reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 9 - HEALTH CARE FINANCING ADMINISTRATION (HCFA) COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:54-9.1 - Introduction

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey Medicaid program utilizes the Federal Centers for Medicare & Medicaid Services' (CMS) Healthcare Common Procedure Coding System (HCPCS), incorporated herein by reference, as amended and supplemented. Revisions to the Healthcare Common Procedure Coding System made by the CMS (code additions, code deletions and replacement codes) will be reflected in this chapter 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 through rulemaking in accordance with the Administrative Procedure Act, 52:14B-1 et seq. HCPCS follows the American Medical Association's Physician's Current Procedural Terminology architecture, employing a five-position code and as many as two 2-position modifiers. Unlike the CPT numeric design, the CMS assigned codes and modifiers contain alphabetic characters. HCPCS was developed as a three-level coding system.
1. Level I Codes: The narratives for these codes are found in CPT-4. CPT-4 is a listing of descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures performed by physicians.
2. Level II Codes: The narratives for Level II codes are found in 10:54-9.10. These codes are not found in the CPT-4 and are assigned by HCFA for use by physicians and other practitioners.
3. Level III Codes: The narratives for Level III codes are found in 10:54-9.10. These codes are assigned by the Division of Medical Assistance and Health Services to be used for those services which are unique to the New Jersey Medicaid program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 9 - HEALTH CARE FINANCING ADMINISTRATION (HCFA) COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:54-9.7 - HCPCS procedure codes and maximum fee allowance schedule for pathology/laboratory

Current through Register Vol. 56, No. 14, July 15, 2024
(a) HCPCS procedure codes and maximum fee allowance schedule for Level 1
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(b) HCPCS procedure codes, procedure description and maximum fee allowance schedule for Level 2
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(c) HCPCS procedure codes, procedure description and maximum fee allowance schedule for Level 3
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New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 9 - HEALTH CARE FINANCING ADMINISTRATION (HCFA) COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:54-9.10 - Descriptions and Qualifiers for Level II and Level III Procedure Codes (except for Pathology/Laboratory)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Introduction:
1. The following is a list of procedure codes with the "modifier L" in the IND column on the list of HCPCS Procedure Codes representing procedure codes specifically used by New Jersey Medicaid and not included in the CPT-4.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 9 - HEALTH CARE FINANCING ADMINISTRATION (HCFA) COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:54-9.11 - Supplemental Information Summarizing the Use of HCPCS

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Anesthesia: The following HCPCS procedure codes do not require the AA modifier when the professional services are rendered by an anesthesiologist:
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(b) Incidental Surgery: Certain surgical procedures when performed incidental to other surgical procedures by the operating surgeon or assistant surgeon are covered in the reimbursement allowance for the primary procedure. Such incidental procedures are as follows:
1. Breast biopsy (HCPCS 19100, 19101, 76095)-with other breast surgery (HCPCS 19110-19240);
2. Tracheostomy (HCPCS 31600-31610) with procedures such as the following:
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3. Exploratory Thoracotomy (HCPCS 32095-32160) with other major thoracic procedures;
4. Splenectomy (HCPCS 38100-38101, 38115) with Gastrectomy procedures (HCPCS 43620-43638);
5. Appendectomy (HCPCS 44950) performed on a non-diseased appendix with any major abdominal surgery;
6. Gastrostomy (HCPCS 43830) following or preceding a subtotal or hemigastrectomy; gastrorrhaphy (HCPCS 43840); vagotomy and pyloroplasty (HCPCS 43640); gastroduodenostomy (HCPCS 43810; or other gastric procedures (HCPCS 43500-43885) or esophageal resections (HCPCS 43400-43499) or pancreatic surgery (48100-48180);
7. Enterolysis (freeing of intestinal adhesions- HCPCS 44005) and Lysis of adhesions (salpingolysis, ovariolysis) with other major abdominal surgery or uterine, salpingeal, ovarian surgery or C-Section;
8. Ileostomy (HCPCS 44310), colostomy or cecostomy (HCPCS 44320) procedures performed in conjunction with procedures such as the following small intestine, colon or rectal procedures (HCPCS 44140-44155, 45110-45135);
9. Exploratory Laparotomy (HCPCS 49000) with other intra-abdominal surgical procedures;
10. Retroperitoneal Exploration (HCPCS 49010) with other major procedures in the pelvic or abdominal area;
11. Omentectomy (HCPCS 49255) with any total or partial gastrectomy for malignancy or other gastric, small bowel, colon, pancreatic surgery or combined abdominal-perineal resection;
12. Exploratory Cystotomy (HCPCS 51020-51045) with other major urinary bladder procedures requiring an incision into the bladder;
13. Biopsy of ovary (HCPCS 58900) and drainage of ovarian cyst (HCPCS 58800-58822) with any intra-abdominal surgery including ovarian, uterine or salpingeal surgery;
14. Exploratory Craniotomy (HCPCS 61304, 61305) with any other brain surgery; (HCPCS 61312-61576; 61680-61711; 62000-62258);
15. Biopsy of Testis, needle (HCPCS 54505)-with any inguinal hernia repairs, orchiectomy, exploration of undescended testis, reduction or fixation of testis, hydrocele and scrotal surgery;
16. Eye Surgery for Removal of Cataracts-(HCPCS 66920, 66930, 66940) with any other optical procedure.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Appendix A

Current through Register Vol. 56, No. 14, July 15, 2024
FISCAL AGENT BILLING SUPPLEMENT
AGENCY NOTE: The Fiscal Agent Billing Supplement is appended as a part of this chapter but is not reproduced in the New Jersey Administrative Code. When revisions are made to the Fiscal Agent Billing Supplement, an updated version will be placed on the fiscal agent website (
www.njmmis.com
) and a copy will be filed with the Office of Administrative Law. For a copy of the Fiscal Agent Billing Supplement, access
www.njmmis.com
or write to:
Molina Medicaid Solutions
PO Box 4801
Trenton, New Jersey 08650-4801
or contact:
Office of Administrative Law
Quakerbridge Plaza, Building 9
PO Box 049
Trenton, New Jersey 08625-0049
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Appendix B

Current through Register Vol. 56, No. 14, July 15, 2024
EMC MANUAL
AGENCY NOTE: The Electronic Media Claims (EMC) Manual is appended as a part of this chapter, but is not reproduced in the New Jersey Administrative Code. When revisions are made to the EMC Manual, an updated version will be placed on the fiscal agent website (
www.njmmis.com
) and a copy will be filed with the Office of Administrative Law. The EMC Manual may be reviewed and downloaded by accessing
www.njmmis.com
. For a paper copy of the EMC Manual, write to:
Molina Medicaid Solutions
PO Box 4801
Trenton, NJ 08650-4801
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 55 - PROSTHETIC AND ORTHOTIC SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:55-1.1 - Introduction

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This chapter of the manual N.J.A.C. 10:55 outlines the rules of the New Jersey Medicaid and NJ FamilyCare programs relevant to the provision of prosthetic and orthotic services to Medicaid and NJ FamilyCare fee-for-service beneficiaries. It also lists the specific requirements which must be followed in order to be approved and to participate as a New Jersey Medicaid and NJ FamilyCare provider of prosthetic and orthotic services.
(b) The Prosthetic and Orthotic Services Manual, N.J.A.C. 10:55, does not include rules for the provision to Medicaid and NJ FamilyCare beneficiaries of dentures, artificial eyes, or hearing aids. These services are covered in the New Jersey Medicaid programs' Dental Services Manual, N.J.A.C. 10:56, Vision Care Services Manual, N.J.A.C. 10:62, and the Hearing Aid Services Manual, N.J.A.C. 10:64, respectively.
(c) Unless otherwise stated, the rules of this chapter apply to Medicaid and NJ FamilyCare-Plan A fee-for service beneficiaries. Prosthetic and orthotic services provided to Medicaid and NJ FamilyCare beneficiaries enrolled in a managed care organization (MCO) are governed and administered by that MCO.
1. NJ FamilyCare-Plans B, C, and D beneficiaries are required to be enrolled in managed care organizations. (See N.J.A.C. 10:79.)
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 55 - PROSTHETIC AND ORTHOTIC SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:55-1.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise.
"Accredited" means those facilities that have met the standards of qualification as established by the American Board for Certification in Orthotics, Prosthetics and Pedorthics, Incorporated, 330 John Carlyle St., Suite 210, Alexandria, VA 22314.
"Certified" means those individuals that have met the standards of qualification and the requirements as established by the American Board for Certification in Orthotics, Prosthetics and Pedorthics, Incorporated (see address in definition of "accredited" above).
"Custom-made" means a device or appliance fabricated (constructed and/or assembled) in an approved facility (see 10:55-1.3 ) and designed to fit and perform a useful function solely for that individual for whom it was ordered.
"Facility" means the work area of operation of the prosthetist, orthotist or pedorthist.
"Orthotic appliances" means a device or brace prescribed by a physician or other practitioner, within the scope of his or her practice as defined by State law, for the purpose of providing support, increased function, and overcoming physical impairment or defects.
1. A brace includes rigid and semi-rigid devices used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body.
"Orthotist" means one licensed by the State of New Jersey as an orthotist in accordance with N.J.A.C. 13:44H and certified by the American Board for Certification in Orthotics, Prosthetics and Pedorthics, Incorporated in the profession of measuring, designing, fabricating and fitting of orthotic devices.
"Pedorthist" means one certified by the American Board for Certification in Orthotics, Prosthetics and Pedorthics, Incorporated, in the profession of designing, manufacturing, fitting and modification of footwear and related appliances.
"Practitioner" means a physician or other medical care individual licensed or certified under State law to practice his or her profession.
"Prosthetic appliances" means functional replacement, corrective, or supportive devices prescribed by a physician or other licensed practitioner within the scope of his or her practice as defined by State law to:
1. Artificially replace a missing portion of the body; or
2. Prevent or correct physical deformity or malfunction; or
3. Support a weak or deformed portion of the body.
"Prosthetist" means one licensed by the State of New Jersey as a prosthetist in accordance with N.J.A.C. 13:44H and certified by the American Board for Certification in Orthotics, Prosthetics and Pedorthics, Incorporated, in the profession of making of artificial parts to replace a missing body part or to augment the performance of a natural function externally.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 55 - PROSTHETIC AND ORTHOTIC SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:55-1.3 - Requirements for approval as a provider of prosthetic and orthotic services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order to be a fully approved New Jersey Medicaid and NJ FamilyCare fee-for-service provider of prosthetic and orthotic services, the applicant shall:
1. Submit a completed application (see 10:49-3.2 ) together with a copy of the facility and personnel accreditation/certification by the American Board for Certification in Orthotics, Prosthetics and Pedorthics. (The applicant may be applying for either orthotics or prosthetics or both); and
2. Meet the following criteria:
i. Appliances shall be fabricated in the facility and not sent out to another facility;
ii. The facility shall employ personnel (owner and/or employee(s)) certified in the field of specialty of the appliance(s) being produced by that facility; and
iii. Facilities and their qualified personnel shall maintain current accreditation/certification by the American Board for Certification in Orthotics, Prosthetics and Pedorthics, Incorporated.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 55 - PROSTHETIC AND ORTHOTIC SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:55-1.4 - Requirements for program participation as prosthetic and orthotic services provider

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An approved Medicaid and NJ FamilyCare fee-for-service provider of prosthetic and orthotic services shall be responsible for the following:
1. Assuring that an appliance furnished by the approved facility conforms to the prescriber's prescription and the description of the appliance as set forth in the accepted nomenclature by the American Board for Certification in Orthotics, Prosthetics and Pedorthics, Incorporated; fitting the appliance properly to the extent that the beneficiary's condition(s) permits; and providing maximum efficiency and comfort consistent with the condition(s) of the beneficiary for whom the appliance is prescribed;
2. Assuming liability for defective materials over which the provider has (or should have had) control;
3. Agreeing to accept return of an appliance when the prescribing physician, after appropriate evaluation of the appliance(s), determines that the appliance(s) does not conform to the prescription and description of the appliance set forth in the accepted nomenclature by the American Board for Certification in Orthotics, Prosthetics and Pedorthics, Incorporated; and/or does not fit properly, and/or is not of acceptable quality, and/or does not provide maximum efficiency and comfort consistent with the condition of the beneficiary for whom it is prescribed, and refabricating the appliance; and
4. Warranting against defective material and workmanship (except for parts normally worn from natural use) for a period of one year from date of delivery to and acceptance by the beneficiary. If it is found that either the material or the workmanship is defective, the provider shall be allowed a reasonable opportunity to make such adjustment and/or corrections or replacement without additional charge to the Medicaid and NJ FamilyCare program, or the beneficiary.
i. The warranty shall not apply to an appliance corrected/altered as a result of a change in the beneficiary's physical condition (anatomical change).
ii. The warranty shall not apply to a misused appliance or an appliance altered by other than the original provider.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 55 - PROSTHETIC AND ORTHOTIC SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:55-1.5 - Prior authorization for prosthetic and orthotic appliances

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This section specifies the services that require prior authorization and the procedures to follow. Prior authorization shall be required for:
1. Any prosthetic appliance (except for preparatory (temporary) upper and lower prostheses) for which the provider's charge is $ 1,000.00 or more;
2. Any orthotic appliance for which the provider's charge is $ 500.00 or more; or
3. Replacement of parts of an appliance when the cost exceeds $ 250, except in an emergency (see (d) below);
i. Prior authorization shall not be required for replacement of parts which involve solely the mechanical aspects of an appliance and for which the charge is $ 250.00 or less.
4. Labor (hourly rate) charges for repair of items or appliances totaling more than $ 250.00 shall be prior authorized by the Medical Assistance Customer Center. (See codes L4200 and L7500 (Repair), at N.J.A.C. 10:55-2.)
i. Total labor (hourly rate) charges for repair of items or appliances, not under warranty, are reimburseable for up to $ 250.00.
5. Any foot and ankle orthotic appliance;
6. Any orthopedic footwear; or
7. Custom molded shoes.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 55 - PROSTHETIC AND ORTHOTIC SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:55-1.6 - Prescription policies

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A personally signed and dated order (prescription) by the prescriber shall be required for the following:
1. Prosthetic and orthotic appliances;
2. Repair and replacement of parts for custom-made prosthetic and orthotic appliances; and
3. Orthopedic footwear.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 55 - PROSTHETIC AND ORTHOTIC SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:55-1.7 - Policy on footwear

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For purposes of the New Jersey Medicaid and NJ FamilyCare programs policies, an "orthopedic shoe" means footwear, with or without accompanying appliances, used to prevent or correct gross deformities of the feet, which is properly fitted as to length and width, and consists of the following basic parts:
1. Correct straight last line;
2. Heels with sufficient bearing surface;
3. Toe with ample room for function;
4. Sole of sufficient weight for foot protection;
5. Rigid shank;
6. Properly fitting upper;
7. Smooth and protective lining; and
8. Snug fitting heel counter.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 55 - PROSTHETIC AND ORTHOTIC SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:55-1.8 - Reimbursement for prosthetic and orthotic appliances

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This section outlines the Program's policy of reimbursement for prosthetic and orthotic services and specifies the procedure for submitting a claim to request payment.
(b) Providers of prosthetic and orthotic appliances shall be reimbursed on a fee-for-service basis not to exceed the maximum fee schedule allowance in N.J.A.C. 10:55-2. Generally, the reimbursement policy for the purchase or repair of any appliance or footwear is in accordance with the lower of the Medicaid and NJ FamilyCare maximum fee allowance or the provider's usual and customary charge. In certain instances, a maximum fee allowance cannot easily be established because of the variety of items that can be provided under the same HCPCS. In those instances, the notation "B.R.," by report, is listed in the fee schedule. In those cases, Medicaid and NJ FamilyCare fee-for-service reimbursement will be established by the Division after a review of the additional material submitted by the provider.
1. An additional labor charge shall only be paid for repair-related activities after warranty or prescription change. Such a charge shall not be reimbursed for a new item or appliance.
2. If it is necessary for the provider to visit the beneficiary at home or another setting to measure, fit or deliver an appliance, the following conditions shall apply:
i. The provider shall be reimbursed for travel time when the distance exceeds five miles one way. If more than one beneficiary is seen during the visit, travel time allowance shall only be billed for the initial beneficiary, in accordance with procedure code X3680, Travel time, N.J.A.C. 10:55-2;
ii. A maximum of three "home visits" shall be allowed, unless there is adequate documentation, including a prescription, justifying the need for additional visits; and
iii. No reimbursement for travel shall be provided if the provider is rendering a service that is not reimbursable by the NJ Medicaid/NJ FamilyCare programs.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 55 - PROSTHETIC AND ORTHOTIC SERVICES › Subchapter 2 - CENTERS FOR MEDICARE AND MEDICAID SERVICES HEALTHCARE COMMON PROCEDURE CODING SYSTEM HCPCS › Section 10:55-2.1 - Introduction

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey Medicaid NJ FamilyCare fee-for-service programs have adopted the Centers for Medicare and Medicaid's Healthcare Common Procedure Coding System (HCPCS). The HCPCS procedure codes listed in this subchapter shall be used when filing a claim for prosthetic and/or orthotic services.
1. The responsibility of the prosthetic and orthotic services provider when rendering services and requesting reimbursement is listed in N.J.A.C. 10:55-1 of the Prosthetic and Orthotic Services chapter.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 55 - PROSTHETIC AND ORTHOTIC SERVICES › Subchapter 2 - CENTERS FOR MEDICARE AND MEDICAID SERVICES HEALTHCARE COMMON PROCEDURE CODING SYSTEM HCPCS › Section 10:55-2.2 - Elements of HCPCS Coding System

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The list of HCPCS procedure codes in 10:55-2.3 and 2.4 is arranged in tabular form with specific information for each code given under columns with the titles "HCPCS Code," "Description," and "Maximum Fee Allowance."
(b) The column titled "MAXIMUM FEE ALLOWANCE" indicates the maximum amount of reimbursement or the following symbol:
1. Where "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. In such instances, the provider shall attach a copy of the report to the claim form.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 55 - PROSTHETIC AND ORTHOTIC SERVICES › Appendix A

Current through Register Vol. 56, No. 14, July 15, 2024
FISCAL AGENT BILLING SUPPLEMENT
AGENCY NOTE: The Fiscal Agent Billing Supplement is appended as part of this chapter but is not reproduced in the New Jersey Administrative Code. When revisions are made to the Fiscal Agent Billing Supplement, an updated copy will be posted on
http://www.njmmis.com
and a copy will be filed with the Office of Administrative Law. If you do not have access to the internet and would like to request a copy of the Fiscal Agent Billing Supplement, write to:
Molina Medicaid Solutions
PO Box 4801
Trenton, New Jersey 08619-4801
or contact:
Office of Administrative Law
Quakerbridge Plaza, Building 9
PO Box 049
Trenton, New Jersey 08625-0049
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 1 - DENTAL SERVICES; GENERAL PROVISIONS › Section 10:56-1.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
This chapter describes the requirements of the New Jersey Medicaid/NJ FamilyCare fee-for-service programs pertaining to the provision of, and reimbursement for, medically-necessary dental services to eligible beneficiaries. In addition to the provider's private office, dental services may be provided in the home, hospital, ambulatory surgical center, approved independent clinic, nursing facility, intermediate care facility for the mentally retarded (ICF/MR), residential treatment center, or elsewhere.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 1 - DENTAL SERVICES; GENERAL PROVISIONS › Section 10:56-1.3 - Provisions for provider participation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A Doctor of Dental Medicine (DMD) or a Doctor of Dental Surgery (DDS), pursuant to N.J.A.C. 13:35 (incorporated herein by reference), who is authorized to provide dental and surgical services by the State of New Jersey, who is an approved Medicaid/NJ FamilyCare fee-for-service participating provider in accordance with (b) below, who complies with all of the rules of the New Jersey Medicaid/NJ FamilyCare fee-for-service programs, shall be eligible to provide dental and surgical dental services to Medicaid/NJ FamilyCare fee-for-service beneficiaries.
1. Any out-of-State dentist may provide dental and surgical services under this program if he or she meets the documentation and licensing requirements in the State which he or she is practicing, and is a New Jersey Medicaid/NJ FamilyCare participating provider.
2. An applicant shall provide the Division with a photocopy of the current license at the time he or she applies for enrollment.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 1 - DENTAL SERVICES; GENERAL PROVISIONS › Section 10:56-1.4 - Prior authorization

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For dental services that require prior authorization, a Prior Authorization Form, (MC-10A), and the Dental Claim Form (MC-10), shall be submitted to:
Division of Medical Assistance and Health Services
Office of Utilization Management
Bureau of Dental Services, Mail Code 21
PO Box 713
Trenton, New Jersey 08625-0713
Telephone: (609) 588-7136
1. Requests for prior authorization should include recent diagnostic radiographs. When appropriate for the service requested, documentation to substantiate or demonstrate the need for the requested dental services shall also be included.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 1 - DENTAL SERVICES; GENERAL PROVISIONS › Section 10:56-1.5 - Basis for reimbursement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Reimbursement for covered services furnished under the New Jersey Medicaid/NJ FamilyCare fee-for-service programs shall be the customary and usual fee of the provider when it does not exceed Federal regulatory maximums and reasonable rates as determined by the Commissioner of Human Services. In no instance shall the charge to the program exceed the usual and customary fee of the provider for identical services to other governmental agencies or other groups or individuals in the community.
1. If a beneficiary receives care from more than one member of a partnership or corporation in the same discipline for the same service, the total maximum payment allowance would be the same as that of a single attending dentist. The allowance fee for a given service shall constitute full payment. No additional charge shall be made by the dentist to, or on behalf of, the covered Medicaid/NJ FamilyCare fee-for-service beneficiary.
2. The procedure codes which are used when submitting claims are listed in N.J.A.C. 10:56-3 --Health Care Financing Administration (HCFA) Common Procedure Coding System (HCPCS). The Fiscal Agent Billing Supplement that follows N.J.A.C. 10:56-3 in Appendix A provides information about the claim form and billing instructions. The provider, when submitting claims for services rendered, shall comply with the provisions of N.J.A.C. 10:56, Appendix A, which is incorporated herein by reference.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 1 - DENTAL SERVICES; GENERAL PROVISIONS › Section 10:56-1.6 - Reimbur sement based on specialist designation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) To obtain reimbursement as a specialist in the Medicaid/NJ FamilyCare programs, a specialist shall:
1. Obtain a specialty certification from the licensing agency of the State of New Jersey or of the state where dental services are to be rendered; or
2. In those states not requiring specialty certification:
i. The specialist shall be a diplomate of a specialty board recognized by the American Dental Association or shall meet the minimum requirements for that specialty as stipulated by the American Dental Association.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 1 - DENTAL SERVICES; GENERAL PROVISIONS › Section 10:56-1.7 - 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 are set forth at N.J.A.C. 10:49-9.
(b) Personal contribution to care for NJ FamilyCare-Plan C services shall be $ 5.00 per visit for dental services, except when the service is provided for preventive dental care.
1. A dental visit is defined as a face-to-face contact with a medical professional, including services provided under the supervision of the dentist, which meets the documentation requirements of this chapter and allows the dentist to request reimbursement for services.
2. Dental visits include dental services provided in the office, patient's home, or any other site, except the hospital, where the child may have been examined by the dentist or the dental staff.
3. Dental services which do not meet the requirements of an office visit, such as surgical services, laboratory or x-ray services, do not require a personal contribution to care.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 1 - DENTAL SERVICES; GENERAL PROVISIONS › Section 10:56-1.8 - Non-covered services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A non-covered service is that procedure which is primarily for cosmetic purposes, for which dental necessity cannot be demonstrated, or which is determined to be beyond the scope of the program by a Medicaid/NJ FamilyCare dental consultant as specified in this chapter.
(b) Medical/dental supplies and equipment and other devices that are essential for the beneficiary's medical/dental condition shall be allowable unless such services are otherwise available at no charge from community services (such as the American Cancer Society or other service organizations).
(c) Standard tooth brushes, dental floss, and like items are considered personal hygiene items and shall not be covered by the Medicaid/NJ FamilyCare fee-for-service program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 1 - DENTAL SERVICES; GENERAL PROVISIONS › Section 10:56-1.9 - Recordkeeping requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Dentists shall maintain individual records which fully disclose the type and extent of services provided to the New Jersey Medicaid/NJ FamilyCare fee-for-service programs beneficiary, including detailing all services rendered for each encounter date. These records shall also fulfill the requirements of the New Jersey State Board of Dentistry as outlined in 13:30-8.7. The Medicaid/NJ FamilyCare Dental Claim Form (MC-10) shall not be an acceptable substitute. Such beneficiary records shall be maintained in the provider's office regardless of the actual place of service (dental office, long-term care facility, or hospital). These records shall be available for a minimum of seven years following the last date of service. The dentist shall also document services in facility records as required in (b) and (c) below. Such information shall be readily available to representatives of the New Jersey Medicaid/NJ FamilyCare fee-for-service programs or their agents as required.
1. The record shall include, but not be limited to, the following:
i. The name, address, and telephone number of the beneficiary, the beneficiary's date of birth and HSP (health services program) number, and, if a minor, name of parent(s) or guardian.
ii. Pertinent dental/medical history; and
iii. Detailed clinical evaluation data to include where applicable:
(1) Beneficiary's chief complaint;
(2) Diagnosis;
(3) Cavities;
(4) Missing teeth; and
(5) Abnormalities;
iv. Preoperative, progress, and postoperative radiographs, which shall be retained for a minimum of seven years following the last date of service. Professional liability insurance companies should be contacted for possible retention for longer periods. The number and type of radiographs shall be entered on the beneficiary's record. Postoperative radiographs shall be taken only when dentally necessary and only when such radiographs have diagnostic value.
v. Treatment plan with description of treatment rendered to include:
(1) Tooth number;
(2) Surfaces involved;
(3) Site and size of treatment area (lesion, laceration, fracture, and so forth);
(4) Materials used;
(5) Date(s) of service(s);
(6) Description of treatment or services rendered at each visit to include the name of the dentist or hygienist rendering it.
(7) All medications;
(8) Diagnostic laboratory and/or radiographic procedure(s) ordered, including the result(s);
(9) Copy of the dental prosthetic work authorization(s) (prescription(s)), and dental prosthetic laboratory receipt(s);
(10) Explanation for any duplication of services within one year (prosthetic services within seven and one-half years);
(11) Reasons for discontinuation of services (including attempts to complete treatment); and
(12) Referral and consultation reports.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 1 - DENTAL SERVICES; GENERAL PROVISIONS › Section 10:56-1.10 - Utilization review, quality control, peer review, and TAMI review

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For the purposes of the New Jersey Medicaid/NJ FamilyCare fee-for-service program, utilization review, quality control and peer review are considered to be ongoing components in regard to the dental services provided to eligible beneficiaries.
(b) Utilization refers to that service, procedure or item provided to a beneficiary by a qualified provider, in a setting, at a time, and in an amount which is appropriate and acceptable to the standards of the profession, at a cost described at N.J.A.C. 10:56-3.
(c) Utilization review is the retrospective analysis of the performance of a dental provider with respect to the efficient provision for the use of services noted in (b) above, from the viewpoint of fiscal accountability.
(d) Quality is that standard of dental care or degree of excellence generally prevailing throughout the profession by those who provide similar service which is not related to any geographical area or population group as judged by competent practitioners who are qualified to perform those procedures.
(e) Dental review is the current ongoing review of the degree of quality in the delivery of continuing dental services and health care which is constantly monitored and maintained by the provision of direction, coordination and regulation through the cooperative efforts between representatives of the New Jersey Medicaid/NJ FamilyCare program and a qualified body of peers.
(f) Peer review is the evaluation by practicing dentists as to the quality and efficiency of services ordered and/or performed by other practicing dentists and is considered to be the all-inclusive term for dental review efforts including dental practice analysis, inpatient hospital and extended care utilization review and dental claims audit and review. In the accomplishment of the above, any or all reviews will include, but not be limited to, the following:
1. A clinical examination made on a sampling of cases. Such examination may be made prior to, during, or upon completion of treatment.
2. Additional diagnostic aids and data which may be requested to evaluate the case.
3. Adequate records, which shall be maintained by the dentist providing treatment and shall be available for inspection.
4. In the event a provider fails to respond to a request of the Division of Medical Assistance and Health Services for office records, radiographs, and/or other materials and correspondence within 30 days, the Division may recover any reimbursement related to the services involved, or if in reference to services not yet paid, reimbursement may be denied.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 2 - PROVISIONS FOR SERVICES › Section 10:56-2.2 - Standards of service

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The dental treatment plan provided shall be in accordance with the ethical and professional standards of the dental profession and meet the same high standard of quality normally provided to the community at large.
(b) All materials used and all therapeutic agents used or prescribed shall meet the specifications established by the American Dental Association.
(c) Experimental procedures, not approved by the New Jersey Board of Dental Examiners (N.J.A.C. 13:30), are not reimbursable by the New Jersey Medicaid/NJ FamilyCare program.
(d) When an emergency arises and consultation with the attending practitioner is impossible, due consideration shall be given to the preservation of those teeth that could be involved in the overall treatment plan of the attending practitioner
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 2 - PROVISIONS FOR SERVICES › Section 10:56-2.3 - Special dental services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Dental services for which no specific procedure code and description are noted, or which are limited or prohibited by this chapter, may be considered on a case-by-case basis, upon request. Such a request shall be submitted on the two part Dental Prior Authorization Form (MC-10A), and the Dental Claim Form (MC-10) and forwarded to the Bureau of Dental Services, Mail Code 21, PO Box 713, Trenton, New Jersey 08625-0713. An unspecified procedure code appropriate for the requested service shall be used when submitting the prior authorization request for these dental services. The request shall be accompanied by all supporting documentation.
1. If such unspecified services are associated with a temporomandibular joint dysfunction diagnosis or therapy, the requesting provider shall comply with the New Jersey Board of Dentistry protocol for diagnosis and treatment planning as set forth in 13:30-8.22.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 2 - PROVISIONS FOR SERVICES › Section 10:56-2.4 - Place of service

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In addition to the private office, dental services may be provided in the home, a hospital, ambulatory surgical center, approved independent clinic, nursing facility, residential treatment center and elsewhere.
(b) Services should be provided in any appropriate setting, governed by medical/dental necessity and not by the convenience or desires of the beneficiary or the providers of services.
1. Specific additional requirements for dental services rendered in the outpatient departments of approved licensed hospitals and services rendered in approved independent clinics are described in N.J.A.C. 10:52 and 10:66, respectively.
i. Hospital outpatient dental clinics are subject to the same New Jersey Medicaid/NJ FamilyCare program requirements and reimbursement schedule, as specified in this chapter, that apply to the dentist in "private" practice (see 10:52-2.3, 10:66 and 13:30.)
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 2 - PROVISIONS FOR SERVICES › Section 10:56-2.5 - House calls and visits to beneficiary residences

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A provider may be reimbursed for a house call/visit (procedure code D9410) in addition to any other services provided on that day. Procedure code D9410 shall include house calls/visits to nursing homes, long-term care facilities, hospice sites, institutions, and other types of extended care facilities.
(b) The following apply to reimbursement for house calls/visits to the facilities identified in (a) above:
1. House calls/visits can be billed in addition to any other services provided to a specific patient on that day; and
2. Billing for house calls/visits using code D9410 shall be limited to once per trip to the facility, regardless of the number of patients examined or treated.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 2 - PROVISIONS FOR SERVICES › Section 10:56-2.6 - Diagnostic services: general

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A complete evaluation of the oral cavity shall be a comprehensive and thorough inspection of the oral cavity to include diagnosis, an oral cancer screening, charting of all abnormalities, and development and recording of a complete treatment plan. It should permit a Division dental consultant (with accompanying radiographs) to determine the appropriateness of the treatment plan.
1. This dental evaluation is reimbursable only when part of a total treatment plan, unless the evaluation discloses no need for treatment, in which case this must be indicated by placing the statement "No Other Treatment Necessary (N.O.T.N.)" under Remarks (Item 20) on the Dental Claim Form (MC-10).
2. Except as provided in 10:78-7.1, for reimbursement purposes, a comprehensive dental evaluation shall be limited to once every six months for those beneficiaries through age 20 and once every 12 months for those beneficiaries 21 years of age or older except as prior authorized by a Division dental consultant.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 2 - PROVISIONS FOR SERVICES › Section 10:56-2.7 - Diagnostic services: radiography

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Radiological procedures shall be limited to those normally required to make a diagnosis and shall show all areas where treatment is anticipated with the exception of soft tissue lesions.
(b) All radiographs should be examined carefully by the provider to assure quality care and to make certain that all necessary treatment has been diagnosed, planned for and/or completed.
(c) Radiographs may be reviewed by dental consultants of the Medicaid/NJ Family Care fee-for-service programs and/or a dentist in private practice not employed by New Jersey Medicaid/NJ Family Care fee-for-service programs, if appropriate. It is recommended that the two film packet be used or a copy may be made by those dentists who wish to retain a set of radiographs in their office at all times.
(d) The originals of all radiographic films shall be available to authorized representatives of the New Jersey Medicaid/NJ Family Care fee-for-service programs. Radiographs shall be forwarded to the Division of Medical Assistance and Health Services in the following situations:
1. When prior authorization is requested; or
2. Upon request by the Medicaid/NJ Family Care fee-for-service programs for utilization review or adjudication purposes.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 2 - PROVISIONS FOR SERVICES › Section 10:56-2.8 - Diagnostic services: Clinical laboratory services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) "Clinical laboratory services" includes services provided by:
1. Independent clinical laboratories, including physician/dentist operated, out of hospital laboratories which perform primarily diagnostic work referred by other practitioners; and
2. Hospital laboratories and laboratories of educational institutions which provide laboratory services to ambulatory beneficiaries as requested by a licensed practitioner.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 56 - MANUAL FOR DENTAL SERVICES › Subchapter 2 - PROVISIONS FOR SERVICES › Section 10:56-2.9 - Preventive dental care

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In addition to an oral evaluation every six months for beneficiaries through age 20 and once every 12 months for beneficiaries 21 years of age or older, preventive dental care encompasses the following recommended services:
1. Prophylaxis, as follows:
i. Dental prophylaxis means the complete removal of calculus and stains from the exposed and unexposed areas of the teeth by scaling and polishing.
ii. For reimbursement purposes, dental prophylaxis shall be limited to once every six months for beneficiaries through age 20 and once every 12 months for beneficiaries 21 years of age or older, except as otherwise prior authorized by a Division dental consultant, and except as provided (a)1ii(1) below.
(1) Beneficiaries with developmental disabilities, neurological impairments, or other disabilities, regardless of age, shall be eligible for evaluation, radiographs as appropriate, prophylaxis, extra-scaling and topical application of fluoride including prophylaxis, as often as every three months. Claims may be submitted directly to the fiscal agent for payment, without prior authorization. In the event that any of the services listed in (A) below are required more often than every three months, a prior authorization request shall be submitted to the Division dental consultant. The nature of the beneficiary's disability shall be recorded under Remarks (Item 20) on the Dental Claim Form.
(A) The following procedure codes shall be used only if a beneficiary is developmentally disabled, neurologically impaired or medically compromised:
Comprehensive Oral Evaluation
D0150-76
Prophylaxis-Adult
D1110-76
Prophylaxis-Child
D1120-76
Topical Application of Fluoride with prophylaxis, Child
D1201-76
Topical Application of Fluoride with prophylaxis, Adult
D1205-76
Full Mouth Debridement
D4355-76
Non-intravenous Conscious Sedation
D9248-76
NOTE: Non-Intravenous Conscious Sedation shall be prior authorized after four times in a 12-month period.