New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 5 - SERVICES COVERED BY MEDICAID AND THE NJ FAMILYCARE PROGRAMS › Section 10:49-5.5 - Services not covered by the Medicaid or NJ FamilyCare-Plan A program

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Listed below
				are some general services and items excluded from payment under the New Jersey
				Medicaid and NJ FamilyCare-Plan A program. There are additional specific
				exclusions and limitations detailed in the second chapter of each Provider
				Services Manual. Payment is not made for the following:
1. Any service, admission, or item, which is
				not medically required for diagnosis or treatment of a disease, injury, or
				condition;
2. Services provided to
				all persons without charge; these services shall not be billed to the Medicaid
				program when provided for a Medicaid beneficiary. Services and items provided
				without charge through programs of other public or voluntary agencies (for
				example, New Jersey State Department of Health and Senior Services, New Jersey
				Heart Association, First Aid Rescue Squads, and so forth) shall be utilized to
				the fullest extent possible;
3. Any
				service or items furnished in connection with elective cosmetic procedures;
i. There are certain exceptions to this rule,
				but the exceptions require prior authorization. A written certification of
				medical necessity and a treatment plan shall be submitted by the physician to
				the appropriate Medical Assistance Customer Center (MACC) for
				consideration;
4.
				Private duty nursing services (except for beneficiaries under EPSDT, CRPD
				waiver and ACCAP programs);
5.
				Services or items furnished for any sickness or injury occurring while the
				covered person is on active duty in the military;
6. Services provided outside the United
				States and territories;
7. Services
				or items furnished for any condition or accidental injury arising out of and in
				the course of employment for which any benefits are available under the
				provisions of any workers' compensation law, temporary disability benefits law,
				occupational disease law, or similar legislation, whether or not the Medicaid
				beneficiary claims or receives benefits thereunder, and whether or not any
				recovery is obtained from a third-party for resulting damages;
8. That part of any benefit which is covered
				or payable under any health, accident, or other insurance policy (including any
				benefits payable under the New Jersey no-fault automobile insurance laws), any
				other private or governmental health benefit system, or through any similar
				third-party liability, which also includes the provision of the Unsatisfied
				Claim and Judgment Fund;
9.
				Services or items furnished prior to or after the period for which the
				beneficiary presents evidence of eligibility for coverage.
i. Payment is made for inpatient hospital
				services (excluding governmental psychiatric hospitals) when ineligibility
				occurs after admission to hospital as an inpatient. Payment is also made for
				certain services that were authorized and initiated before loss of eligibility
				such as dental, vision care, prosthetics and orthotics, and durable medical
				equipment. Also, see "Retroactive Eligibility" at
				10:49-2.7(c);
10. Any services or items
				furnished for which the provider does not normally charge;
11. Any admission, service, or item,
				requiring prior authorization, where prior authorization has not been obtained
				or has been denied (see N.J.A.C. 10:49-6, Authorizations required);
12. Services furnished by an immediate
				relative or member of the Medicaid beneficiary's household;
13. Services billed for which the
				corresponding health care records do not adequately and legibly reflect the
				requirements of the procedure described or procedure code utilized by the
				billing provider, as specified in the Provider Services Manual;
i. Final payment shall be made in accordance
				with a review of those services actually documented in the provider's health
				care record. Further, the medical necessity for the services must be apparent
				and the quality of care must be acceptable as determined upon review by an
				appropriate and qualified health professional consultant.
ii. All such determinations will be based on
				rules and regulations of the New Jersey Medicaid Program, the minimum
				requirements described in the appropriate New Jersey Medicaid Provider Services
				Manual, to include those elements required to be documented in the provider's
				records according to the procedure code(s) utilized for payment, and on
				accepted professional standards. (See
				10:49-9.5, Provider Certification
				and Recordkeeping.)
iii. Any other
				evidence of the performance of services shall be admissible for the purpose of
				proving that services were rendered only if the evidence is found to be clear
				and convincing. "Clear and convincing evidence" of the performance of services
				includes, but is not limited to, office records, hospital records, nurses
				notes, appointment diaries, and beneficiary statements.
iv. Therefore, any difference between the
				amount paid to the provider based on the claim submitted and the Medicaid
				Agent's value of the procedure as determined by the Medicaid Agent's
				evaluation, may be recouped by the Medicaid Agent.
14. Any claim submitted by a provider for
				service(s) rendered, except in a medical emergency, to a Medicaid or a NJ
				FamilyCare-Plan A beneficiary who is restricted to receiving the service from
				another provider only. (See
				10:49-2.13(e)2,
				Special Status program);
15.
				Services or items reimbursed based upon submission of a cost study when there
				are no acceptable records or other evidence to substantiate either the costs
				allegedly incurred or beneficiary income available to offset those costs. In
				the absence of financial records, a provider may substantiate costs or
				available income by means of other evidence acceptable to the Medicaid Agent or
				the Division. If upon audit, financial records or other acceptable evidence are
				unavailable for these purposes:
i. All
				reported costs for which financial records or other acceptable evidence are
				unavailable for review upon audit are deemed to be non-allowable;
				and/or
ii. Beneficiary income shall
				be presumed to equal the maximum income allowable for a Medicaid or NJ
				FamilyCare beneficiary for those beneficiaries whose records relating to income
				are completely unavailable;
iii.
				The Medicaid Agent or the Division shall seek recovery of any resulting
				overpayments;
16.
				Services provided primarily for the diagnosis and treatment of infertility,
				including sterilization reversals, and related office (medical or clinic),
				drugs, laboratory services, radiological and diagnostic services and surgical
				procedures;
17. Claims for
				services, goods or supplies which are furnished, rendered, prescribed or
				ordered in violation of Federal or State civil or criminal statutes, or in
				violation of licensure statutes, rules and/or regulations; and
18. Any item or service (other than an
				emergency item or service, not including items or services furnished in an
				emergency room of a hospital) furnished at the direction or on the prescription
				of a physician, individual or entity, during the period when such physician,
				individual or entity is excluded from participation in the Medicaid and NJ
				FamilyCare programs, and when the physician, individual or entity furnishing
				such item or service has received written notice from the Division that the
				physician, individual or entity has been excluded from participation in the
				Medicaid and NJ FamilyCare programs.