New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:66-1.1 - Scope of service

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This chapter describes the policies and
				procedures of the New Jersey Medicaid and NJ FamilyCare fee-for-service
				programs pertaining to the provision of, and reimbursement for, medically
				necessary services in an independent clinic setting. The term independent
				clinic includes, but is not limited to, clinic types, such as: ambulatory care
				facilities, ambulatory surgical centers, ambulatory care/family planning
				clinics, substance use disorder treatment facilities, mental health independent
				clinics, and Federally qualified health centers (FQHCs).
(b) Medically necessary services provided in
				an independent clinic setting shall be in compliance with all applicable State
				and Federal Medicaid and NJ FamilyCare fee-for-service laws, and all applicable
				policies, rules and regulations as specified in the appropriate provider
				services manual of the New Jersey Medicaid and NJ FamilyCare fee-for-service
				programs. Services provided in an out-of-State independent clinic setting shall
				be in compliance with all applicable laws, rules and regulations of the state
				in which the facility is located.
(c) Independent clinic services are
				preventive, diagnostic, therapeutic, rehabilitative, or palliative services
				that are provided by a facility (freestanding) that is not part of a hospital
				but is organized and operated to provide medical care to outpatients, including
				such services provided outside the clinic by clinic personnel to any Medicaid
				or NJ FamilyCare fee-for-service beneficiary who does not reside in a permanent
				dwelling or does not have a fixed home or mailing address. Clinic services do
				not include services provided by hospitals to outpatients.
(d) The chapter is divided into six
				subchapters, as follows:
1.N.J.A.C. 10:66-1
				contains scope of service, definitions, provisions for provider participation,
				prior authorization, basis for reimbursement, recordkeeping requirements,
				personal contribution to care requirements for NJ FamilyCare-Plan C and
				copayments for NJ FamilyCare-Plan D, and the medical exception
				process.
2.N.J.A.C. 10:66-2
				contains policies and procedures pertaining to specific Medicaid-covered and NJ
				FamilyCare-covered services provided in an independent clinic. Where unique
				characteristics or requirements exist concerning a particular Medicaid-covered
				or NJ FamilyCare-covered service, the service is separately identified and
				discussed.
3.N.J.A.C. 10:66-3
				contains information about HealthStart, a program for pregnant women and
				children.
4.N.J.A.C. 10:66-4 and
				its Appendices contain information about Federally qualified health centers,
				including rules governing the provision of services; the Medicaid cost report
				containing the forms used by Federally qualified health centers to determine
				Medicaid and NJ FamilyCare fee-for-service reimbursement amounts; and
				instructions for the proper completion of the forms. The Appendices are:
				Appendix A, Pre-2001 Cost Report; Appendix B, FQHC Annual Cost Reporting
				Requirements; Appendix C, New FQHC Medicaid Cost Reports for First and Second
				Years of Operation; Appendix D, Change in Scope of Service Application
				Requirements; and Appendix E, Medicaid Managed Care Wrap-around
				Reports.
5.N.J.A.C. 10:66-5
				contains information about ambulatory surgical centers, including covered
				services, anesthesia services, facility services, and medical
				records.
6.N.J.A.C. 10:66-6
				pertains to the Healthcare Common Procedure Coding System (HCPCS). The HCPCS
				contains procedure codes and maximum fee allowances corresponding to
				Medicaid-reimbursable services.