reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 2 - PROVISIONS FOR SPECIFIC SERVICES › Section 10:58-2.14 - Family planning services; general

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Family planning services may be provided by the CNM, including medical history and physical examination (including pelvis and breast), diagnostic and laboratory tests, drugs and biologicals, medical supplies and devices, counseling, continuing medical supervision, continuity of care and genetic counseling.
(b) Services provided primarily for the diagnosis and treatment of infertility, including related office visits, drugs, laboratory services, radiological and diagnostic services and surgical procedures, are not covered by the New Jersey Medicaid/NJ FamilyCare programs, except when a service is provided that is ordinarily considered an infertility service, but is provided for another purpose. The certified nurse midwife shall submit the claim for that service, with supporting documentation, for medical review and approval of payment to the Division of Medical Assistance and Health Services, Office of Utilization Management, Mail Code #14, PO Box 712, Trenton, NJ 08625-0712.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 2 - PROVISIONS FOR SPECIFIC SERVICES › Section 10:58-2.15 - Family planning services; Norplant System (NPS)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Norplant System (NPS) is a Medicaid/NJ FamilyCare covered service when provided as follows:
1. The NPS is used only in reproductive age women with established regular menstrual cycles;
2. The Food and Drug Administration (FDA)-approved physician prescribing information is followed; and
3. Patient education and counseling are provided relating to the NPS, including pre and post-insertion instructions, indications, contraindications, benefits, risks, side effects, and other contraceptive modalities.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 2 - PROVISIONS FOR SPECIFIC SERVICES › Section 10:58-2.16 - HealthStart maternity and pediatric services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of HealthStart is to provide comprehensive maternity and child health care services for all pregnant women (including those determined to be presumptively eligible) and for children (under two years of age) in the State of New Jersey who are eligible for Medicaid benefits. For reimbursement for certified nurse midwives billing independently, refer to 10:58-3.2 and 3.5. For other requirements regarding HealthStart in any setting, refer to the Independent Clinic Services chapter, N.J.A.C. 10:66-3. The CNM shall not become a HealthStart Pediatric Care provider. The CNM shall be an EPSDT provider for adolescent Medicaid recipients. (See 10:58-2.2 for EPSDT services.)
(b) Separate reimbursement is available for HealthStart Maternity Care and Health Support Services procedure codes.
(c) Maternity medical care services should be billed as a total obstetrical package, when feasible, but may be billed as separate procedures.
(d) The enhanced reimbursement for the delivery and postpartum care may be claimed only for a patient who had received at least one antepartum HealthStart Maternity Care visit and had at least one health support services visit.
(e) The modifier "WM" accompanying any given procedure code in the HCPCS list of codes refers to those services provided by CNM and the modifier shall be included at the end of each code when billing for CNM services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 2 - PROVISIONS FOR SPECIFIC SERVICES › Section 10:58-2.18 - Birth center facility services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Birth center facility services shall include, but not be limited to, administrative, nursing, and technical services related to labor and delivery.
(b) Other services and items not directly related to the care of the patient, such as guest meals and accommodations, televisions, telephones, and similar items, are non-covered services that shall not be eligible for payment by the Division. These services and other personal items may be billed to the patient directly, provided the patient is informed and agrees to accept responsibility for personal items.
(c) Physician services provided in birth centers shall be considered as professional physician services, in accordance with N.J.A.C. 10:54. Physician services shall be reimbursed using a separate physician Medicaid/NJ FamilyCare provider number and appropriate procedure codes, in accordance with N.J.A.C. 10:54.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 3 - CENTERS FOR MEDICARE & MEDICAID SERVICES CMS HEALTHCARE COMMON PROCEDURE CODING SYSTEM HCPCS › Section 10:58-3.1 - Introduction

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey Medicaid/NJ FamilyCare programs adopted the Centers for Medicare & Medicaid Services (CMS) 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, 42 U.S.C. §
										1320d et seq., 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 Level I codes consist of the American Medical Association (AMA) Current Procedural Terminology (CPT) codes, which are assigned to specific procedures by the AMA. HCPCS Level II codes are assigned to specific procedures by CMS. An updated copy of the CPT codes may be obtained from the American Medical Association, P.O. Box 10950, Chicago, IL 60610, or by accessing
www.ama-assn.org
. An updated copy of the Level II codes may be obtained by accessing the HCPCS website at
www.cms.hhs.gov/medicare/hcpcs
or by contacting PMIC, 4727 Wilshire Blvd., Suite 300, Los Angeles, CA 90010.
(b) Listed below are some of the general policies of the New Jersey Medicaid/NJ FamilyCare programs relevant to HCPCS. (The responsibility of the CNM when rendering specific services and requesting reimbursement is listed in N.J.A.C. 10:58-1.)
1. When filing a claim, the HCPCS procedure codes, including modifiers, must be used in accordance with the narratives in the CPT or 10:58-3.3, 3.4 and 3.5, whichever is applicable.
2. The use of a procedure code will be interpreted by the New Jersey Medicaid/NJ FamilyCare programs as evidence that the CNM personally furnished, as a minimum, the stated service.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 3 - CENTERS FOR MEDICARE & MEDICAID SERVICES CMS HEALTHCARE COMMON PROCEDURE CODING SYSTEM HCPCS › Section 10:58-3.3 - HCPCS Procedure Codes (Level 1) and maximum fee allowance schedule for nurse midwifery services

Current through Register Vol. 56, No. 14, July 15, 2024
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New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 3 - CENTERS FOR MEDICARE & MEDICAID SERVICES CMS HEALTHCARE COMMON PROCEDURE CODING SYSTEM HCPCS › Section 10:58-3.4 - HCPCS Procedure Codes (Level II) and maximum fee allowance schedule for certified nurse midwifery services

Current through Register Vol. 56, No. 14, July 15, 2024
HCPCS
Maximum Fee
Codes
Descriptions
Allowance
J2790
RhoGAM, Rho (D) Immune
$ 26.00
Globulin (Human)
Single dose (Micro-Dose)
J2790 22
RhoGAM, Rho (D) Immune
$ 45.00
Globulin (Human)
Single dose (Full dose)
(22--Services greater than usual)
J1050
Medroxyprogesterone acetate, 100 mg
9.05
J1055
Medroxyprogesterone acetate for
44.54
contraceptive use, 150 mg
J1056
Lunelle (25mg medroxyprogesterone and 5 mg
Lower of AWP
estradiol cypionate)/0.5 ml
minus 12.5
percent or the
acquisition
cost +
+ Effective September 18, 2006, the Maximum Fee Allowance based on the AWP
minus 12.5 percent is $ 24.95 per 0.5 ml. Enter the lower of the AWP minus
12.5 percent or the acquisition cost in Block 24G on the CMS 1500 claim
form.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 3 - CENTERS FOR MEDICARE & MEDICAID SERVICES CMS HEALTHCARE COMMON PROCEDURE CODING SYSTEM HCPCS › Section 10:58-3.5 - HCPCS Procedure Codes (Level III) and maximum fee allowance schedule for certified nurse midwifery services

Current through Register Vol. 56, No. 14, July 15, 2024
HCPCS
Follow-up
Maximum Fee
IND
Codes
MOD
Days
Descriptions
Allowance
(a) Intrauterine Devices:
W0001
WM
30
Supplying and inserting the
$ 304.00
intrauterine device "Paragard" by a CNM
including the post-insertion visit.
W0002
WM
30
Supplying and inserting the
$ 137.00
intrauterine device "Progestasert" by a
CNM including the post-insertion visit.
W0004
WM
30
Removal of an IUD by a CNM followed at
$ 317.00
the same visit by the insertion of the
intrauterine device "Paragard" by a CNM
including the post-insertion visit.
W0008
WM
30
Removal of an IUD by a CNM followed at
$ 150.00
the same visit by the insertion of the
intrauterine device "Progestasert" by a
CNM including the post-insertion visit.
(b) HealthStart:
N
W9025
WM
HealthStart Initial Antepartum
67.00
Maternity Medical Care Visit by
Certified Nurse Midwife
N
W9026
WM
HealthStart Subsequent Antepartum
19.00
Maternity Medical Care Visit by
Certified Nurse Midwife
N
W9027
WM
HealthStart Regular Delivery by
371.00
Certified Nurse Midwife
N
W9028
WM
HealthStart Postpartum Care Visit by
19.00
Certified Nurse Midwife
N
W9029
WM
HealthStart Regular Delivery and
390.00
Postpartum Visit by Certified Nurse
Midwife
N
W9030
WM
HealthStart Total Obstetrical Care by
723.00
Certified Nurse Midwife
(c) Injections:
(d) EPSDT:
N
W9820
WM
Early and Periodic Screening, Diagnosis
18.00
and Treatment (EPSDT) from 2 through 20
years of age
(e) Maternity Care:
N
W9855
WM
Initial Visit Antepartum Visit by
15.40
Certified Nurse Midwife
N
W9856
WM
Subsequent Antepartum Visit by
11.20
Certified Nurse Midwife
(f) Delivery Services:
Z0250
WM
Home Delivery Pack (All drugs and
40.00
supplies, etc. necessary for delivery
in this setting.)
(g) Birth Centers Facility Fee:
W9858
Birth Center Services, global
1,300.00
W9859
Birth Center Services, limited
500.00
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Appendix A

Current through Register Vol. 56, No. 14, July 15, 2024
DRUG EFFICACY STUDY IMPLEMENTATION (DESI)
(Update of drug products and known related drug products that lack substantial evidence of effectiveness)
Appendix A at N.J.A.C. 10:51, incorporated herein by reference, is a list of drugs that the Food and Drug Administration (FDA) has proposed to withdraw from the market which is updated periodically by the Centers for Medicare & Medicaid Services (CMS) subsequent to published listing changes in the Federal Register.
AGENCY NOTE: Appendix A is filed as part of this chapter by reference but is not reproduced in the New Jersey Administrative Code. When revisions are made to Appendix A, replacement pages will be distributed to providers and copies will be filed with the Office of Administrative Law. For a copy of Appendix A, access
www.njmmis.com
or write to:
Gainwell Technologies
PO Box 4801
Trenton, NJ 08650-4801
or contact:
Office of Administrative Law
Quakerbridge Plaza, Building 9
PO Box 049
Trenton, NJ 08625-0049
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Appendix B

Current through Register Vol. 56, No. 14, July 15, 2024
FISCAL AGENT BILLING SUPPLEMENT
AGENCY NOTE: The Fiscal Agent Billing Supplement is appended as a part of this chapter/manual but is not reproduced in the New Jersey Administrative Code. When revisions are made to the Fiscal Agent Billing Supplement, replacement pages will be distributed to providers and copies will be filed with the Office of Administrative Law. For a copy of the Fiscal Agent Billing Supplement, access
www.njmmis.com
or write to:
Gainwell Technologies
PO Box 4801
Trenton, NJ 08650-4801
or contact:
Office of Administrative Law
Quakerbridge Plaza, Building 9
PO Box 049
Trenton, NJ 08625-0049
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Appendix C

Current through Register Vol. 56, No. 14, July 15, 2024
EMC MANUAL
AGENCY NOTE: The Electronic Media Claims (EMC) Manual is filed as an incorporated Appendix of this chapter/manual, but is not reproduced in the New Jersey Administrative Code. When revisions are made to the EMC Manual, replacement pages will be distributed to providers and copies will be filed with the Office of Administrative Law. For a copy of the EMC Manual, access www.njmmis.com or write to:
Gainwell Technologies
PO Box 4801
Trenton, NJ 08650-4801
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:58A-1.1 - Introduction: certified advanced practice nurse (APN)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This chapter is concerned with the provision of health care services by certified advanced practice nurses (APNs), in accordance with the New Jersey Medicaid and NJ FamilyCare fee-for-service programs' policies and procedures and the standards set forth by the New Jersey Legislature (45:11-23 et seq. and P.L. 1991, c. 377, as revised by P.L. 1999, c. 85 ) and by the New Jersey Board of Nursing (N.J.A.C. 13:37-7 ). Throughout this chapter, all use of the terms "advanced practice nurse" and "APN" refer to a certified advanced practice nurse because all advanced practice nurses are required to be certified.
(b) An approved New Jersey Medicaid/NJ FamilyCare fee-for-service APN provider may be reimbursed for medically necessary covered services provided within the scope of the APNs' license and an approved New Jersey Medicaid/NJ FamilyCare fee-for-service Program Provider Agreement.
(c) An APN may enroll in the New Jersey Medicaid/NJ FamilyCare fee-for-service program and provide covered, medically necessary services as an independent APN, or may provide such services as part of another entity, such as a hospital or clinic, physician group practice, or a mixed clinical practitioner practice.
(d) Unless otherwise stated, the rules of this chapter apply to Medicaid and NJ FamilyCare fee-for-service beneficiaries and to Medicaid and NJ FamilyCare fee-for-service services that are not the responsibility of the managed care organization (MCO) with which the beneficiary is enrolled. Advanced practice nurse services that are to be provided by the beneficiary's selected MCO are governed and administered by that MCO.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:58A-1.3 - Provider participation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order to participate in the Medicaid and NJ FamilyCare fee-for-service programs as an APN practitioner, the APN shall apply to, and be approved by, the New Jersey Medicaid/NJ FamilyCare fee-for-service program. Application for approval by the New Jersey Medicaid/NJ FamilyCare fee-for-service program as an advanced practice nurse (APN) requires completion and submission of the "Medicaid Provider Application" (FD-20) and the "Medicaid Provider Agreement" (FD-62).
1. The FD-20 and FD-62 may be obtained from and submitted to: Molina Medicaid Solutions
Provider Enrollment
PO Box 4804
Trenton, New Jersey 08650-4804
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:58A-1.4 - Recordkeeping

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The APN, in any and all settings, shall keep such legible individual written records and/or electronic medical records (EMR) as are necessary to fully disclose the kind and extent of service(s) provided, the procedure code being billed and the medical necessity for those services.
(b) Documentation of services performed by the APN shall include, as a minimum:
1. The date of service;
2. The name of the beneficiary;
3. The beneficiary's chief complaint(s), reason for visit;
4. Review of systems;
5. Physical examination;
6. Diagnosis;
7. A plan of care, including diagnostic testing and treatment(s);
8. The signature of the APN rendering the service; and
9. Other documentation appropriate to the procedure code being billed. (See N.J.A.C. 10:58A-4, HCPCS Codes.)
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:58A-1.5 - Basis of reimbursement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A claim is a request for payment for a Medicaid-reimbursable or NJ FamilyCare-reimbursable service provided to a Medicaid-eligible or NJ FamilyCare fee-for-service eligible individual. The claim may be submitted via hard copy or by means of an approved method of automated data exchange.
(b) An approved New Jersey Medicaid or NJ FamilyCare APN provider (see 10:58A-1.3, Provisions for participation) shall be reimbursed on a fee-for-service basis in accordance with N.J.A.C. 10:58A-4. Reimbursement shall be limited to payment for medically necessary covered services provided within the appropriate scope of practice in accordance with the individual category of certification for advanced practice.
(c) APN services may be reimbursed (see N.J.A.C. 10:49-7 and 8) under either of two billing mechanisms provided by Medicaid or NJ FamilyCare. The two mechanisms are: a direct billing entity as stated in this chapter or an employee reimbursed by another Medicaid or NJ FamilyCare provider who bills Medicaid or NJ FamilyCare on behalf of the APN's services, that is, physician employer, group or clinic.
1. When an APN is employed by an APN/physician group, the Medicaid or NJ FamilyCare program does not routinely reimburse both an APN visit and, on the same day, a visit to an MD or DO within the same billing entity.
i. If specific circumstances should require the two same-day visits, however, the provider entity shall document the medical necessity for the second visit (see concurrent care in (a)2 below).
ii. If a beneficiary receives care from more than one member of a group practice, a partnership or corporation in the same specialty, the total maximum fee allowance shall be the same as that for a single practitioner.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:58A-1.6 - Personal contribution to care requirements for NJ FamilyCare-Plan C and copayments for NJ FamilyCare-Plan D

Current through Register Vol. 56, No. 14, July 15, 2024
(a) General policies regarding the collection of personal contribution to care for NJ FamilyCare--Plan C and copayments for NJ FamilyCare--Plan D fee-for-service are set forth in N.J.A.C. 10:49-9.
(b) Personal contribution to care for NJ FamilyCare-Plan C services is $ 5.00 a visit for office visits, except as noted in (c) below.
1. An office visit is defined as a face-to-face contact with a medical professional, which meets the documentation requirements at 10:58A-1.4.
2. Office visits include APN services provided in the office, beneficiary's home, or any other site, except a hospital, where the child may have been examined by the APN. Generally, these procedure codes are in the 90000 HCPCS series of reimbursable codes at N.J.A.C. 10:58A-4.
3. APN services which do not meet the requirements of an office visit as defined in this chapter, such as surgical services, immunizations, laboratory or x-ray services, do not require a personal contribution to care.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:58A-2.1 - General provisions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This subchapter describes the New Jersey Medicaid and NJ FamilyCare fee-for-service programs' policies and procedures for the provision of Medicaid and NJ FamilyCare fee-for-service services by APN providers. Services are separately identified and discussed only where unique characteristics or requirements exist. Unless indicated otherwise, reimbursement provisions are located in 10:58A-1.5, Basis for reimbursement.
(b) The New Jersey Medicaid/NJ FamilyCare fee-for-service program shall reimburse for APN services provided only when the patient is an eligible Medicaid/NJ FamilyCare fee-for-service beneficiary at the time services are rendered. APNs shall verify the patient's current eligibility status prior to providing services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:58A-2.2 - Provisions concerning medical services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For patient contacts where the patient presents with a chief complaint, the evaluation and management procedure codes at 10:58A-4.2(r)1  through 6 shall be applied.
(b) In the absence of patient complaints, the Preventive Medicine services codes and the Newborn Care code shall be applied for adults and for children. See 10:58A-4.2(r)7  and 8.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:58A-2.3 - Surgical procedures

Current through Register Vol. 56, No. 14, July 15, 2024
Typically, office visits are not reimbursed in combination with surgical procedures. (When two services are rendered, for example, an office visit and a surgical procedure, the program will pay the higher fee, either the visit or the procedure.) For procedure codes within the APN's scope of practice that are excluded from this general policy, see the codes listed as such at 10:58A-4.5(a).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:58A-2.4 - Pharmaceutical services-drugs prescribed and/or administered by an APN

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All covered pharmaceutical services provided by APNs under the New Jersey Medicaid/NJ FamilyCare fee-for-service programs shall be prescribed and administered in accordance with: 13:37-7.9 and 7.10; 10:49; 10:51; and this chapter.
(b) The Pharmaceutical Services manual, N.J.A.C. 10:51, sets forth the provisions for covered and non-covered pharmaceutical services, prior authorization, quantity of medication, administration of drugs, pharmaceutical dosage and directions, telephone-rendered original prescriptions, changes or additions to the original prescription, non-proprietary or generic dispensing, and prescription refill.
(c) The Medicaid/NJ FamilyCare fee-for-service programs will reimburse the clinical practitioner directly for the cost of the drugs described at 10:58A-4.3.
(d) The Medicaid/NJ FamilyCare program will reimburse APNs for certain approved drugs administered by inhalation, intradermally, subcutaneously, intramuscularly or intravenously in the office, home or independent clinic setting according to the following reimbursement methodologies. See N.J.A.C. 10:58A-4 for a listing of HCPCS procedure codes.
1. When an APN office or home visit is made for the sole purpose of administering a drug, reimbursement shall be limited to the cost of the drug and/or its administration. In these situations, there is no reimbursement for an APN's office or home visit. If, in addition to the APN's administration of a drug, the criteria of an office or home visit are met, the cost of the drug and/or administration may, if medically indicated, be reimbursed in addition to the visit.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:58A-2.5 - Medical exception process (MEP)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For pharmacy claims with service dates on or after September 1, 1999, which exceed prospective drug utilization review (PDUR) standards recommended by the New Jersey Drug Utilization Review Board (NJ DURB) and approved by the Commissioners of the Department of Human Services (DHS) and the Department of Health and Senior Services (DHSS), the Division of Medical Assistance and Health Services has established a medical exception process (MEP). See N.J.A.C. 10:51.
(b) The MEP shall be administered by a contractor, referred to as the MEP contractor, under contract with the Department of Human Services.
(c) The MEP shall apply to all pharmacy claims, regardless of claim media, unless there is a recommended exemption by the NJ DURB, which has been approved by the Commissioners of DHS and DHSS, in accordance with the rules of those Departments.
(d) The MEP is as follows:
1. The MEP contractor shall contact prescribers of conflicting drug therapies, or drug therapies that exceed established PDUR standards, to request written justification to determine medical necessity for continued drug utilization.
i. The MEP contractor shall send a Medical Necessity Form (MNF), which includes, but may not be limited to, the beneficiary name, Health Benefits Identification (HBID) number, dispense date, drug quantity and drug description. The prescriber shall be requested to provide the reason for the medical exception, diagnosis, expected duration of therapy and expiration date for medical exception.
ii. The prescriber shall provide information requested on the MNF to the MEP contractor.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:58A-2.6 - Clinical laboratory services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) "Clinical laboratory services" means professional and technical laboratory services performed by a clinical laboratory certified by CMS in accordance with the Clinical Laboratory Improvement Act (CLIA) and ordered by a physician or other licensed practitioner, within the scope of his or her practice, as defined by the laws of the State of New Jersey and/or of the state in which the practitioner practices.
(b) Clinical laboratory services are furnished by clinical laboratories and by physician office laboratories (POLs) that meet the Centers for Medicare and Medicaid Services regulations pertaining to clinical laboratory services defined in the Clinical Laboratory Improvement Amendments (CLIA) of 1988, section 1902(a)(9) of the Social Security Act, 42 U.S.C. §
										1396(a)(9), and as indicated at 10:61-1.2, the Medicaid and NJ FamilyCare fee-for-service programs' Independent Clinical Laboratory Services manual and N.J.A.C. 8:44 and N.J.A.C. 8:45.
(c) All independent clinical laboratories and other entities performing clinical laboratory testing shall possess certification as required by CLIA 1988, and the New Jersey Department of Health and Senior Services rules found in N.J.A.C. 8:44 and N.J.A.C. 8:45.
(d) An APN may claim reimbursement for clinical laboratory services performed for his or her own patients within his or her own office, subject to the following:
1. An APN shall meet the conditions of the CLIA regulations before she or he may perform clinical laboratory testing for Medicaid/NJ FamilyCare fee-for-service beneficiaries; and
2. The clinical laboratory tests shall be standard clinical laboratory procedures consistent with the APN's CLIA certification, certificate of waiver or certificate of registration as an independent clinical laboratory.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:58A-2.7 - Evaluation and management services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The evaluation and management codes can indicate services performed in a clinical practitioner's office, in a patient's home, in a boarding home, in nursing facilities and residential health care facilities, in clinics, in Federally qualified health centers (FQHCs), and in hospitals.
(b) Reimbursement for an initial office visit or initial residential health care facility visit will be disallowed, if a preventive medicine service, EPSDT examination or office consultation was billed within a 12-month period by the same clinical practitioner, group of clinical practitioners, or shared health care facility sharing a common record.
(c) Provisions for initial visits, evaluation and management are:
1. For office visits and for other care apart from inpatient hospital, providers are permitted to bill for an initial visit only once for a specific patient, subject to the following exceptions.
i. When a shared health care facility, a group of physicians and/or other practitioners including, but not limited to, APNs, share a common record, the Division will reimburse only one initial visit to that provider group.
ii. Further encounters with that patient will be billed and reimbursed by means of "established patient" codes. See 10:58A-4.1 through 4.5.
iii. Reimbursement for an initial office visit also precludes subsequent reimbursement to the same provider for an initial residential health care facility visit and vice versa.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:58A-2.8 - Family planning services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Family planning services include medical history and physical examination (including pelvic and breast); the ordering of diagnostic and laboratory tests; the prescribing of drugs and biologicals, medical devices and supplies; and providing continued medical supervision, counseling, and continuity of care.
1. The New Jersey Medicaid and NJ FamilyCare fee-for-service programs shall not reimburse for services for the diagnosis or treatment of infertility. Services provided primarily for the diagnosis and treatment of infertility, including related office visits, drugs, laboratory services, radiological and diagnostic services and surgical procedures shall not be covered by the New Jersey Medicaid/NJ FamilyCare fee-for-service program.
i. Exception: When a service is provided that is ordinarily considered an infertility service, but is provided for another purpose, the APN shall submit the claim with supporting documentation for medical review and approval of payment to the Division of Medical Assistance and Health Services, Office of Utilization Management, PO Box 712, (Mail Code #14), Trenton, New Jersey 08625-0712.
ii. When a prescription drug is provided that is ordinarily used for infertility, but is provided for medical conditions unrelated to infertility, the clinical practitioner who prescribes this drug should clearly indicate on the prescription that the drug is being provided for a condition other than infertility, and provide a copy of this documentation to the pharmaceutical provider.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:58A-2.9 - Mental health services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Advanced practice nurses who are certified in the advanced practice category of "Psychiatric/Mental Health" (APN, Psychiatric/Mental Health) are qualified to perform and be reimbursed independently for psychiatric evaluations for the New Jersey Medicaid/NJ FamilyCare fee-for-service program.
1. For each psychiatric therapy patient contact, written documentation shall be developed and maintained to support each medical or remedial therapy, service, activity, or session for which billing is made. The documentation shall consist of the following:
i. The specific services rendered and modality used, such as individual, group, and/or family therapy;
ii. The date services were rendered;
iii. The duration of services provided (1 hour, 1/2 hour);
iv. The signature of the APN, Psychiatric/Mental Health, who rendered the service;
v. The setting in which services were rendered;
vi. A notation of impediments, unusual occurrences or significant deviations from the treatment described in the Plan of Care;
vii. Notations of progress, impediments, treatment, or complications; and
viii. Other relevant information.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:58A-2.10 - Pre-Admission Screening and Resident Review (PASRR) and Pre-Admission Screening (PAS)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Federal legislation (1919 of the Social Security Act, 42 U.S.C. §
										1396r ) established Pre-Admission Screening and Resident Review (PASRR) (PAS) for MI/MR applicants to Medicaid/NJ FamilyCare-participating nursing facilities (NFs) and further reviews, as indicated by a significant change in a beneficiary's mental or physical condition, for residents of Medicaid/NJ FamilyCare-participating NFs.
(b) Through PASRR, NF applicants or residents of NFs are evaluated to assess the appropriateness of their admission to the facility or continued residence within the facility, in respect to whether they need specialized services for the treatment of mental illness or mental retardation. Persons in need of specialized services will be directed to an alternate placement.
(c) The initial Preadmission Screening (PAS) screening is conducted by professional staff designated by the New Jersey Department of Health and Senior Services (DHSS), to determine whether the individual requires nursing facility level of care.
1. After the professional staff designated by DHSS has determined that the individual meets the criteria for the NF-level of care, an individual identified as meeting the criteria for mental retardation services is referred to the staff of the Division of Developmental Disabilities for a specialized service evaluation.
2. An individual identified as meeting criteria for mental illness is evaluated by a psychiatrist, an attending physician or an APN who is certified in the advanced practice category of Psychiatric/Mental Health to determine the need for specialized services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:58A-2.11 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is a Federally mandated comprehensive child health program for Medicaid/NJ FamilyCare-Plan A beneficiaries under 21 years of age. The Omnibus Budget Reconciliation Act of 1989 (OBRA '89) codified EPSDT. The term "EPSDT Services" means a preventive and comprehensive health program: for Medicaid and NJ FamilyCare--Plan A beneficiaries under 21 years of age for the purpose of assessing a beneficiary's health needs through initial and periodic examinations, health education and guidance and identification, diagnosis and treatment of health problems; for eligible NJ FamilyCare B and C enrollees, covering early and periodic screening and diagnostic medical examinations, dental, vision, hearing and lead screening services, and those treatment services identified through the examination that are available under the MCO contractor's benefit package or specified services under the FFS program (see 10:49-5.6 ). EPSDT service shall include, at a minimum, the following:
1. EPSDT Screening Services;
2. Vision Services;
3. Dental Services;
4. Hearing Services; and
5. Such necessary health care diagnostic services, treatment and other measures to correct or ameliorate defects, and physical and mental illnesses and conditions discovered by the screening services. (See 42 CFR 441 Subpart B.)
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:58A-2.12 - Obstetrical/gynecological (OB/GYN) care

Current through Register Vol. 56, No. 14, July 15, 2024
Reimbursement for specified OB/GYN services at 10:58A-4.2(g)  provided under the Medicaid and NJ FamilyCare fee-for-service programs shall be limited to advanced practice nurses who are certified in the advanced practice category of "OB/GYN."
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 2 - PROVISION OF SERVICES › Section 10:58A-2.13 - New Jersey Vaccines for Children program

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey Vaccines for Children (VFC) program provides free vaccines for administration to beneficiaries under 19 years of age who are eligible for New Jersey Medicaid and NJ FamilyCare services. Medicaid and NJ FamilyCare programs shall not provide reimbursement to providers for administering these vaccines exclusive of the VFC program.
1. The Center for Disease Control (CDC) is expected to periodically add vaccines to the approved list for the VFC program. This list, "VFC Resolutions," is hereby incorporated by reference, as amended and supplemented. The VFC Resolutions lists the vaccines provided by the VFC Program for individuals under age 19. The Medicaid/NJ FamilyCare program shall not reimburse for any vaccine so added to the VFC Resolutions that are not obtained from the VFC program. Providers can access the VFC Resolutions on the CDC website at
http://www.cdc.gov/vaccines/
.
i. Any change to the reimbursement amount for the administration of vaccines administered under the VFC Program and/or the reimbursement amounts for such vaccines that are also appropriate for and administered to individuals who are not under age 19 and are, therefore, ineligible to receive them under the VFC Program, will be made by rulemaking in accordance with the Administrative Procedure Act, 52:14B-1 et seq.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 3 - HEALTHSTART › Section 10:58A-3.1 - HealthStart services

Current through Register Vol. 56, No. 14, July 15, 2024
The New Jersey HealthStart program provides comprehensive maternity services for pregnant women (including those determined to be presumptively eligible) and child health services for children (through two years of age) who are eligible for Medicaid/NJ FamilyCare fee-for-service benefits.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 3 - HEALTHSTART › Section 10:58A-3.2 - Purpose

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of HealthStart is to provide for comprehensive maternity services to pregnant Medicaid/NJ FamilyCare fee-for-service beneficiaries, including those determined to be presumptively eligible and preventive child health services for Medicaid/NJ FamilyCare fee-for-service beneficiaries up to the age of two.
1. Pediatric HealthStart services are an expansion of the EPSDT program as described at 10:58A-2.11.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 3 - HEALTHSTART › Section 10:58A-3.3 - Scope of services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) HealthStart maternity services provided by a HealthStart-certified APN are health support services provided in accordance with the HealthStart guidelines. HealthStart pediatric services include up to nine preventive visits, as recommended by the American Academy of Pediatrics, provided by a HealthStart-certified provider who assumes the primary responsibility for coordination and continuity of care.
(b) HealthStart maternity health support services include:
1. Case coordination services;
2. Health education assessment and counseling services;
3. Nutrition assessment and counseling services;
4. Social-psychological assessment and counseling services.
5. Home visitation; and
6. Outreach, referral and follow-up services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 3 - HEALTHSTART › Section 10:58A-3.4 - HealthStart provider participation criteria

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following Medicaid-enrolled or NJ FamilyCare fee-for-service enrolled provider types are eligible to participate as HealthStart providers: independent clinics, hospital outpatient departments, local health departments meeting the New Jersey State Department of Health and Senior Services' Improved Pregnancy Outcome criteria and/or approved as Child Health Conferences, physicians and physician groups, certified nurse midwives and APNs.
(b) In addition to New Jersey Medicaid/NJ FamilyCare fee-for-service program rules applicable to provider participation, HealthStart APN providers shall:
1. Sign an Addendum to the New Jersey Medicaid and NJ FamilyCare fee-for-service programs' Provider Agreement;
2. Have a valid HealthStart Provider Certificate; and
3. Provide maternity health support services and/or pediatric services in accordance with this subchapter.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 3 - HEALTHSTART › Section 10:58A-3.5 - Termination of HealthStart Provider Certificate

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey State Department of Health and Senior Services is responsible for enforcement of its requirements for HealthStart Provider Certificates and for evaluation and enforcement of its requirements within the Standards and Guidelines for HealthStart Providers.
(b) Causes for termination of the HealthStart Provider Certificate by the New Jersey State Department of Health and Senior Services are as follows:
1. Failure to comply with HealthStart standards;
2. Failure to complete the recertification process; and/or
3. Voluntary withdrawal from the HealthStart program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 3 - HEALTHSTART › Section 10:58A-3.6 - Records: documentation, confidentiality and informed consent for HealthStart maternity care providers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) HealthStart APN maternity care providers shall have policies which protect patient confidentiality, provide for informed consent, and document health support services in accordance with the New Jersey State Department of Health and Senior Services' Guidelines for HealthStart Maternity Care Providers.
(b) An individual record shall be maintained for each patient throughout the pregnancy.
(c) Each record shall be confidential and shall include at least the following: history and physical examination findings, assessment, a care plan, treatment services, laboratory reports, counseling and health instructions provided, and documentation of referral and follow-up services.
(d) There shall be policies and procedures for informed consent for all HealthStart services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 3 - HEALTHSTART › Section 10:58A-3.7 - Health support services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Health support services are a component of comprehensive maternity care. In order to render HealthStart health support services, an APN provider must be affiliated with, or have a formal agreement with an obstetrical provider rendering the medical maternity care component. Health support services are provided as follows:
1. Case coordination services shall facilitate the delivery of continuous, coordinated and comprehensive services for each patient in accordance with this subchapter and as follows:
i. A permanent case coordinator shall be assigned to each patient no later than two weeks after the HealthStart enrollment visit;
ii. Prenatal case coordination activities shall include, but not be limited to:
(1) Orienting the patient to all services;
(2) Developing, maintaining and coordinating the care plan in consultation with the patient;
(3) Coordinating and monitoring the delivery of all services and referrals;
(4) Monitoring and facilitating the patient's entry into and continuation with maternity services;
(5) Facilitating and providing advocacy for obtaining referral services;
(6) Reinforcing health teachings and providing support;
(7) Providing vigorous follow up for missed appointments and referrals;
(8) Arranging home visits;
(9) Meeting with the patient and coordinating patient care conferences; and
(10) Reviewing, monitoring and updating the patient's complete record;
iii. Postpartum care coordination activities shall include, but not be limited to:
(1) Arranging and coordinating the postpartum visit and any home visit;
(2) Arranging with the obstetrical care provider to obtain the labor, delivery and postpartum hospital summary record information no later than two weeks after delivery;
(3) Linking the patient to appropriate service agencies including: the Special Supplemental Food Program for Women, Infants and Children (WIC), pediatric care (preferably with a HealthStart pediatric care provider), future family planning, Special Child Health Services County Case Management Unit, and other health and social agencies, if needed;
(4) Arranging for the transfer of pertinent information or records to the pediatric care and/or future family planning service providers;
(5) Coordinating referrals and following up on missed appointments and referrals; and
(6) Reinforcing health instructions for mother and baby.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 3 - HEALTHSTART › Section 10:58A-3.8 - Standards for HealthStart pediatric care certificate

Current through Register Vol. 56, No. 14, July 15, 2024
(a) APN pediatric care services shall be comprehensive, integrated and coordinated.
(b) HealthStart APN pediatric care providers shall:
1. Directly provide preventive child health care, maintenance of complete patient history, outreach for preventive care, initiation of referrals for appropriate medical, educational, social, psychological and nutritional services, and follow-up of referrals and sick care;
2. Directly provide or arrange for non emergency room-based, 24-hour practitioner telephone access for eligible patients; and
3. Directly provide or arrange for sick care and emergency care.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 3 - HEALTHSTART › Section 10:58A-3.9 - Professional requirements for HealthStart pediatric care providers

Current through Register Vol. 56, No. 14, July 15, 2024
All HealthStart APN pediatric care providers shall be certified in the practice of pediatrics or family practice. This may be demonstrated by certification by the New Jersey Board of Nursing, or by hospital admitting privileges in pediatrics or family practice or by documentation of a formal arrangement with a physician who is board certified in pediatrics or family practice.