reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 73 - CASE MANAGEMENT SERVICES › Subchapter 3 - CARE MANAGEMENT ORGANIZATION SERVICES › Section 10:73-3.17 - Crisis management

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The CMO shall
				identify, in each ISP and subsequent ISP, potential crisis(es) and shall
				include, in the ISP, a crisis management plan for each child, youth or young
				adult and his or her family or other caregiver(s). The crisis management plan
				shall assure that services are available to respond to a crisis on a 24
				hour-a-day/seven-days-a-week basis.
(b) The crisis management plan shall include
				specification of the coordination of the crisis management plan with the CSA
				crisis management services and the available local crisis intervention
				services.
(c) The CMO shall
				maintain the capacity to respond face-to-face as needed to assess the need for
				additional crisis services that are not otherwise identified in the ISP, to
				provide support and to facilitate the provision of other crisis or emergency
				intervention services, as warranted.
(d) Mobile response services may be provided
				by a mobile response agency (see N.J.A.C. 10:77-6 ) for up to 72 hours,
				spanning up to four days. Subsequent stabilization management services shall be
				included in the CMO's Individual Service Plan and shall be coordinated by the
				Child-Family Team, and shall not be provided by the mobile response
				agency.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 73 - CASE MANAGEMENT SERVICES › Subchapter 3 - CARE MANAGEMENT ORGANIZATION SERVICES › Section 10:73-3.18 - Community resource development

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each CMO shall
				catalog all available services and community resources available to support the
				ISP design, and shall provide a list of these services and resources to the CSA
				for inclusion in the Statewide database that shall be maintained for children's
				services.
(b) Each CMO shall assure
				that children, youth and young adults and their families have a choice of
				entities to provide the services identified in the ISP, and based on a thorough
				understanding of the cultural diversity of its service area, each CMO shall
				identify and develop accessible, culturally responsive services and supports,
				which shall include affiliations with informal or natural helping networks,
				such as neighborhood associations determined by the Child/Family Team to be
				appropriate, which support the ISP of one or more beneficiaries within the
				service area of the CMO.
(c) Each
				CMO shall develop policies and procedures for identifying and recruiting
				appropriate informal community supports in the ISP and for providing
				supervision and oversight of their activities.
(d) Each CMO shall develop and maintain
				working affiliation agreements or Memoranda of Understanding (MOUs) with all
				participants in the community service/resource network and shall identify in
				the MOUs specific goals, roles, and responsibilities for collaborative
				activity.
1. Each CMO shall develop working
				relationships reflected in Memoranda of Understanding with all key service
				providers, community organizations, and system partners.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 73 - CASE MANAGEMENT SERVICES › Subchapter 3 - CARE MANAGEMENT ORGANIZATION SERVICES › Section 10:73-3.19 - Financial management

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Under the CSOC
				children's system of care, the care provided and the payment for care is
				individualized and child centered rather than program and service centered. The
				CMO has responsibilities, as a systems partner, to assist in the implementation
				of this principle as outlined in this subchapter and their individual DHS
				contract.
(b) Financial management
				and monitoring responsibilities of the CMOs shall include:
1. The design and implementation of
				Individual Service Plans (ISPs) that shall include a range of services and
				social supports, some of which will be eligible for reimbursement under
				Medicaid/NJ FamilyCare or other DHS/DCF contracts;
2. The administration of a flexible funding
				pool for purchasing services and social supports that contribute to the goals
				of an ISP, but are not reimbursable under Medicaid/NJ FamilyCare program or
				other DHS/DCF contracts;
3. The use
				of DCF funds to develop a local network of innovative community resources
				available to ISP through the flexible funding pool, and the community resource
				fund, organized specifically to contribute to ISP goals and outcomes;
4. The monitoring and tracking of the costs
				of the ISP in conjunction with DHS/DCF and CSA eligibility and other system
				partners, including, but not limited to, other State agencies;
5. The reporting of financial outcomes,
				correlating the clinical outcomes with the financial resources consumed to
				produce the clinical outcomes; and
6. The tracking and managing of funds
				consistent with DHS/DCF child monthly cost benchmarks.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 73 - CASE MANAGEMENT SERVICES › Subchapter 3 - CARE MANAGEMENT ORGANIZATION SERVICES › Section 10:73-3.20 - Information management

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each CMO shall
				establish and maintain an integrated electronic child and family
				file.
(b) Each CMO shall use the
				software provided by the CSA to obtain, organize, analyze, and distribute the
				following information:
1. Records management,
				including creating and maintaining individual electronic case
				records;
2. Real time enrollment,
				electronic assessment and ISP information;
3. Tracking of client status, ISP outcomes,
				service/resource availability and utilization, and quality of care and cost
				indicators;
4. Interfacing with the
				CSA's system, including the transfer of data for the purposes of updating
				individual electronic case records and facilitating the claims payment process
				for authorized service requests;
5.
				Maintaining a registry of service providers practicing within the CMO's area of
				responsibility, and providing access to this registry as needed; and
6. Reporting, as required by DHS/DCF in the
				CMO contract, which shall include the capability to report on services
				provided, payments made, and child and family outcomes by client and/or
				servicing provider.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 73 - CASE MANAGEMENT SERVICES › Subchapter 3 - CARE MANAGEMENT ORGANIZATION SERVICES › Section 10:73-3.21 - Quality assessment/evaluation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each CMO shall
				develop an annual Quality Assessment and Performance Improvement (QAPI)
				Plan.
(b) In addition to the CMO's
				annual QAPI Plan, each CMO shall be evaluated by DCF, or its designated agent,
				based on various performance measures, including the following:
1. Timeliness of service plan
				development;
2. Progress towards
				the financial benchmarks specified in the CMO's contract;
3. Cultural, ethnic, and linguistic
				competency;
4. Individual service
				plan appropriateness;
5.
				Restrictiveness of living environment;
6. Hospital or CCIS readmission
				rate;
7. Changes in the level of
				functioning of the child;
8.
				Placement stability;
9. Permanency
				including supporting the DYFS mandates and requirements in this
				regard;
10. Length of stay in
				residential treatment centers;
11.
				Reduction in the use of congregate care and increased use of community based
				treatment options;
12. Involvement
				of the child and family; and
13.
				Consumer satisfaction with the services provided.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 73 - CASE MANAGEMENT SERVICES › Subchapter 3 - CARE MANAGEMENT ORGANIZATION SERVICES › Section 10:73-3.22 - Staffing requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) CMO staffing
				shall include:
1. An administrative staff, to
				include an executive director;
2.
				Adequate support staff to effectively perform clerical, financial, quality
				management, and MIS functions;
3.
				Direct care staff for clinical operations; and
4. Support for the community resource
				development function, consistent with DHS and DCF rules, and ISP planning and
				implementation.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 73 - CASE MANAGEMENT SERVICES › Subchapter 3 - CARE MANAGEMENT ORGANIZATION SERVICES › Section 10:73-3.23 - Staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Executive
				Director shall have a Master's degree in a relevant discipline, such as social
				work, counseling, psychology, psychiatric nursing, criminal justice or special
				education, with a minimum of five years' post Master's related supervisory
				experience in child welfare, children's mental health, juvenile justice,
				special education, public administration or management or a related public
				sector human services or behavioral health field.
(b) Supervisors shall have a Master's degree
				in a relevant discipline, such as social work, counseling, psychology,
				psychiatric nursing, criminal justice or special education, with a minimum of
				two years post Master's related supervisory experience in child welfare,
				children's mental health, juvenile justice, special education or a related
				public sector human services or behavioral health field working with at risk
				children and families.
1. Supervisors shall
				have experience in clinical assessment and child/adolescent development, with
				community-based experience preferred.
2. Supervisors shall be clinically and
				culturally competent/responsive, with the training and experience necessary to
				manage complex cases in the community across child serving systems. Supervisors
				shall possess a valid driver's license.
3. Supervisors shall have experience with
				community relations and resource development. Bilingual ability (such as
				Spanish/English) is preferred in geographic areas with high concentrations of
				non-English speaking consumers.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 73 - CASE MANAGEMENT SERVICES › Subchapter 3 - CARE MANAGEMENT ORGANIZATION SERVICES › Section 10:73-3.24 - Recordkeeping

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each CMO provider shall maintain all
				records in accordance with N.J.A.C. 10:3 and in compliance with all applicable
				State laws and rules including, but not limited to,
				10:49-9.8.
(b) Each CMO provider shall keep such
				individual legible records as are necessary to fully disclose the nature and
				extent of the services provided.
(c) Each CMO provider shall make all records,
				data, and information required by this chapter available to DHS, CSOC, DMAHS,
				DMHAS, CP &P, or other authorized agents, as requested.
(d) Each CMO provider shall maintain the
				following data in support of all CMO fee-for-service claims:
1. The name of the client;
2. The name, agency (if applicable), and
				title of the individual providing the service;
3. The dates of service;
4. The length of time that the service was
				provided;
5. The length of time of
				the face-to-face contact (excluding travel to or from client contact);
				and
6. The name of individual(s)
				with whom contact was maintained on behalf of the client.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 73 - CASE MANAGEMENT SERVICES › Subchapter 3 - CARE MANAGEMENT ORGANIZATION SERVICES › Section 10:73-3.25 - Reimbursement methodology for CMO services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Claims
				for CMO services shall be submitted on a monthly fee-for-service basis for the
				care management component of the CMO's services.
1. The CMO shall bill for the first month
				that a beneficiary begins receiving services from the CMO, regardless of the
				specific initial date of services.
2. The CMO shall not bill for the month that
				a beneficiary ceases receiving services from the CMO, regardless of the
				specific discharge date.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 73 - CASE MANAGEMENT SERVICES › Subchapter 4 - YOUTH CASE MANAGEMENT YCM SERVICES › Section 10:73-4.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This subchapter sets forth the
				requirements that all providers shall follow to receive reimbursement for the
				provision of youth case management (YCM) services to eligible Medicaid/NJ
				FamilyCare beneficiaries and children, youth, and young adults receiving
				services from the Children's System of Care (CSOC) and that shall apply to all
				YCM services provided under Title XIX and Title XXI of the Social Security Act
				or under State-funded only programs.
(b) Children, youth, and young adults receive
				youth case management services under the auspices of the Department of Human
				Services' Division of Medical Assistance and Health Services and the Department
				of Children and Families' Children's System of Care (CSOC). The services are
				rendered by providers licensed by the Department of Human Services and
				administered jointly by the Division of Mental Health and Addiction Services
				(DMHAS) in accordance with N.J.A.C. 10:37H, CSOC, and the Division of Medical
				Assistance and Health Services (DMAHS) in accordance with these
				rules.
(c) All YCM services shall
				be provided and administered in accordance with all applicable State and
				Federal laws, rules and regulations, including, but not limited to, N.J.A.C.
				10:3, and 10:49 and this chapter.
(d) If a conflict exists between DHS/DCF
				contract requirements and the requirements of this subchapter, the terms set
				forth in the DHS/DCF contract shall prevail.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 73 - CASE MANAGEMENT SERVICES › Subchapter 4 - YOUTH CASE MANAGEMENT YCM SERVICES › Section 10:73-4.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this subchapter,
				  shall have the following meanings, unless the context clearly indicates
				  otherwise:
"Collateral contact or activities" means non face-to-face
				  contact or activities that the youth case manager engages in on behalf of the
				  child, youth or young adult to advocate for, link to, coordinate and monitor
				  the services included in the individualized service plan or otherwise support
				  the provision of YCM services including, but not limited to, telephone
				  contacts, development, review and update of service plans and 14-day plans,
				  completion and follow-up of entitlements paperwork, completion of paperwork and
				  data entry for prior authorization, and completion of service documentation and
				  progress notes.
"Unit of service" means 15 continuous minutes of face-to-face
				  contact with, or on behalf of, an enrolled beneficiary, or other collateral
				  contacts or activities which support the provision of youth case management
				  services, not including travel time.
"Youth Case Management" means services provided in accordance
				  with N.J.A.C. 10:37H and these rules to facilitate a level of case management
				  that assists children, youth or young adults in accessing and receiving the
				  appropriate level of care, interventions and supports to maintain the optimal
				  functioning level in the community.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 73 - CASE MANAGEMENT SERVICES › Subchapter 4 - YOUTH CASE MANAGEMENT YCM SERVICES › Section 10:73-4.3 - Provider enrollment and participation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Prior to
				enrollment as a Medicaid/NJ FamilyCare provider, any agency applying to render
				youth case management services shall first be under contract with the
				Children's System of Care, and licensed by DHS as an approved youth case
				management provider. Such contract and license shall be in full effect and
				shall not be currently suspended or terminated.
(b) In order to participate as a Medicaid/NJ
				FamilyCare/CSOC provider of youth case management services, a provider shall
				apply to, and be approved by, the New Jersey Medicaid/NJ FamilyCare
				fee-for-service program as a youth case management provider, in accordance with
				N.J.A.C. 10:49-3 and this subchapter. Providers who are enrolled as other
				provider types in the Medicaid/NJ FamilyCare program shall complete a separate
				application to enroll as a youth case management provider.
1. All applicants shall obtain the Medicaid
				"Provider Application" (FD-20), the Medicaid "Provider Agreement" (FD-62) and
				the CMS 1513 form at
www.njmmis.com
, or
				from:
Gainwell Technologies
Provider Enrollment
PO Box 4804
Trenton, NJ 08650-4804
2. All applicants shall complete and submit
				the forms to: Department of Children and Families
PO Box 717
Trenton, NJ 08625-0717
Attn: Director, Division of Child Behavioral Health
				  Services
3. The Director,
				Children's System of Care, will review the contract status of the applicant and
				will forward the application, if approved, to the Medicaid/NJ FamilyCare
				program for further processing.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 73 - CASE MANAGEMENT SERVICES › Subchapter 4 - YOUTH CASE MANAGEMENT YCM SERVICES › Section 10:73-4.4 - Eligibility and referral for YCM services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A
				child, youth, or young adult may be eligible for YCM services if:
1. He or she meets the requirements of this
				subchapter and is:
i. Enrolled in Medicaid/NJ
				FamilyCare, as described at N.J.A.C. 10:49-2, and not enrolled in:
(1) The Medically Needy Program, except that
				pregnant women in that program may be eligible;
(2) The Home and Community Based Services
				Waiver Program;
(3) The DDD Waiver
				Program;
(4) The Traumatic Brain
				Injury Waiver Program;
(5) The
				Community Resources for People with Disabilities Waiver Program; or
(6) The Home Care Expansion Program;
				or
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 73 - CASE MANAGEMENT SERVICES › Subchapter 4 - YOUTH CASE MANAGEMENT YCM SERVICES › Section 10:73-4.5 - Youth Case Management (YCM) services; program description

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Youth
				Case Management (YCM) services are case management services provided to
				Medicaid/NJ FamilyCare beneficiaries of CSOC services who are under the age of
				18 or those young adults between the ages of 18 and 21 who are transitioning
				from the child service system to the adult service system. YCM services ensure
				that individualized mental, emotional, and/or behavioral health services are
				obtained for the child, youth, or young adult by advocating for necessary
				mental/behavioral services and other necessary financial, educational, social,
				or other services to serve the needs of the child, youth, or young adult by
				restoring, enhancing, and maintaining an optimal level of functioning,
				ultimately reducing or eliminating the need for case management services.
1. YCM services that are included as part of
				a transition/discharge plan from inpatient psychiatric hospitalization, CMO
				services or other more intensive level of services, including, but not limited
				to, discharge from a residential mental health rehabilitation program or
				inpatient psychiatric hospitalization, are intended to support the maintenance
				of the child, youth or young adult's attained treatment goals to facilitate a
				successful transition from inpatient hospitalization or CMO services and
				prevent a relapse which would result in rehospitalization or the need for
				additional intensive services or return to previous out-of-home
				placement.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 73 - CASE MANAGEMENT SERVICES › Subchapter 4 - YOUTH CASE MANAGEMENT YCM SERVICES › Section 10:73-4.6 - Referral and authorization process for Youth Case Management services

Current through Register Vol. 56, No. 14, July 15, 2024
(a)
				The CSA shall conduct a basic preliminary screening of each child, youth, or
				young adult referred to the CSA by the Children's System of Care to determine
				the level of case management appropriate to meet the case management needs of
				the child, youth, or young adult. Upon determination that YCM services are
				needed, the CSA will refer the child, youth, or young adult and authorize YCM
				services for the first 90 days of service.
1.
				For children, youth or young adults who are court-ordered to receive a YCM
				assessment, the initial authorization of YCM services shall not exceed 30
				days.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 73 - CASE MANAGEMENT SERVICES › Subchapter 4 - YOUTH CASE MANAGEMENT YCM SERVICES › Section 10:73-4.7 - Individual YCM service plan

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The individual
				YCM service plan shall be based on the results of the YCM agency's evaluation
				of the mental health/behavioral health needs as well as the case management
				needs of the child, youth or young adult. The YCM service plan shall be
				completed and registered with the CSA within 14 business days of the initial
				referral. Once approved and authorized by the CSA, the youth case management
				service provider will be authorized to provide continued YCM services.
				Authorizations for the individual services in the YCM service plan will be sent
				directly to individual provider.
(b) The child, youth or young adult's YCM
				service plan shall be developed in partnership with a team that shall be
				coordinated by the youth case manager. The YCM agency shall develop a team and
				shall include the following members:
1. The
				youth case manager assigned to the child, youth or young adult;
2. The child, youth, or young adult and the
				parent or caregiver; and
3. Any
				interested person the child, youth or young adult or their family wishes to
				include as a member of the team such as family, friends or clergy, and may
				include current providers of services as well as other entities providing
				formal or informal support to the child/youth/young adult and their
				family.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 73 - CASE MANAGEMENT SERVICES › Subchapter 4 - YOUTH CASE MANAGEMENT YCM SERVICES › Section 10:73-4.9 - Recordkeeping

Current through Register Vol. 56, No. 14, July 15, 2024
(a) YCM providers
				shall keep such individual records as are necessary to fully disclose the kind
				and extent of services provided.
(b) Each YCM provider shall maintain the
				following data in support of all claims:
1.
				The name and address of the child, youth or young adult;
2. The reason for the initial
				referral;
3. The name, credentials
				and title of the staff member(s) providing the service(s);
4. The exact date(s), time(s) and location(s)
				of the case management service(s) provided;
5. The total number of complete units of
				service provided per day;
6. The
				length of face-to-face contact with, or on behalf of, the child, youth or young
				adult (excluding travel to or from child, youth or young adult contact or
				collateral contact);
7. The name of
				individual(s) with whom face-to-face contact was maintained on behalf of the
				child, youth or young adult;
8. A
				summary of services provided in accordance with the goals of the service plan;
				and
9. The length of time spent in
				collateral activities which support the provision of YCM services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 73 - CASE MANAGEMENT SERVICES › Subchapter 4 - YOUTH CASE MANAGEMENT YCM SERVICES › Section 10:73-4.10 - Basis of reimbursement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Reimbursement
				for YCM services shall be fee-for-service.
(b) All reimbursement shall be restricted to
				approved Medicaid/NJ FamilyCare YCM providers and shall be subject to all
				applicable Medicaid/NJ FamilyCare rules, including N.J.A.C. 10:49 and these
				rules.
(c) A unit of service shall
				be defined as 15 minutes of face-to-face services or other collateral contact
				and activities that support the provision of youth case management services
				described at
				10:73-4.6(b),
				provided directly to, or on behalf of, the child, youth or young adult
				receiving services. Non-consecutive shorter time periods shall not be added
				together to total 15 minutes. Transportation of a beneficiary shall not be
				included.
1. Examples of face-to-face
				services or other collateral contact and activities which can be included in
				calculating billable units of YCM services shall include, but are not limited
				to:
i. Preparing and reviewing a written
				service plan to address the needs of the child, youth, or young
				adult;
ii. Aiding in identifying
				and/or accessing local, State or Federal benefit programs for which the child,
				youth or young adult may be eligible, including telephone contact and/or
				working face-to-face with the child, youth, or young adult and his or her
				family to complete a PE application for Medicaid/NJ FamilyCare benefits;
				assisting the family in completing a Medicaid/NJ Family Care application; as
				well as assisting the family in applying for any other benefits for which they
				may be eligible;
iii. Communicating
				with current service providers to monitor the child, youth or young adult's
				progress towards attaining the goals of the service plan;
iv. Identifying and contacting potential
				service providers to meet the needs of the child, youth or young
				adult;
v. Preparing referral
				information for potential service providers;
vi. Completing paperwork and data entry for
				prior authorization; and
vii.
				Completing service documentation and progress notes.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 73 - CASE MANAGEMENT SERVICES › Subchapter 5 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM › Section 10:73-5.1 - Introduction

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey Medicaid/NJ FamilyCare
				program adopted the Centers for Medicare & Medicaid Services Healthcare
				Common Procedure Coding System (HCPCS) codes for 2006, established and
				maintained by CMS in accordance with the Health Insurance Portability and
				Accountability Act of 1996,
				P.L.
				104-191, and incorporated herein by reference, as
				amended and supplemented, and published by PMIC, 4727 Wilshire Blvd., Suite
				300, Los Angeles, CA 90010. Revisions to the Healthcare Common Procedure Coding
				System made by 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 Department and specification of new reimbursement amounts for
				new codes will be made by rulemaking in accordance with the Administrative
				Procedure Act,
				N.J.S.A.
				52:14B-1et seq. The HCPCS codes as listed in
				this subchapter are relevant to Medicaid/NJ FamilyCare adult case management
				services, Medicaid/NJ FamilyCare/CSOC YCM services and care management
				organization services and must be used when filing a claim.
1. The responsibilities of the case
				management services provider when rendering adult case management services are
				listed in N.J.A.C. 10:73-2.
2. The
				responsibilities of the care management organization services provider when
				rendering services are listed in N.J.A.C. 10:73-3.
3. The responsibilities of the case
				management services provider when rendering youth case management services are
				listed in N.J.A.C. 10:73-4.
4. "P"
				is listed under Ind (indicator) which means that prior authorization is
				required.
5. "TJ" is listed under
				Mod (modifier) which means that service is rendered for children.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 73 - CASE MANAGEMENT SERVICES › Subchapter 5 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM › Section 10:73-5.2 - HCPCS codes for case management services

Current through Register Vol. 56, No. 14, July 15, 2024
HCPCS
Maximum
						  Fee
IND
Code
Mod
Description
Allowance
P
T1017
TJ
Youth Case
						  Management Services (unit of
$ 20.30/unit
service=15 consecutive minutes)
P
Z5008
Care Management Organization
						  (CMO) Services
$ 960.00
for Children, Youth, and Young Adults
receiving DCBHS Services; per month
Z5006
Clinical Case Management
						  Program/Mental
$ 30.19/unit
Health (CMP/MH), Adults (unit of service=15
consecutive minutes)
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 73 - CASE MANAGEMENT SERVICES › Subchapter 5 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM › 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. The Fiscal Agent Billing Supplement can be downloaded free of charge from
www.njmmis.com
. When revisions are made to
				  the Fiscal Agent Billing Supplement, a revised version will be posted on the
				  njmmis website and copies will be filed with the Office of Administrative Law.
				  If you do not have access to the internet and require a copy of the Fiscal
				  Agent Billing Supplement, write to:
Gainwell Technologies
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 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 1 - GENERAL PROVISIONS › Section 10:74-1.1 - Purpose

Current through Register Vol. 56, No. 14, July 15, 2024
The rules in this chapter set forth the manner in which the
				  New Jersey Medicaid/NJ FamilyCare programs shall provide covered health
				  services to eligible persons through the Managed Care program, by means of
				  managed care organizations (MCOs).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 1 - GENERAL PROVISIONS › Section 10:74-1.2 - Authority

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The State Medicaid program provides
				managed medical services under the authority of the New Jersey 1115
				demonstration project entitled "New Jersey FamilyCare Comprehensive
				Demonstration" and under Section 1932(a) of the Social Security Act (
				42 U.S.C. §
										1396u-2(a) ).
(b) Managed care organizations sign a
				contract with the Department to provide medical services, which governs each
				MCO that signs the contract. If the contracted MCO faces a conflict between
				their organization rules and the contract provisions, then the contract
				provisions shall govern the resolution of such a conflict.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 1 - GENERAL PROVISIONS › Section 10:74-1.3 - Scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The provisions within this chapter affect
				Medicaid/NJ FamilyCare beneficiaries.
(b) The rules in this chapter also affect
				Medicaid/NJ FamilyCare providers, including managed care entities and those
				providers who will continue to provide certain services on a fee-for-service
				basis to beneficiaries who are also enrolled in managed care.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 1 - GENERAL PROVISIONS › Section 10:74-1.5 - Provider lock-in program under managed care

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The managed
				care contractor may implement a lock-in program that restricts its enrollees to
				a single pharmacy and/or other provider type for a reasonable period of time.
				The program shall include policies, procedures, and criteria for establishing
				the need for the lock-in, which shall be prior approved by DMAHS and shall
				include the following components to the program:
1. Enrollees shall be notified prior to the
				lock-in and shall be permitted to choose or change providers for good
				cause;
2. The lock-in restrictions
				do not apply to emergency services furnished to the enrollee. A 72hour
				emergency supply of medication at pharmacies other than the designated lock-in
				pharmacy shall be permitted to assure the provision of necessary medication
				required in an interim/urgent basis when the assigned pharmacy does not
				immediately have the medication;
3.
				The lock-in restriction shall not apply while the beneficiary is receiving
				services on an inpatient basis, including, but not limited to, medical and
				pharmacy services provided in a hospital, rehabilitation facility, or nursing
				facility. Upon discharge from the inpatient facility, the beneficiary shall
				resume accessing services from the pharmacy and/or provider previously
				designated by the lock-in program.
4. Care management and education
				reinforcement of appropriate medication/provider use shall be provided. A plan
				for an education program for enrollees shall be developed and submitted to the
				Division for review and approval;
5. The continued need for lock-in shall be
				periodically evaluated by the contractor, but no less frequently than every two
				years, for each enrollee in the program;
6. Prescriptions from all participating
				prescribers shall be honored and shall not be required to be written by the PCP
				only; and
7. The contractor shall
				submit quarterly reports on Provider Lock-in participants, as determined by the
				DMAHS.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 3 - BENEFITS › Section 10:74-3.1 - Scope of benefits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The definition of "comprehensive risk
				contract" found at 42 CFR Part 438, as amended and supplemented, is
				incorporated herein by reference.
(b) Under the risk contract, all MCO/managed
				health care contractors shall provide standard service packages as detailed in
				the managed care contract, which shall exactly equal the services included in
				the New Jersey Medicaid/NJ FamilyCare program in amount, duration, and scope of
				services.
(c) The standard service
				package shall be provided in accordance with medical necessity without any
				predetermined limits, unless specifically stated; service utilization shall be
				controlled by the MCO through pre-certification programs and prior
				authorization for medical necessity.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 3 - BENEFITS › Section 10:74-3.2 - Responsibilities of the contractor

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The contractor
				shall make available emergency services, as defined in N.J.A.C. 10:74-1, on a
				24-hour-a-day, seven-day-a-week basis.
(b) The contractor shall offer health
				education services as an integral part of its health care delivery system to
				its enrollees in order to assure appropriate use of health services and to
				promote the maintenance of health, including, but not limited to, instruction
				to beneficiaries regarding:
1. Their rights
				and responsibilities as members of managed care organizations; and
2. Appropriate measures to achieve/maintain
				wellness or prevent illness.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 3 - BENEFITS › Section 10:74-3.4 - Fee-for-service program services requiring MCO assistance to Medicaid/NJ FamilyCare-Plans A, B, C, and D enrollees to access the services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The
				following services shall be provided to Plans A, B, C, and D enrollees through
				the Medicaid/NJ FamilyCare fee-for-service program and may necessitate
				contractor assistance to the enrollee (such as, for example, providing medical
				orders) to access the services:
1. Personal
				care assistant services (not covered for Medicaid/NJ FamilyCare-Plans B, C, and
				D unless enrolled in MLTSS);
2.
				Medical day care (not covered for Medicaid/NJ FamilyCare-Plans B, C, and D
				unless enrolled in MLTSS);
3.
				Outpatient rehabilitation services, including physical, occupational, and
				speech/language therapy;
4.
				Elective/induced abortions and related services, including surgical procedure,
				cervical dilation, insertion of cervical dilator, anesthesia including para
				cervical block, history and physical exam on day of surgery; PT, PTT, OB panel
				of lab tests, pregnancy test, urinalysis and urine drug screen, glucose and
				electrolytes; routine venipuncture, ultrasound, pathological examination of
				aborted fetus; Rhogam and its administration;
5. Transportation, lower mode;
6. Sex abuse examinations;
7. Services provided by DHS mental
				health/substance abuse residential facilities or group homes;
8. Family planning services and supplies when
				furnished by a non-MCO-participating provider;
9. Home health agency services for the aged,
				blind and disabled; and
10.
				Prescription drugs (legend and non-legend covered by the Medicaid/NJ FamilyCare
				program) for the aged, blind, or disabled.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 3 - BENEFITS › Section 10:74-3.5 - Fee-for-service services for Medicaid/NJ FamilyCare-Plans A, B, C, and D enrollees not requiring case management by the MCO

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following
				services shall be provided to Plans A, B, C, and D enrollees through the
				Medicaid/NJ FamilyCare fee-for-service program without requiring case
				management by the MCO:
1. Inpatient
				psychiatric hospital services for individuals under 21 and for individuals 65
				years of age and over
2. Outpatient
				mental health services for non-DDD clients, non-MLTSS clients, and non-Fully
				Integrated Dual Eligible Special Needs Program (FIDE-SNP) clients;
3. Outpatient substance use disorder services
				for non-DDD clients, non-MLTSS clients, and non-Fully Integrated Dual Eligible
				Special Needs Program (FIDE-SNP) clients:
i.
				Diagnosis;
ii. Treatment;
				and
iii. Detoxification;
4. Drugs paid fee-for-service by
				the Medicaid/NJ FamilyCare program:
i. Costs
				for methadone maintenance and its administration;
ii. Atypical antipsychotic drugs;
iii. Suboxone and Subutex or any other drug
				within this category when used for the treatment of opioid dependence;
				and
iv. Generically-equivalent drug
				products of the drugs listed above; and
5. Family planning services and supplies when
				furnished by a non-MCO-participating provider.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 3 - BENEFITS › Section 10:74-3.9 - General Medicaid/NJ FamilyCare program limitations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The
				following service requirements and limitations shall apply in the standard
				service package or capitation payments, even if provided by the MCO:
1. Although services of podiatrists shall be
				provided, New Jersey Medicaid/NJ FamilyCare does not ordinarily cover routine
				foot care or treatment of flat foot conditions. These services shall be
				provided only when medical necessity is determined.
2. Occupational therapy and treatment for
				speech, language or hearing disorders shall be covered only when provided to an
				enrollee by a nursing facility, an approved home health agency, a hospital
				inpatient and outpatient department or an independent outpatient
				clinic.
3. Elective/induced
				abortions are not covered under an MCO program but will continue to be paid on
				a fee-for-service basis by the Medicaid/NJ FamilyCare program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 3 - BENEFITS › Section 10:74-3.10 - General Medicaid/NJ FamilyCare program exclusions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The
				following shall not be considered covered services in the capitation rate, if
				provided:
1. All claims arising directly or
				indirectly from services provided by or in institutions owned or operated by
				the Federal government;
2. Elective
				cosmetic surgery;
3. Rest
				cures;
4. Personal comfort and
				convenience items; services and supplies not directly related to the care of
				the patient, including, but not limited to, guest meals and accommodations,
				telephone charges, travel expenses other than those services which may be
				specifically covered under the standard benefits package (such as ambulance
				services), take-home supplies and similar costs;
5. Services involving the use of equipment in
				facilities, the purchase, rental or construction of which has not been approved
				by applicable laws of the State of New Jersey and regulations issued pursuant
				thereto;
6. Infertility treatment
				services;
7. Services provided in
				an inpatient psychiatric institution that is not an acute care hospital to
				individuals under 65 years of age and over 21 years of age; and
8. Private duty nursing in an institution or
				hospital setting and private duty nursing provided in any setting for
				individuals 21 years of age or older.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 3 - BENEFITS › Section 10:74-3.11 - Reporting and verification of services

Current through Register Vol. 56, No. 14, July 15, 2024
All services, including, but not limited to, those listed in
				  10:74-3.9 and 3.10, shall be
				  reported on encounters despite the limitations or exclusions, and the
				  contractor shall document and verify that the services were provided.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 3 - BENEFITS › Section 10:74-3.12 - Availability of services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each contractor
				shall demonstrate the availability and accessibility of institutional
				facilities and professional, allied and supporting paramedical personnel to
				perform the agreed-upon services.
(b) Each contractor shall ensure that no
				distinctions will be made with regard to quality of service or availability of
				covered benefits between Medicaid/NJ FamilyCare enrollees under this subchapter
				and any other parties served by the contractor.
(c) Each Medicaid/NJ FamilyCare enrollee
				shall be given the choice of a primary care provider who will supervise and
				coordinate his or her care.
(d)
				Generally, the contractor shall have only one enrollment area for all
				Medicaid/NJ FamilyCare parties served, including those served under these
				regulations. Modifications of such enrollment area for purposes of contracting
				under this subchapter shall be achieved by means of contract
				amendment.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 4 - MARKETING › Section 10:74-4.1 - Marketing

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The contractor shall obtain written
				approval from the Division prior to the commencement of marketing activities,
				regarding the form and content of the following:
1. Informational and instructional materials
				to be distributed to inform Medicaid/NJ FamilyCare enrollees of the scope and
				nature of benefits provided by the contractor;
2. Informational and instructional materials
				to be distributed to inform Medicaid/NJ FamilyCare enrollees of changes in
				program scope or administration;
3.
				Public information releases pertaining to the enrollment of Medicaid/NJ
				FamilyCare individuals in the contractor's plan; and
4. Instruction to community-based
				organizations that will empower them to provide instruction to their
				beneficiaries to achieve better health outcomes.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 5 - INFORMATION PROVIDED TO ENROLLEES › Section 10:74-5.1 - Information to be provided to the enrollees by the contractor

Current through Register Vol. 56, No. 14, July 15, 2024
(a) At such
				time as a Medicaid/NJ FamilyCare beneficiary signs an enrollment application of
				an MCO, the contractor shall inform the beneficiary that:
1. There is normally a minimum 30 to 45-day
				processing period between the date of application and the effective date of
				enrollment;
2. During this interim
				period, the Medicaid/NJ FamilyCare-Plan A only enrollee may continue to receive
				health services under his or her current arrangement as long as he or she
				retains Medicaid/NJ FamilyCare-Plan A eligibility; and
3. Subject to the termination of Medicaid/NJ
				FamilyCare eligibility, the disenrollment rules in N. J.A.C. 10:74-7 and the
				termination provisions in the contract between the contractor and the
				Department, the initial enrollment period shall extend for one year.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 5 - INFORMATION PROVIDED TO ENROLLEES › Section 10:74-5.2 - Advance directives

Current through Register Vol. 56, No. 14, July 15, 2024
All managed care organizations providing services under the
				  New Jersey Medicaid/NJ FamilyCare program shall be subject to the provisions of
				  State and Federal statutes regarding advance directives, including, but not
				  limited to, appropriate notification to enrolled beneficiaries of their rights,
				  development of policies and practices, and communication to and education of
				  staff, community and interested parties. Detailed information may be located at
				  10:49-9.15, and sections
				  1902(a)(58), and 1902(w) of the Social Security Act (
				  42 U.S.C. §§
										1396a(a)(58) and
				  1396a(w)
				  ).