee-for-service programs' Dental Services
				chapter, N.J.A.C. 10:56-3 (HCPCS), contains dental procedure codes and maximum
				fee allowances.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:66-2.3 - Substance use disorder treatment services

Current through Register Vol. 56, No. 14, July 15, 2024
(a)
				Substance use disorder treatment services provided in independent clinics
				include: substance use disorder outpatient rehabilitative services; substance
				use disorder intensive outpatient (IOP) services; substance use disorder
				partial care services; non-hospital based withdrawal management services;
				ambulatory outpatient withdrawal management services; short-term residential
				services; and opioid treatment and maintenance services, in accordance with
				N.J.A.C. 10:161A and 10:161B.
1. Medicaid and
				NJ FamilyCare fee-for-service beneficiaries shall be eligible for substance use
				disorder treatment facility services only if those services:
i. Are prescribed by a physician or an
				advanced practice nurse (APN) as described in (c) through (i) below;
ii. Meet the Federal financial participation
				requirements under Title XIX of the Social Security Act (
				42 U.S.C. §
												1396 );
iii. Are included in the facility's Medicaid
				or NJ FamilyCare fee-for-service approval letter; and
iv. Are licensed by the State of New Jersey
				Department of Human Services as per N.J.A.C. 10:161A for residential services,
				N.J.A.C. 10:161B for outpatient, and/or N.J.A.C. 10:161B-11 for opioid
				treatment services, as applicable.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:66-2.4 - Early and periodic screening, diagnostic and treatment (EPSDT) services program

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The early and
				periodic screening, diagnostic and treatment (EPSDT) services program is a
				Federally mandated comprehensive child health program for Medicaid and NJ
				FamilyCare fee-for-service beneficiaries from birth through 20 years of age.
				(See 42 CFR 441 Subpart B.)
(b)
				EPSDT includes screening services; vision services; dental services; hearing
				services; and other necessary health care, diagnostic services, treatment and
				other measures to correct or ameliorate defects and physical and mental
				illnesses and conditions discovered by the screening services.
1. An expanded program for Medicaid and NJ
				FamilyCare fee-for-service beneficiaries up to the age of two is known as
				HealthStart. For additional information, including provider enrollment
				requirements, see N.J.A.C. 10:66-3.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:66-2.5 - Family planning services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Family planning
				services include medical history and physical examination (including pelvis and
				breast), diagnostic and laboratory tests, drugs and biologicals, medical
				supplies and devices, counseling, continued medical supervision, continuity of
				care, and genetic counseling. Services provided primarily for the diagnosis and
				treatment of infertility, including sterilization reversals, and related clinic
				visits, drugs, laboratory services, radiological and diagnostic services, and
				surgical procedures are not covered by the New Jersey Medicaid or NJ FamilyCare
				fee-for-service program.
1. Exception: When a
				service is provided that is ordinarily considered an infertility service, but
				is provided for another purpose, then the independent clinic must submit the
				claim with supporting documentation for medical review and approval of payment
				to the Division of Medical Assistance and Health Services, Office of
				Utilization Management, PO Box 712, (Mail Code #14), Trenton, New Jersey
				08625-0712.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:66-2.6 - Laboratory services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) As required by the Clinical Laboratory
				Improvement Amendments of 1988 (CLIA), referenced at 42 CFR 493, all facilities
				or entities that perform clinical laboratory testing shall have their CLIA
				identification number on file with the New Jersey Medicaid and NJ FamilyCare
				fee-for-service programs.
(b) A
				clinic shall only claim reimbursement for those laboratory services that have
				been performed by them on their premises, for their patients, and for which
				they have received approval by the New Jersey Medicaid and NJ FamilyCare
				fee-for-service programs, as indicated in
				10:66-1.3(a).
(c) Laboratory procedures are reimbursable
				only when performed in accordance with the applicable CLIA-mandated certificate
				of registration, certificate of waiver, or certificate of physician-performed
				microscopy procedures.
(d) Specific
				laboratory procedures are reimbursable when performed in conjunction with an
				EPSDT screening, if the requirements of (a), (b) and (c) above are
				met.
(e) The outpatient substance
				use disorder treatment program shall provide laboratory services directly in
				the program or shall ensure the availability of services through written
				affiliation agreements, as indicated in N.J.A.C. 10:161B-13.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:66-2.7 - Mental health services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Mental health
				services shall include comprehensive intake evaluation, individual
				psychotherapy, off-site crisis intervention, family therapy, family conference,
				group psychotherapy, psychological testing, partial care, and medication
				management. Mental health services shall not include:
1. Student education, including preparation
				of school-assigned classwork or homework; or
2. Incentive programs, including, but not
				limited to, non-therapeutic token economies and subcontract work
				responsibilities.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:66-2.9 - Other services

Current through Register Vol. 56, No. 14, July 15, 2024
Other services, such as evaluation and management (E/M), and
				  minor surgery are reimbursable when billed by an independent clinic
				  individually approved to provide the service(s) as indicated at
				  10:66-1.3, Provisions for provider
				  participation. See N.J.A.C. 10:66-6 (HCPCS) for the procedure codes and maximum
				  fee allowances corresponding to the Medicaid-reimbursable and NJ FamilyCare
				  fee-for-service-reimbursable service(s).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:66-2.10 - Pharmaceutical services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For covered
				pharmaceutical services, see the New Jersey Medicaid and NJ FamilyCare
				fee-for-service program's Pharmaceutical Services chapter, N.J.A.C.
				10:51.
(b) For specific
				requirements for the provision of pharmaceutical services in independent
				clinics, in addition to those in (a) above, providing substance use disorder
				treatment services, see N.J.A.C. 10:161B-14.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:66-2.11 - Podiatric services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Podiatric services that are medically
				necessary are Medicaid and NJ FamilyCare fee-for-service reimbursable when
				performed by a licensed podiatrist in an independent clinic which is
				specifically approved to perform such services by the New Jersey Medicaid and
				NJ FamilyCare fee-for-service program. See the New Jersey Medicaid and NJ
				FamilyCare fee-for-service programs' Podiatry Services chapter, N.J.A.C. 10:57,
				for additional information.
(b) A
				podiatrist should be Board Qualified, or preferably, Board-Certified by a Board
				recognized by the American Podiatric Medical Association.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:66-2.12 - Radiological services

Current through Register Vol. 56, No. 14, July 15, 2024
Specified radiological services may be reimbursed when
				  provided in a clinic that is specifically approved to provide such services by
				  the New Jersey Department of Environmental Protection, Radiation Protection
				  Element, and performed by or under the direction of a physician who is
				  recognized as a specialist in radiology by the New Jersey Medicaid and NJ
				  FamilyCare fee-for-service programs. See the New Jersey Medicaid and NJ
				  FamilyCare fee-for-service programs' Physician's Services chapter, N.J.A.C.
				  10:54, for additional information.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:66-2.13 - Rehabilitative services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Rehabilitative
				services, as provided in an independent clinic setting, include physical
				therapy, occupational therapy, speech-language pathology and audiology,
				including the use of such supplies and equipment as are necessary in the
				provision of such services. Rehabilitative services are provided for the
				purpose of attaining maximum reduction of physical or mental disability.
				Rehabilitative services shall be made available to Medicaid and NJ FamilyCare
				fee-for-service beneficiaries as an integral part of a comprehensive medical
				program.
(b) Rehabilitative
				services shall be provided by or under the direction of a physical therapist,
				occupational therapist, speech-language pathologist or audiologist employed by
				or under contract to the clinic. These therapy services are discussed at (c),
				(d) and (e) below, respectively.
1. All
				treatments shall be individual and shall consist of a minimum of 30
				minutes.
2. A plan of treatment
				shall be completed during the Medicaid or NJ FamilyCare fee-for-service
				beneficiary's initial evaluation visit and retained on file.
i. The plan of treatment shall be definitive
				as to the type, amount, frequency, and duration of the rehabilitative services
				that are to be furnished and shall include the beneficiary's diagnosis and the
				anticipated goal(s) of the treatment.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:66-2.14 - Renal dialysis service for end-stage renal disease (ESRD)

Current through Register Vol. 56, No. 14, July 15, 2024
An independent clinic providing renal dialysis service for
				  end-stage renal disease (ESRD) shall comply with all applicable Federal
				  regulations and State rules in accordance with N.J.A.C. 8:43A.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:66-2.16 - Termination of pregnancy

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Termination of
				pregnancy is a Medicaid and NJ FamilyCare fee-for-service-covered service when
				the following conditions are present:
1. The
				procedure is performed in an appropriately licensed ambulatory care facility,
				an ambulatory surgical center, or an ambulatory care/family planning/surgical
				facility licensed and authorized by the New Jersey State Department of Health
				to perform terminations of pregnancy with specific approval of the New Jersey
				Medicaid or NJ FamilyCare program;
2. The procedure is performed in accordance
				with the requirements of the New Jersey Board of Medical Examiners, N.J.A.C.
				13:35;
3. The procedure is
				performed by a physician licensed to practice medicine and surgery in the State
				of New Jersey; and
4. The procedure
				is medically necessary. A physician may take the following factors into
				consideration in determining whether a termination of pregnancy is medically
				necessary:
i. To save the life of the
				mother;
ii. The pregnancy was the
				result of an act of rape;
iii. The
				pregnancy was the result of an act of incest;
iv. Physical, emotional, and psychological
				factors;
v. Family reasons;
				and
vi. Age.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:66-2.17 - Transportation services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Transportation
				services shall be covered under the Medicaid and NJ FamilyCare-Plan A, B, C,
				and D programs and the Alternate Benefit Program (ABP) when the following
				conditions are met:
1. The clinic is approved
				to provide transportation service by the Division to partial care programs
				only.
i. Approval by the Division shall not
				be granted for the provision of ambulance or mobility assistance vehicle (MAV)
				service.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:66-2.18 - Vision care services

Current through Register Vol. 56, No. 14, July 15, 2024
Vision care services are reimbursable when administered by a
				  licensed ophthalmologist or optometrist as indicated in the New Jersey Medicaid
				  and NJ FamilyCare fee-for-service programs' Vision Care Services chapter,
				  N.J.A.C. 10:62. See the New Jersey Medicaid and NJ FamilyCare fee-for-service
				  programs' Vision Care Services chapter, N.J.A.C. 10:62-3 (HCPCS), for procedure
				  codes and maximum fee allowance for reimbursement of both professional services
				  and optical appliances and services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:66-2.20 - Vaccines for Children program

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Vaccines
				for Children (VFC) program provides free vaccines for administration to
				beneficiaries under 19 years of age who are eligible for New Jersey Medicaid
				and NJ FamilyCare--Plan A services. The vaccines covered under the VFC program
				may also be provided to any child without health insurance and to any child who
				is an American Indian or an Alaskan Native.
(b) Providers shall receive an enhanced
				administration fee for the administration of vaccines ordered directly from the
				VFC Program. The Medicaid/NJ FamilyCare--Plan A program shall not provide
				reimbursement to providers for administering vaccines that are not obtained
				from the VFC program.
(c) The
				Centers for Disease Control and Prevention (CDC) is expected to periodically
				update the approved list of vaccines covered under the VFC program. The
				Medicaid/NJ FamilyCare--Plan A program will not reimburse for any vaccine so
				added to the VFC list of approved vaccines that are not obtained from the VFC
				program. Upon receipt of updates from the CDC, the Medicaid/NJ FamilyCare
				Program will update the list of VFC-covered vaccines at
				N.J.A.C.
				10:66-6.2(q)  by notice of
				administrative change.
(d)
				Providers shall bill the HCPCS procedure codes 90465, 90466, 90467, 90468,
				90471, 90472, 90473 or 90474 when administering vaccines under this program, as
				appropriate.
(e) Vaccines which are
				covered by the VFC program but are administered to beneficiaries over 19 years
				of age shall be billed with only the appropriate HCPCS procedure code and be
				reimbursed the fee-for-service rate. The administration fee is included in the
				reimbursement for the vaccine.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 3 - HEALTHSTART › Section 10:66-3.1 - Purpose

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of
				HealthStart is to provide for comprehensive maternity care services to pregnant
				Medicaid and NJ FamilyCare fee-for-service beneficiaries, including those
				determined to be presumptively eligible, and preventive child health care
				services for Medicaid beneficiaries up to the age of two and NJ FamilyCare
				fee-for-service beneficiaries.
1. Pediatric
				HealthStart services are an expansion of the EPSDT program as described at
				10:66-2.4.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 3 - HEALTHSTART › Section 10:66-3.2 - Scope of services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) HealthStart
				maternity care services provided by a HealthStart-certified provider are
				obstetrical care services provided in accordance with the recommendations of
				the American College of Obstetricians and Gynecologists and a program of
				support services provided in accordance with N.J.A.C. 10:54-6. HealthStart
				pediatric care services include up to nine preventive visits, as recommended by
				the American Academy of Pediatrics, provided by a HealthStart-certified
				provider who assumes the primary responsibility for coordination and continuity
				of care.
(b) HealthStart
				comprehensive maternity care includes both medical maternity care services and
				health support services, which are described below in (b)1 and 2, respectively.
1. Medical maternity care services include:
i. Ambulatory prenatal services;
ii. Admission arrangements for
				delivery;
iii. Obstetrical delivery
				services; and
iv. Postpartum
				medical services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 3 - HEALTHSTART › Section 10:66-3.3 - HealthStart provider participation criteria

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The
				following Medicaid-enrolled and NJ FamilyCare fee-for-service-enrolled provider
				types are eligible to participate as HealthStart providers: independent
				clinics, hospital outpatient departments, local health departments, physician
				groups, and certified nurse midwives meeting the New Jersey State Department of
				Health Improved Pregnancy Outcome criteria.
(b) In addition to New Jersey Medicaid and NJ
				FamilyCare fee-for-service programs' rules applicable to provider
				participation, HealthStart providers shall:
1. Sign an Addendum to the New Jersey
				Medicaid and NJ FamilyCare fee-for-service programs' Provider
				Agreement;
2. Have a valid
				HealthStart Provider Certificate for HealthStart Maternity Care Service,
				HealthStart Medical Maternity Service, HealthStart Health Support Service, or
				HealthStart Pediatric Care Service; and
3. Provide maternity care and/or pediatric
				care services in accordance with the requirements for issuance of a HealthStart
				Provider Certificate and in accordance with N.J.A.C. 10:54-6.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 3 - HEALTHSTART › Section 10:66-3.4 - Termination of HealthStart Provider Certificate

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New
				Jersey State Department of Health shall be responsible for enforcement of its
				requirements for HealthStart Provider Certificates and for evaluation and
				enforcement of its requirements within the Standards and Guidelines for
				HealthStart Providers.
(b) Failure
				to comply with HealthStart standards shall be cause for termination of the
				HealthStart Provider Certificate by the New Jersey State Department of Health.
1. Termination of the HealthStart Provider
				Certificate shall result in the termination of the HealthStart Provider
				Agreement with the New Jersey Medicaid and NJ FamilyCare fee-for-service
				programs. Providers who are terminated by the New Jersey Medicaid or NJ
				FamilyCare fee-for-service program have the right to request a hearing as
				indicated in the Administration chapter in
				10:49-10.3, Opportunity for fair
				hearing.
2. A HealthStart Provider
				Certificate is time limited. Failure to complete the recertification process
				shall result in termination of the provider's HealthStart provider status by
				the New Jersey State Department of Health.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 3 - HEALTHSTART › Section 10:66-3.5 - Standards for a HealthStart Comprehensive Maternity Care Provider Certificate

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Comprehensive
				maternity care services must be integrated and coordinated.
(b) HealthStart maternity care providers,
				excluding physicians and nurse midwives who are in private practice, shall
				provide comprehensive maternity care services within the following
				organizational requirements:
1. The provider
				shall provide directly or through an approved agreement, at one contiguous
				site, the following services: ambulatory prenatal and postpartum care, case
				coordination services; nutrition assessment, guidance and counseling services;
				health education assessment and instruction; social-psychological assessment,
				guidance and counseling;
2. The
				provider shall provide or arrange for the admission of the patient to the
				appropriate level of care facility for obstetrical delivery services;
3. The provider shall provide or arrange for
				all necessary laboratory services;
4. The provider shall provide one or more
				prenatal home visits for each high risk patient;
5. The provider shall provide at least one
				postpartum home visit for each high risk patient;
6. The provider shall adopt procedures and
				policies which assure the delivery of coordinated, integrated and comprehensive
				care; and
7. The provider shall
				provide referral and follow-up services, which must include, but not be limited
				to: referral for specialized evaluation, counseling and treatment for extensive
				social, psychological, nutritional and medical needs.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 3 - HEALTHSTART › Section 10:66-3.6 - Access to service

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All HealthStart
				services shall be accessible to patients.
(b) HealthStart maternity care providers
				shall facilitate patient access to services by scheduling an initial medical
				visit appointment within two weeks of the patient's first request for
				services.
(c) HealthStart maternity
				care providers shall provide or arrange for 24 hour access to case coordination
				and medical services for emergency situations.
(d) HealthStart maternity care providers
				shall arrange for language translation and/or interpretation
				services.
(e) HealthStart maternity
				care providers may implement a presumptive eligibility processing if so
				approved by the Division of Medical Assistance and Health Services.
(f) HealthStart maternity care providers
				shall undertake community outreach activities to encourage women to seek early
				prenatal care and increase awareness of the availability of maternity care
				services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 3 - HEALTHSTART › Section 10:66-3.7 - Care plan

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A care plan
				shall be developed and maintained by the case coordinator for each
				patient.
(b) A care plan shall be
				based on the medical, nutritional, social-psychological and health education
				assessments.
(c) A care plan shall
				include, but not be limited to: identification of risk conditions and/or
				problems, prioritization of needs, outcome objectives, planned interventions,
				time frames, referrals and follow-up activities, and identification of staff
				persons responsible for the services.
(d) The care plan shall be developed and
				revised in consultation with the patient and staff providing services to the
				patient.
(e) The initial care plan
				shall be completed after a case conference and no later than one month after
				the initial registration visit.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 3 - HEALTHSTART › Section 10:66-3.8 - Maternity medical care services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Maternity
				medical care services include antepartum, intrapartum and postpartum care
				provided by the obstetrical care practitioner(s) in accordance with N.J.A.C.
				10:54-6.
(b) Prenatal services are
				as follows:
1. Frequency of prenatal visits
				for an uncomplicated pregnancy shall be every four weeks during the first 28
				weeks, then every two weeks until 36 weeks, and weekly thereafter. Prenatal
				visits for complications should be scheduled as needed.
2. Initial prenatal visit content shall
				include, but not be limited to:
i.
				History;
ii. Review of
				systems;
iii. Comprehensive
				physical examination;
iv. Risk
				assessment;
v. Patient
				counseling;
vi. Routine laboratory
				tests;
vii. Development of the care
				plan; and
viii. Special tests
				and/or procedures as medically indicated.
3. Subsequent prenatal visit content shall
				include, but not be limited to:
i. Review and
				revision of the patient care plan;
ii. Interim history;
iii. Physical examination;
iv. Patient counseling and
				treatment;
v. Laboratory
				tests;
vi. Special tests and/or
				procedures which are medically indicated;
vii. Identification of new or developing
				problems; and
viii. Management,
				including transfer, of any new or persistent problems.
4. Transfer of the prenatal records to the
				hospital of delivery shall occur no later than 34 weeks gestation.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 3 - HEALTHSTART › Section 10:66-3.9 - Health support services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Case
				coordination services shall facilitate the delivery of continuous, coordinated
				and comprehensive services for each patient in accordance with N.J.A.C. 10:54-6
				as follows:
1. A permanent case coordinator
				shall be assigned to each patient no later than two weeks after the HealthStart
				enrollment visit.
2. Prenatal case
				coordination activities shall include, but not be limited to:
i. Orienting the patient to all
				services;
ii. Developing,
				maintaining and coordinating the care plan in consultation with the
				patient;
iii. Coordinating and
				monitoring the delivery of all services and referrals;
iv. Monitoring and facilitating the patient's
				entry into and continuation with maternity services;
v. Facilitating and providing advocacy for
				obtaining referral services;
vi.
				Reinforcing health teachings and providing support;
vii. Providing vigorous follow up for missed
				appointments and referrals;
viii.
				Arranging home visits;
ix. Meeting
				with the patient and coordinating patient care conferences; and
x. Reviewing, monitoring and updating the
				patient's complete record.
3. Postpartum care coordination activities
				shall include, but not be limited to:
i.
				Arranging and coordinating the postpartum visit and any home visit;
ii. Arranging with the obstetrical care
				provider to obtain the labor, delivery and postpartum hospital summary record
				information no later than two weeks after delivery;
iii. Linking the patient to appropriate
				service agencies including: the Special Supplemental Food Program for Women,
				Infants and Children (WIC), pediatric care (preferably with a HealthStart
				pediatric care provider), future family planning, Special Child Health Services
				County Case Management Unit, early intervention services for infants with
				disabilities, and other health and social agencies, if needed;
iv. Arranging for the transfer of pertinent
				information or records to the pediatric care and/or future family planning
				service providers;
v. Coordinating
				referrals and following up on missed appointments and referrals; and
vi. Reinforcing health instructions for
				mother and baby.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 3 - HEALTHSTART › Section 10:66-3.10 - Professional staff requirements for HealthStart comprehensive maternity care services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All HealthStart
				comprehensive maternity care services shall be delivered through a team
				approach by qualified professionals.
(b) Physicians and/or certified nurse
				midwives shall be Medicaid and NJ FamilyCare fee-for-service providers and have
				obstetrical admitting privileges at a licensed maternity care
				facility.
(c) Case coordinators
				shall have as a minimum a license as a registered nurse; or a bachelor's degree
				in social work, health or behavioral science.
(d) Health professionals shall have a valid
				license to practice their professions as required by the State of New
				Jersey.
(e) All other
				professionals, for whom no license to practice is required, shall meet
				generally accepted professional standards for qualification.
(f) Paraprofessionals shall be familiar with
				the local community, have knowledge and/or skills in maternal and child health
				services and be supervised by a health professional.
(g) Prenatal, delivery, and postpartum
				medical services shall be delivered by a physician and/or a certified nurse
				midwife.
(h) Nutritional,
				social-psychological and health education assessment and development of the
				care plan shall be provided by the appropriate professional in each of the
				specialty areas or the case coordinator or medical care professional. If the
				nutritional or social-psychological assessment portion of the care plan are
				provided by the case coordinator or medical care professional, then they shall
				be reviewed by the nutritionist or social worker, respectively.
(i) Nutritional and social-psychological
				basic counseling shall be provided by a case coordinator with at least one year
				of experience in providing services to maternity patients or by the appropriate
				specialist in each of the areas or by a registered nurse or obstetrical care
				provider.
(j) Short term
				specialized social-psychological and nutritional counseling services shall be
				provided by a social worker and nutritionist respectively. The social worker
				and nutritionist shall be available on site during patient visits.
(k) There shall be adequate professional,
				paraprofessional and clerical staff to provide, in a timely manner, maternity
				care services as described herein which meet the needs of the
				patients.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 3 - HEALTHSTART › Section 10:66-3.11 - Records: documentation, confidentiality and informed consent for HealthStart comprehensive maternity care providers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) HealthStart
				maternity care providers shall have policies which protect patient
				confidentiality, provide for informed consent, and document prenatal, labor,
				delivery and postpartum services in accordance with N.J.A.C. 10:54-6.
(b) An individual record shall be maintained
				for each patient throughout the pregnancy.
(c) Each record shall be confidential and
				shall include at least the following: history and physical examination
				findings, assessment, a care plan, treatment services, laboratory reports,
				counseling and health instructions provided, and documentation of referral and
				follow-up services.
(d) There shall
				be policies and procedures for appropriate informed consent for all HealthStart
				services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 3 - HEALTHSTART › Section 10:66-3.12 - Standards for HealthStart pediatric care certificate

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Pediatric care
				services shall be comprehensive, integrated and coordinated.
(b) HealthStart pediatric care providers
				shall:
1. Directly provide preventive child
				health care, maintenance of complete patient history, outreach for preventive
				care, initiation of referrals for appropriate medical, educational, social,
				psychological and nutritional services, and follow-up of referrals and sick
				care;
2. Directly provide or
				arrange for non emergency room-based, 24-hour physician telephone access to
				eligible patients; and
3. Directly
				provide or arrange for sick care and emergency care.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 3 - HEALTHSTART › Section 10:66-3.13 - Professional requirements for HealthStart pediatric care providers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All HealthStart
				pediatric care providers shall be pediatricians or have a physician on staff
				who possesses a knowledge of pediatrics. This may be demonstrated by
				eligibility for board certification by the American Academy of Pediatrics, the
				American Osteopathic Board of Pediatrics, and/or by hospital admitting
				privileges in pediatrics.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 3 - HEALTHSTART › Section 10:66-3.14 - Preventive care services by HealthStart pediatric care providers

Current through Register Vol. 56, No. 14, July 15, 2024
(a)
				HealthStart pediatric care providers shall provide preventive health visits in
				accordance with the recommended guidelines of the American Academy of
				Pediatrics and the New Jersey State Department of Health Guidelines for
				HealthStart Pediatric Care. The schedule shall include a two-to-four week
				visit, a two-month visit, a four-month visit, a six-month visit, a nine-month
				visit, a 12-month visit, a 15-month visit, an 18-month visit, and a 23 to
				24-month visit. Each visit shall include, at a minimum, medical, family and
				social history, unclothed physical examination, developmental and nutritional
				assessment, vision and hearing screening, dental assessment, assessment of
				behavior and social environment, anticipatory guidance, age appropriate
				laboratory examinations, and immunizations. Referrals shall be made as
				appropriate.
(b) Each provider
				shall provide or arrange for sick care and 24 hour telephone physician access
				during non-office hours. If not directly provided by the HealthStart provider,
				sick care and 24 hour telephone access shall be provided for each child by a
				single designated provider via a documented agreement. Information on care
				given shall be communicated to the primary HealthStart pediatric care provider.
				Telephone access provided exclusively via emergency room staff is not
				permitted. Referral to the emergency room should occur only for emergency
				medical care or urgent care.
(c)
				Case coordination, outreach and follow-up services shall include letter and/or
				telephone call reminders to the child's parent or guardian for preventive
				well-child visits and letters and/or telephone follow-up of missed
				appointments. Referrals for home visit services for follow-up shall be made
				when appropriate. For all referrals and follow-up visits, the provider shall
				document the completion of such referrals and/or visits. If the referral is not
				completed, a letter or phone call to the child's parent or guardian and/or to
				the referred agency shall be sent or made. All of the activity shall be
				recorded on the patient's chart.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 3 - HEALTHSTART › Section 10:66-3.15 - Referral services by HealthStart pediatric care providers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All
				HealthStart pediatric care providers shall make provision for consultation for
				specialized health and other pediatric services. Services shall include medical
				services, as well as social, psychological, educational, and nutritional
				services.
1. This may include, but is not
				limited to: the Special Supplemental Food Program for Women, Infants and
				Children (WIC); Division of Child Protection and Permanency; Special Child
				Health Services Case Management Units and Child Evaluation Centers; early
				intervention programs; county welfare agencies/boards of social services;
				certified home health agencies; community mental health centers; and local and
				county health departments.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 3 - HEALTHSTART › Section 10:66-3.16 - Records: documentation, confidentiality and informed consent for HealthStart pediatric care providers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) HealthStart
				pediatric care providers shall have policies that protect patient
				confidentiality, provide for informed consent, and document comprehensive care
				services in accordance with the New Jersey State Department of Health
				Guidelines for HealthStart Pediatric Care Providers.
(b) An individual record shall be maintained
				for each patient.
(c) Each record
				shall be confidential and shall include at least the following: history and
				physical examination, results of required assessments, care plan, treatment
				services, laboratory reports, counseling and health instruction provided and
				documentation of referral and follow-up services.
(d) There shall be policies and procedures
				for appropriate informed consent for all HealthStart pediatric
				services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 4 - FEDERALLY QUALIFIED HEALTH CENTER (FQHC) › Section 10:66-4.2 - Hospital visits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An inpatient
				hospital visit performed by a clinic physician for a registered Medicaid or NJ
				FamilyCare fee-for-service patient of a Federally qualified health center shall
				be reimbursed only if the clinic is specifically approved to provide this
				service by the programs.
1. For a salaried
				physician in a Federally qualified health center, an inpatient hospital visit
				shall be billed by the FQHC as a medical encounter.
2. For a physician under contract with a
				Federally qualified health center, the physician may receive reimbursement as
				an individual provider as long as the clinic is not also billing for the same
				service. The only contracted physician's costs that may be reported in the
				FQHC's Medicaid cost report are for visits that are billed by the
				FQHC.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 4 - FEDERALLY QUALIFIED HEALTH CENTER (FQHC) › Section 10:66-4.3 - Audited financial statement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The audited
				financial statement of a Federally qualified health center shall be:
1. Conducted by one of the following:
i. A licensed certified public accountant or
				persons working for a licensed certified public accounting firm; or
ii. A public accountant licensed on or before
				December 31, 1970; or
iii. Persons
				working for a public accounting firm licensed on or before December 31, 1970,
				sufficiently independent as defined by GAO standards, to produce unbiased
				opinions, conclusions, or judgments;
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 4 - FEDERALLY QUALIFIED HEALTH CENTER (FQHC) › Appendix B

Current through Register Vol. 56, No. 14, July 15, 2024
FQHC Annual Cost Reporting Requirements
The following cost report instructions apply to FQHCs that
				  were Medicaid providers on October 31, 2000, for their fiscal years ending on
				  and after June 30, 2001.
In addition, these cost report instructions are for the third
				  year and thereafter, for FQHCs that become Medicaid providers on and after
				  November 1, 2000. The FQHC's first year as a Medicaid provider may represent
				  less than a full year of operation, but is counted as a full year for cost
				  reporting, and a cost report is due to the Division for this period, ending on
				  December 31 of the initial year.
Federally qualified health centers (FQHCs) shall file the
				  Medicare Cost Report (CMS 222-92 (3/93) and all updates), with the Division of
				  Medical Assistance and Health Services (DMAHS). There are services covered by
				  Medicaid that are not covered by Medicare. The cost information below should be
				  included on the Medicare Cost Report that is submitted to Medicare and to the
				  Division. This information will provide Medicaid with cost detail for the
				  additional Medicaid covered services.
Add the following lines to the FQHC Medicare Cost Report,
				  Worksheet A under the category of Facility Health Care Staff Costs:
Cost Center
Line Number
Obstetrics/Gynecology
11
Podiatrist
11.01
Cardiologist
11.02
Specialty Physician (Specify type)
11.03
Specialty Nurse Practitioner (Specify
						  type)
11.04
Nurse Mid-Wife
11.05
Add the following lines added under the category of Costs
				  Other than RHC/FQHC Services:
Cost Center
Line Number
Radiology
56
Outreach
56.01
Community Service
56.02
Patient Transportation
56.03
The above subscripted lines will provide additional detailed
				  data on specific costs. The Medicare Cost Report with subscripted lines should
				  be submitted both in hard copy format and on disk to the Division. In addition,
				  FQHCs are required to submit encounter data on Worksheet 2 of the Medicaid Cost
				  Report appearing in N.J.A.C. 10:66-4 Appendix C and the audited financial
				  statements for the cost reporting period. These items are due to the Division
				  on an annual basis and no later than five months after the close of each FQHC's
				  fiscal year.