New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:52-1.10 - Prior authorization

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Prior authorization shall be required for certain dental procedures (see N.J.A.C. 10:56, Dental Services) and partial hospitalization provided in the outpatient department of an acute care hospital beyond exempt time frames (see 10:52-2.10(d) and (e) ).
(b) Other services require adherence to special procedures, such as the requirements of the Second Opinion Program, before certain elective surgical procedures are performed. Specific services are described in the "Policies and Procedures for Providing Specific Services" in N.J.A.C. 10:52-2. Hospital entitlement to Medicaid/NJ FamilyCare reimbursement is subject to providing these services in accordance with the policies and procedures as outlined in N.J.A.C. 10:52-2. For general information about prior and retroactive authorization, see N.J.A.C. 10:49-6.1, Administration.
(c) For out-of-State services, see 42 CFR 431.52. Prior authorization as outlined in (d) below shall be required for inpatient and outpatient hospital services provided to a beneficiary outside the State of New Jersey, except as provided in (e) below. Hospital covered services for a beneficiary with an Eligibility Identification Number with the 1st and 2nd digits of 90 or the 3rd and 4th digits of 60, residing out-of-State at the discretion of the New Jersey Department of Human Services, shall not require prior authorization. However, any covered service that requires prior authorization as a prerequisite for payment to New Jersey Medicaid/NJ FamilyCare providers also requires prior authorization if it is to be reimbursed by the Division in any other state, except that prior authorization is not required for emergency and interstate transfers.
(d) A request for authorization for reimbursement for out-of-State services shall be directed to the Medical Assistance Customer Center (MACC) in the area where the beneficiary resides except as listed in (d)1 below. For a listing of MACCs, see the Directory at N.J.A.C. 10:49, Appendix, Form 13 or online at:
http://www.state.nj.us/humanservices/dmahs/info/resources/macc/index.html
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1. Requests for prior authorization of out-of-State psychiatric services shall be directed to the Division of Medical Assistance and Health Services, Mental Health Unit, Office of Utilization Management, PO Box 712, Mail Code #18, Trenton, NJ 08625-0712.
i. For beneficiaries under age 18 and those individuals who are over the age of 18 and under the age of 21 who were receiving mental/behavioral health services through the Department of Children and Families (DCF) and/or the DCF Children's System of Care prior to their 18th birthday, requests for prior authorization of out -of-State psychiatric services shall be coordinated by the Care Management Organization (CMO) or other authorized entity coordinating the beneficiary's mental/behavioral health services and shall be directed by that entity to the DCF Contracted Systems Administrator (CSA). As part of the coordination of inpatient out-of-State psychiatric hospital services for these beneficiaries, the CMO and/or CSA shall direct requests for prior authorization for these services to the DMAHS in accordance with (d)1 above.