New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:66-1.2 - 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 indicates
				  otherwise:
"Ambulatory care facility" means a health care facility or a
				  distinct part of a health care facility, licensed by the New Jersey State
				  Department of Health, or similarly licensed by a comparable agency of the state
				  in which the facility is located, which provides preventive, diagnostic, and
				  treatment services to persons who come to the facility to receive services and
				  depart from the facility on the same day.
"Ambulatory care/family planning facility" means a health
				  care facility or a distinct part of a health care facility, licensed by the New
				  Jersey State Department of Health, or similarly licensed by a comparable agency
				  of the state in which the facility is located, to provide specified surgical
				  procedures.
"Ambulatory surgical center (ASC)" means any distinct entity
				  that: operates exclusively for the purpose of providing surgical services to
				  patients not requiring hospitalization; has an agreement with the Centers for
				  Medicare & Medicaid Services (CMS) as a Medicare participating provider for
				  ambulatory surgical services; is licensed, if required, by the New Jersey State
				  Department of Health, or is similarly licensed by a comparable agency of the
				  state in which the facility is located; and meets the enrollment requirements
				  of the New Jersey Medicaid/NJ FamilyCare programs as indicated in the
				  Administration chapter at
				  N.J.A.C.
				  10:49-3.2 and
				  N.J.A.C.
				  10:66-1.3.
"American Society of Addiction Medicine (ASAM)" means the
				  professional society representing physicians, clinicians, and associated
				  professionals in the field of addiction medicine. Their main office is located
				  at 4601 North Park Ave., Upper Arcade, Suite 101, Chevy Chase, MD 20815, or
				  they can be contacted on their website at:
www.asam.org
.
"ASAM level of care" refers to the ASAM Patient Placement
				  Criteria developed by the American Society of Addiction Medicine, contained in
				  "Patient Placement Criteria for the Treatment of Substance Related Disorder,"
				  2nd Edition revised (2001) (ASAM PPC-2R), incorporated herein by reference, as
				  amended and supplemented, which can be obtained from the ASAM Publications
				  Center, by calling 1-800-844-8948.
"Audited financial statements" are defined in requirements
				  set forth in
				  10:66-4.3. This section provides a
				  set of guidelines so that FQHC providers will know the criteria for a
				  satisfactory audit.
"Behavioral health services" refers to the treatment and
				  amelioration of behavioral/mental health conditions, as well as efforts to
				  prevent and intervene in substance use disorder.
"Clinical practitioner" means a physician (including doctor
				  of medicine, osteopathy, dentistry, podiatry, optometry, and chiropractic
				  medicine), advanced practice nurse, certified nurse midwife, and clinical
				  psychologist.
"Clinic services" means preventive, diagnostic, therapeutic,
				  rehabilitative, or palliative services that are furnished by a facility that is
				  not a part of a hospital but is organized and operated to provide medical care
				  to outpatients. The term includes the following services furnished to
				  outpatients:
1. Services furnished at the clinic by or under the direction
				  of a physician or dentist; and
2. Services furnished outside the clinic, by clinic personnel
				  under the direction of a physician, to an eligible individual who does not
				  reside in a permanent dwelling or does not have a fixed home or mailing
				  address.
"Compensated hours" means, in the case of a Federally
				  qualified health center only, all hours for which an employee receives
				  compensation, payment or any form of remuneration, including regular time,
				  overtime, vacation time, sick time, personal time, educational time, and all
				  other compensated time.
"Dental clinic" means an independent clinic, whether
				  freestanding, or a distinct component of a multi-service ambulatory care
				  facility, licensed by the New Jersey State Board of Dentistry, or similarly
				  licensed by a comparable agency of the state in which the facility is
				  located.
"Dentist" means an individual who is licensed to practice
				  dentistry in the state in which treatment is provided, whose practice is
				  limited solely to dentistry and its specialties, as recognized by the American
				  Dental Association, and who meets the requirements of N.J.A.C. 10:56.
"DHS" means the New Jersey Department of Human
				  Services.
"Division of Mental Health and Addiction Services" or
				  "DMHAS" means the division of the New Jersey Department of Human Services that
				  is responsible for the administration of the State's mental health and
				  addiction programs.
"Drug treatment center" means an independent clinic, whether
				  freestanding, or a distinct part of a facility which is licensed or approved by
				  the New Jersey State Department of Health and Senior Services (DHSS), or is
				  similarly licensed by a comparable agency of the state in which the facility is
				  located, to provide health care for the prevention and treatment of drug
				  addiction and drug abuse, in accordance with N.J.A.C. 8:43A-26, Drug Abuse
				  Treatment Services.
"End Stage Renal Disease (ESRD) facility" means a
				  freestanding facility approved by the Centers for Medicare & Medicaid
				  Services (CMS) for participation in the Medicare program as an end stage renal
				  disease facility.
"Federally qualified health center (FQHC)" means an entity
				  that is receiving a grant under Section 330 of the Public Health Service Act;
				  or is receiving funding from such a grant under a contract with the recipient
				  of such a grant and meets the requirements to receive a grant under Section 330
				  of the Public Health Service Act; or based on the recommendation of the Health
				  Resources and Services Administration within the Public Health Service, is
				  determined by the Secretary to meet the requirements for receiving such a
				  grant; or was treated by the Secretary, for purposes of Medicare Part B, as a
				  Federally Funded Health Center as of January 1, 1990; and includes an
				  outpatient health program or facility operated by a tribe or tribal
				  organization under the Indian Self-Determination Act ( Public Law 93-638 ) or
				  by an urban Indian organization receiving funds under Title V of the Indian
				  Health Care Improvement Act for the provision of primary health
				  services.
"Freestanding facility" means a facility which may not be
				  part of a hospital. However, a clinic may be located in the same building as a
				  hospital, as long as there is no administrative, organizational, financial or
				  other connection between the clinic and the hospital.
"Independent clinic" means a facility that is not part of a
				  hospital but is organized and operated to provide medical care to
				  outpatients.
"Level of Care Index-Adult-3 (LOCI 3)" is a comprehensive
				  program for guiding assessments and documenting treatment, placement, and
				  planning information for the six dimensions of the ASAM criteria placement
				  findings for adults. This program can be accessed on the ASAM website:
http://www.asam.org/quality-practice/guidelines-and-consensus-documents/the-asam-criteria
.
"Local health department clinic" means an independent clinic
				  that is licensed or approved by the New Jersey State Department of Health (DOH)
				  to provide medical care to outpatients in accordance with N.J.A.C. 8:52.
"Managed care wraparound payments" means DMAHS payments made
				  to FQHCs for the difference between the Medicaid FQHC encounter rate and
				  amounts paid to FQHCs by managed care organizations for encounters provided to
				  Medicaid and FamilyCare beneficiaries.
"Medical director" means a physician, doctor of medicine
				  (M.D.) or osteopathy (D.O.), who is responsible for the direction, provision
				  and quality of medical services provided to patients and who is qualified in
				  accordance with
				  8:43A-1.14.
"Medicare Economic Index (MEI)" means that factor that
				  adjusts reimbursement rates for annual inflation, which is determined in
				  accordance with section 1842(b)(3) of the Social Security Act,
				  42 U.S.C.
				  §
										1395u(b)(3) and
				  regulation at
				  42 C.F.R.
				  405.504.
"Medicare limit" means the Medicare FQHC urban payment limit
				  as provided for in section 1833(a)(3) of the Social Security Act,
				  42 U.S.C. §
										1395l(a) and section
				  1861(v)(1)(A)
				  of the Social Security Act,
				  42
				  U.S.C. §
										1395x(v), and
				  section
				  1886(d)(2)(D)
				  of the Social Security Act,
				  42 U.S.C.
				  §
										1395ww(d). The
				  Medicare limit is adjusted for inflation annually by the Medicare Economic
				  Index (MEI) applicable to primary care services.
"Mental health clinic" means an independent clinic, whether
				  freestanding, or a distinct component of a multi-service ambulatory care
				  facility, that meets the minimum standards established by the Community Mental
				  Health Services Act implementing rules, including, but not limited to, N.J.A.C.
				  10:37, and is approved by the Division of Mental Health and Addiction Services
				  (DMHAS), in accordance with that Division's rules, or is similarly licensed by
				  a comparable agency of the state in which the facility is located.
"Mental health services worker" means an individual who
				  possesses a bachelor's degree or associate's degree in psychosocial
				  rehabilitation or mental health services, or related life or work experience,
				  such as assuming leadership roles during participation in mental health
				  services or mental health consumer initiatives.
"New Jersey Substance Abuse Monitoring System (NJSAMS)" is
				  the automated client data collection system required by DHS to be used by all
				  DHS New Jersey substance use disorder treatment facilities and providers to
				  record and report consumer data including, but not limited to, admission,
				  status, treatment services, utilization management, and discharge
				  information.
"Opioid" means both opiates and synthetic narcotics.
"Opioid treatment provider" is a program licensed by DHS
				  where opioid agonist treatment medication, such as methadone or buprenorphine,
				  is dispensed, along with a comprehensive range of medical and rehabilitative
				  services to alleviate the adverse medical, psychological, or physical effects
				  attributed to the use of opioids. The program must be certified as an Opioid
				  Treatment Program by the Federal Substance Abuse and Mental Health Services
				  Administration (SAMHSA) and comply with all regulations enforced by the Drug
				  Enforcement Administration (DEA) as referenced in
				  N.J.A.C.
				  10:161B-11.1.
"Outpatient" means a patient of an organized medical
				  facility, or a distinct part of that facility who is expected by the facility
				  to receive and who does receive professional services for less than a 24-hour
				  period, regardless of the hour of admission, whether or not a bed is used, or
				  whether or not the patient remains in the facility past midnight.
"PA" means prior authorization. See
				  10:66-1.4.
"Patient" means a beneficiary who is receiving needed
				  professional services that are directed by a licensed practitioner of the
				  healing arts towards the maintenance, improvement, or protection of health, or
				  lessening of illness, disability, or pain.
"Personal care assistant" means a person who has successfully
				  completed a training program in personal care services and is certified by the
				  New Jersey State Department of Law and Public Safety, Board of Nursing, as a
				  homemaker-home health aide; who successfully completes a minimum of 12 hours
				  in-service education per year offered by the agency; and who is supervised by a
				  registered professional nurse employed by a Division homemaker/personal care
				  assistant provider agency.
"Physician" means a doctor of medicine (M.D.) or osteopathy
				  (D.O.) licensed to practice medicine and surgery by the New Jersey State Board
				  of Medical Examiners, or similarly licensed by comparable agencies of the state
				  in which he or she practices.
"Podiatrist" means an individual licensed to practice
				  podiatry in the state in which treatment is provided, and whose practice is
				  limited to podiatry, within the scope of practice for that state.
"Prevocational services" means interventions, strategies and
				  activities within the context of a partial care program that assist individuals
				  to acquire general work behaviors, attitudes and skills needed to take on the
				  role of worker and in other life domains, such as: responding to criticism,
				  decision making, negotiating for needs, dealing with interpersonal issues,
				  managing psychiatric symptoms and adherence to prescribed medication
				  directions/schedules. Examples of interventions not considered prevocational or
				  covered by Medicaid and NJ FamilyCare include: technical occupational skills
				  training, college preparation, student education, including preparation of
				  school assigned classwork or homework and individualized job
				  development.
"Prospective Payment System (PPS)" means a payment rate per
				  encounter which is determined in accordance with
				  42 U.S.C. §
										1396a(a) and adjusted
				  annually by the MEI applicable to primary care services.
"Psychologist" means an individual who is licensed to
				  practice psychology in the state in which treatment is provided, and who is a
				  Diplomate of the American Board of Professional Psychology (Diplomate
				  Qualified) or has been notified of admissibility to the examination by the
				  American Board of Professional Psychology (Diplomate Eligible).
"Satellite" means an affiliate of a separately enrolled
				  independent clinic. A satellite is located at a site distinct from that of the
				  separately enrolled independent clinic but shares the same governing
				  authority.
"Special minimum wage certificate" means a certificate issued
				  by the U.S. Department of Labor pursuant to 29 C.F.R. § 525, which permits
				  a worker with a disability to be paid at a rate below the rate which would
				  otherwise be required by statute.
"Specialist" means a fully licensed physician who:
1. Is a diplomate of a specialty board approved by the
				  American Board of Medical Specialties or the Advisory Board of the American
				  Osteopathic Association;
2. Is a fellow of the appropriate American specialty college
				  or a member of an osteopathic specialty college;
3. Is currently admissible to take the examination
				  administered by a specialty board approved by the American Board of Medical
				  Specialties or the Advisory Board of the American Osteopathic Association, or
				  has evidence of completion of an appropriate qualifying residency approved by
				  the American Medical Association or American Osteopathic Association;
4. Holds an active staff appointment with specialty
				  privileges in a voluntary or governmental hospital which is approved for
				  training in the specialty in which the physician has privileges; or
5. Is recognized in the community as a specialist by his or
				  her peers.
"Specialist in dentistry" means an individual who is licensed
				  to practice dentistry in the state in which treatment is provided, and whose
				  practice is limited solely to his or her specialty, which is recognized by the
				  American Dental Association. Additional conditions regarding the qualifications
				  for a dental specialist for the New Jersey Medicaid and NJ FamilyCare
				  fee-for-service programs are located in the New Jersey Medicaid and NJ
				  FamilyCare fee-for-service programs' Dental Services chapter, N.J.A.C.
				  10:56.
"Specialist in podiatry" means an individual who is licensed
				  to practice podiatry in the state in which treatment is provided, and who is a
				  Diplomate of the appropriate American Podiatry Association-recognized board or
				  has been notified of admissibility to examination by the appropriate American
				  Podiatry Association recognized board.
"Substance use disorder treatment facility" means an
				  independent clinic, whether freestanding, or a distinct part of a facility,
				  that is licensed or approved by the New Jersey State Department of Health
				  (DOH), or is similarly licensed by DHS, Division of Mental Health and Addiction
				  Services (DMHAS), to provide health care for the prevention and treatment of
				  drug addiction and drug abuse, in accordance with N.J.A.C. 8:43A-26 and/or
				  10:161B, as applicable.
"Therapeutic subcontract work activity" means production,
				  assembly and/or packing/collating tasks for which individuals with disabilities
				  performing these tasks are paid less than minimum wage and, pursuant to 29
				  C.F.R. § 525, a special minimum wage certificate has been issued to the
				  organization/program by the U.S. Department of Labor.
"Vocational services" means those interventions, strategies
				  and activities that assist individuals to acquire skills to enter a specific
				  occupation and take on the role of colleague (that is, a member of a
				  profession) and/or assist the individual to directly enter the workforce and
				  take on the role of an employee, working as a member of an occupational group
				  for pay with a specific employer.
"Withdrawal management" or "detoxification" means the
				  short-term provision of care, usually not in excess of 30 days, prescribed by a
				  physician and conducted under medical supervision, for the purpose of
				  withdrawing a person from a specific psychoactive substance in a safe and
				  effective manner, according to established written medical protocols.