reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 3 - HEALTHSTART › Section 10:58A-3.10 - Preventive care services by HealthStart pediatric care providers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) HealthStart pediatric care providers shall provide preventive health visits in accordance with the recommended guidelines of the American Academy of Pediatrics and this chapter. The schedule shall include a two to four week visit, a two month visit, a four month visit, a six month visit, a nine month visit, a 12 month visit, a 15 month visit, an 18 month visit and a 23 to 24 month visit. Each visit shall include, at a minimum, medical, family and social history, unclothed physical examination, developmental and nutritional assessment, vision and hearing screening, dental assessment, assessment of behavior and social environment, anticipatory guidance, age appropriate laboratory examinations and immunizations. Referrals shall be made as appropriate.
(b) Each provider shall provide or arrange for sick care and 24 hour telephone physician/APN access during non-office hours. If not directly provided by the HealthStart provider, sick care and 24-hour telephone access shall be provided for each child by a single designated provider via a documented agreement. Information on care given shall be communicated to the primary HealthStart pediatric care provider. Telephone access provided exclusively via emergency room staff is not permitted. Referral to the emergency room should occur only for emergency medical care or urgent care.
(c) Case coordination, outreach and follow-up services shall include letter and/or telephone call reminders to the child's parent or guardian for preventive well-child visits and letters and/or telephone follow-up of missed appointments. Referrals for home visit services for follow-up shall be made when appropriate. For all referrals and follow-up visits, the provider shall document the completion of such referrals and/or visits. If the referral is not completed, a letter or phone call to the child's parent or guardian and/or to the referred agency shall be sent or made. All of the activity shall be recorded on the patient's chart.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 3 - HEALTHSTART › Section 10:58A-3.11 - Referral services by HealthStart pediatric care providers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All HealthStart APN pediatric care providers shall make provision for consultation for specialized health and other pediatric services. Services shall include medical services, as well as social, psychological, educational and nutritional services.
1. This may include, but is not limited to: the Special Supplemental Food Program for Women, Infants and Children (WIC); Division of Youth and Family Services, Special Child Health Services Case Management Units and Child Evaluation Centers; early intervention programs; county welfare agencies/boards of social services; certified home health agencies; community mental health centers; and local and county health departments.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 3 - HEALTHSTART › Section 10:58A-3.12 - Records: documentation, confidentiality and informed consent for HealthStart pediatric care providers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) HealthStart pediatric care providers shall have policies that protect patient confidentiality, as defined at 10:49-9.7, and provide for informed consent and document comprehensive care services in accordance with this Chapter.
(b) An individual record shall be maintained for each patient.
(c) Each record shall be confidential and shall include at least the following: history and physical examination, results of required assessments, care plan, treatment services, laboratory reports, counseling and health instruction provided and documentation of referral and follow-up services.
(d) There shall be policies and procedures for appropriate informed consent for all HealthStart pediatric services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 3 - HEALTHSTART › Section 10:58A-3.13 - HealthStart services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This section applies to APN services provided by an APN who has a HealthStart certificate.
(b) HealthStart pediatric care provides for up to nine preventive child health visits for a child under two years of age.
1. All preventive child health visits shall be billed using the HealthStart Preventive Child Health Visit codes appropriate to the child's age at the time of visit.
2. Claims shall be submitted using Form MC-19, EPSDT/HealthStart Screening and Related Procedures.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 4 - CENTERS FOR MEDICARE & MEDICAID SERVICES CMS HEALTHCARE COMMON PROCEDURE CODING SYSTEM HCPCS › Section 10:58A-4.1 - Introduction to the HCPCS procedure code system

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey Medicaid and NJ FamilyCare fee-for-service programs use the Centers for Medicare and Medicaid Services' (CMS) Healthcare Common Procedure Code System (HCPCS) for 2009, established and maintained by CMS in accordance with the Health Insurance Portability and Accountability Act of 1996, Pub.L. 104-191, and incorporated herein by reference, as amended and supplemented, and as 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 subchapter 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, 52:14B-1 et seq. HCPCS follows the American Medical Association's Physicians' Current Procedure Terminology (CPT) architecture, employing a five-position code and as many as two two-position modifiers. Unlike the CPT numeric design, the CMS-assigned codes and modifiers contain alphabetic characters. Because of copyright restrictions, the CPT procedure narratives for Level I codes are not included in this subchapter, but are hereby incorporated by reference.
1. Copies of the CPT may be ordered from the American Medical Association, P.O. Box 10950, Chicago, IL 60610 or by accessing
http://www.ama-assn.org
. An updated copy of the HCPCS (Level II) codes may be obtained by accessing the HCPCS website at
http://www.cms.hhs.gov/TransactionCodeSetsStands/
or by contacting PMIC, 4727 Wilshire Blvd., Suite 300, Los Angeles, CA 90010.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Appendix - APPENDIX

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 but is not reproduced in the New Jersey Administrative Code. When revisions are made to the Fiscal Agent Billing Supplement, a revised version will be placed on
http://www.njmmis.com
and shall be filed with the Office of Administrative Law.
If you do not have internet access and would like to request a copy of the Fiscal Agent Billing Supplement, write to:
Molina Medicaid Solutions
PO Box 4801
Trenton, New Jersey 08650-4801
or contact:
Office of Administrative Law
Quakerbridge Plaza, Bldg. 9
PO Box 049
Trenton, New Jersey 08625-0049
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 59 - MEDICAL SUPPLIER MANUAL › Subchapter 1 - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT › Section 10:59-1.1 - Introduction

Current through Register Vol. 56, No. 14, July 15, 2024
This chapter outlines the policies and procedures of the New Jersey Medicaid/NJ FamilyCare program relevant to medical supplies and durable medical equipment, including enteral, total parenteral nutrition and other intravenous therapies. This chapter provides specific requirements that must be met by a Medical Supplier to qualify for reimbursement under the New Jersey Medicaid/NJ FamilyCare program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 59 - MEDICAL SUPPLIER MANUAL › Subchapter 1 - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT › Section 10:59-1.4 - Non-covered items or services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey Medicaid/NJ FamilyCare program does not cover medical supplies and durable medical equipment under the following conditions:
1. A particular item of DME is not covered when, in the opinion of the Division, the item is not considered cost-effective or safe and effective for the treatment of a beneficiary's medical condition;
2. Items available without charge through programs of other public or voluntary agencies (for example: New Jersey State Department of Health and Senior Services, Heart Association, American Cancer Society) are not covered;
3. Supplies which are administered or directly furnished by practitioners or by home health agencies as part of per visit reimbursement are not covered separately;
4. Medical supplies, routinely used DME and other therapeutic equipment/supplies essential to furnish the services offered by a facility for the care and treatment of its residents are considered part of the NF's per diem and therefore, not covered. Examples of this type of equipment and supplies include, but are not limited to, the following:
i. Administration pumps;
ii. Aspirators;
iii. Canes;
iv. Communication equipment (life-safety devices including alarms and apnea monitors);
v. Crutches;
vi. Enteral nutritional supplements and related supplies (including IV poles and enteral pumps);
vii. Geri-chairs;
viii. Hospital beds (including mattress and side rails);
ix. IPPB machines;
x. IV supplies and related equipment;
xi. Lifts;
xii. Low end pressure relief systems, for example, mattress overlays, mattress replacements, powered mattress systems and air powered flotation beds;
xiii. Nebulizers;
xiv. Oxygen and related equipment;
xv. Traction apparatus;
xvi. Walkers;
xvii. Standard wheelchairs and accessories including adjustable leg rests and detachable armrests; and
xviii. Medical supplies, for example, incontinency pads, bandages, dressings, compresses, sponges, plasters, tapes, cellu-cotton or other types of pads used to save labor or linen, colostomy bags, hot water bags, thermometers, catheters, rubber gloves, and disposable syringes.
5. Exceptions to (a)4 above include certain durable medical equipment not routinely used in a nursing facility and which is required due to the medical need of the individual resident;
6. Items not meeting the definitions of medical supplies and DME outlined at 10:59-1.2, Definitions;
7. Delivery and shipping costs;
8. Services being provided to a beneficiary who loses eligibility, except as described at 10:49-5.4(a)9; and
9. Travel time, except for services provided by a pedorthist.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 59 - MEDICAL SUPPLIER MANUAL › Subchapter 1 - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT › Section 10:59-1.5 - Policy for providing medical supplies and DME

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Medical supplies and equipment require a legible, dated prescription or a Certificate of Medical Necessity (CMN) personally signed by the prescribing practitioner. Either document shall contain the following information:
1. The beneficiary's name, address and Medicaid/NJ FamilyCare eligibility identification number; and
2. A description of the specific supplies and/or equipment prescribed;
i. For example, the phrase "wheelchair" or "patient needs wheelchair" is insufficient. The order shall describe the type and style of the wheelchair.
3. The length of time the medical equipment items or supplies are required;
4. A diagnosis and summary of the patient's physical condition to support the need for the item(s) prescribed; and
5. The prescriber's name, address and signature.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 59 - MEDICAL SUPPLIER MANUAL › Subchapter 1 - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT › Section 10:59-1.6 - Prior authorization (PA)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Prior authorizations issued by the Medicaid/NJ FamilyCare program are intended to reflect decisions regarding medical necessity and purchase/rental options. The issuance of prior authorization is not a guarantee of Medicaid/NJ FamilyCare payment. Payment is determined based on the satisfaction of all applicable claims processing edits established by the Division of Medical assistance and Health Services. Payment is made, based on the satisfaction of the conditions of this chapter.
(b) When a procedure code requires PA, the provider shall first obtain authorization from the appropriate Medical Assistance Customer Center (MACC). (See a list of MACCs at N.J.A.C. 10:49, Appendix Form #17.) The Division will provide written notification of the disposition of the PA request.
1. An exception is provided for orthopedic footwear not attached to a bar or brace. In these situations, the PA shall be submitted to the Podiatric Consultant in the Medicaid/NJ FamilyCare Central Office (See N.J.A.C. 10:57).
2. Urgent requests may be made by telephone, but the provider shall submit the written PA request within five calendar days (see 10:49-6.1 ).
3. For procedure codes L3000 through L3003, L3010, L3020, L3030, L3040, L3050, L3060, L3070, L3080 and L3090, up to four units of orthotics may be provided by the same provider to the same beneficiary during a 12-month period.
4. For procedure codes L3201 through L3207, L3215 through L3217, L3219, L3221 and L3222, up to two units may be provided by the same provider to the same beneficiary during a 12-month period.
5. For procedure code L3260, up to four units may be provided by the same provider to the same beneficiary during a 12-month period.
6. HCPCS procedure codes L3001, L3002, L3003, L3010, L3020, L3030, L3040, L3050, L3060, L3070, L3080, L3090, L3215 through L3223, and L3201 through L3207 do not require prior authorization for the following diagnosis codes: 343.0 to 343.9, 707.0 to 707.9, 711.0 to 712.9, 715.0 to 722.9, 724.0 to 728.9, 730.0 to 737.9, 754.2 to 754.79, 755.0 to 755.39, 755.6 to 755.69, 756.1 to 756.19, 756.8 to 756.89, and 892.0 to 897.7.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 59 - MEDICAL SUPPLIER MANUAL › Subchapter 1 - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT › Section 10:59-1.7 - Policy considerations for purchase, rental and repair of DME

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Medical suppliers may request payment for medical supply services only after the supply/equipment has been delivered to the beneficiary (see 10:49-9.5 ). All requests for payment shall be submitted timely, in accordance with 10:49-7.2.
(b) For durable medical equipment requiring prior authorization (PA), decisions regarding rental or purchase rest with the Division of Medical Assistance and Health Services.
1. Durable medical equipment may be rented when, in the judgment of the Medicaid/NJ FamilyCare program, the medical need for the equipment is of such a duration that rental of the equipment is more economically practical than authorizing its purchase.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 59 - MEDICAL SUPPLIER MANUAL › Subchapter 1 - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT › Section 10:59-1.8 - Basis of reimbursement for medical supplies and DME

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Payment for purchase of medical supplies or DME shall be based on the following methods:
1. If there is no Medicaid/NJ FamilyCare Fee schedule, reimbursement shall be based on the lesser of the provider's usual and customary charge to the general public or a calculated maximum fee allowance equal to 130 percent of a supplier's invoice cost or 80 percent of the manufacturer's price list for supplies and equipment priced by report.
i. The invoice shall include the supplier as the addressee, item description, quantity, and cost.
ii. The manufacturer's price list shall include a manufacturer's name, item description, and suggested retail price per unit or package, and a notation by a supplier indicating the number of units per package, if not described by a manufacturer.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 59 - MEDICAL SUPPLIER MANUAL › Subchapter 1 - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT › Section 10:59-1.9 - Dual Medicare/Medicaid/NJ FamilyCare coverage

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When a Medicaid/NJ FamilyCare beneficiary also has Medicare coverage, the Medicaid/NJ FamilyCare program requires that Medicare benefits be used first and to the fullest extent. Responsibility for payment by the New Jersey Medicaid/NJ FamilyCare program shall be limited to the unsatisfied deductible and/or coinsurance to the extent that the combined Medicare/Medicaid/NJ FamilyCare payment does not exceed the Medicaid/NJ FamilyCare maximum allowable.
(b) In those instances where Medicare policy disallows reimbursement for an item/service under certain circumstances, for example, a special wheelchair for a NF resident, the provider shall obtain prior authorization from the Medicaid/NJ FamilyCare--Plan A program and submit a hard copy claim to the Medicaid/NJ FamilyCare--Plan A program with an Explanation of Benefits from Medicare attached.
(c) Medicare/Medicaid/NJ FamilyCare claims shall be filed timely, in accordance with N.J.A.C. 10:49-7.2.
(d) When a beneficiary is eligible for Medicare/Medicaid/NJ FamilyCare coverage, a Medicare/Medicaid/NJ FamilyCare claim will cross over from the Medicare DMERC Region A to the Medicaid/NJ FamilyCare fiscal agent. There are instances, however, where claims will not cross over from Medicare to Medicaid/NJ FamilyCare, for example, claims denied by Medicare or claims where the Medicaid/NJ FamilyCare fiscal agent is unable to match pertinent identifying data (see N.J.A.C. 10:49-7.2(d)3 for further instructions).
(e) There are situations in which Medicare coverage differs significantly from coverage considered medically necessary by the Medicaid/NJ FamilyCare program. In these situations, the provider may request PA from the Medicaid/NJ FamilyCare program prior to requesting Medicare payment.
1. The provider must request PA for the higher level of service under the procedure code assigned by the Division for "reconciliation of downgraded Medicare/Medicaid/NJ FamilyCare claims."
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 59 - MEDICAL SUPPLIER MANUAL › Subchapter 1 - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT › Section 10:59-1.10 - Third party liability (TPL), excluding Medicare

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When a Medicaid/NJ FamilyCare beneficiary has other health insurance, the Medicaid/NJ FamilyCare program requires that such benefits be used first and to the fullest extent. Supplementation may be made for Medicaid/NJ FamilyCare covered services, but the combined total payment shall not exceed the amount payable under the Medicaid/NJ FamilyCare program in the absence of other coverage (see 10:49-7.3 ).
(b) Regardless of the status of a provider's claim with other Regardless of the status of a provider's claim with other third parties, all claims for Medicaid/NJ FamilyCare reimbursement shall be received by the Medicaid/NJ FamilyCare fiscal agent within the time frames specified in 10:49-7.2, Timeliness of claim submission.
(c) The Medicaid/NJ FamilyCare program has not established any crossover arrangements with any third party insurer.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 59 - MEDICAL SUPPLIER MANUAL › Subchapter 1 - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT › Section 10:59-1.11 - Recycling durable medical equipment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey Medicaid and NJ FamilyCare programs shall utilize the services of a durable medical equipment (DME) recycling contractor, acting as an agent of the State, to recycle certain DME for reuse by Medicaid and NJ FamilyCare fee-for-service beneficiaries when such equipment is considered medically necessary.
(b) The New Jersey Medicaid and NJ FamilyCare fee-for-service programs shall recycle certain DME when the aggregate cost of recycling an item of DME, including costs for pickup and delivery, repairs, maintenance, tracking of DME and other directly related costs, are less than the Medicaid/NJ FamilyCare maximum fee allowance for the purchase of new DME.
1. Coverage and reimbursement for DME which is determined recyclable by the New Jersey Medicaid and NJ FamilyCare fee-for-service programs shall be limited to such equipment when this equipment is available from the DME recycling contractor.
2. Recyclable DME shall include, but not be limited to, the following:
i. Canes, all types;
ii. Commodes;
iii. Communication devices;
iv. Crutches, all types;
v. Durable bathroom equipment;
vi. Hospital beds, all types;
vii. Walkers, all types;
viii. Wheelchairs and wheelchair components.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 59 - MEDICAL SUPPLIER MANUAL › Subchapter 1 - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT › Section 10:59-1.12 - Parenteral therapy

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Parenteral therapy refers to the administration of a drug by the intravenous or subcutaneous route of administration.
(b) Total parenteral nutrition (TPN) means the administration of a patient's total daily nutritional needs via the parenteral route of administration.
(c) All parenteral therapy services, including total parenteral nutrition (TPN), require prior authorization (see 10:59-1.6 ).
(d) For parenteral therapy other than TPN, coverage through the medical supplier shall be limited to supplies and equipment. Medicaid/NJ FamilyCare fee-for-service maximum fee allowances for drug costs related to TPN solutions shall only be reimbursed to medical suppliers who are also licensed as providers of pharmaceutical services.
1. Coverage for all medical supplies and DME related to TPN therapy shall be based on monthly fee allowances as established by the Division (see 10:59-2.3 for monthly fee allowances and unit descriptions).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 59 - MEDICAL SUPPLIER MANUAL › Subchapter 1 - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT › Section 10:59-1.13 - Augmentative/alternative communication system (ACS)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) ACS requires prior authorization. Requests for prior authorization shall include the following:
1. A list of specialists involved in the multi-disciplinary team evaluation of the beneficiary, including, at a minimum, a speech-language pathologist, physical therapist, occupational therapist, and social worker.
2. An evaluation report by the speech-language pathologist, which shall include the following:
i. The communication status of the beneficiary, including relevant mental and physical disabilities;
ii. A list of augmentative/alternative communication devices/systems tried during the evaluation period;
iii. The rationale for the selection of the prescribed device/system and a description of how it will enhance functional communicative abilities;
iv. A certification that the beneficiary can mentally and physically benefit from the device/system and is willing to use it;
v. Recommendations for follow-up instruction so that maximum benefit may be obtained;
vi. A description of the beneficiary's gross and fine motor abilities, perceptual skills, reading skills, and cognitive abilities;
vii. Results of an audiometric screening and/or audiologic evaluation, as appropriate;
viii. A summary of past speech-language treatment;
ix. Results of the trial period with the device; and
x. A list of recommended augmentative communication devices, including all necessary accessories, prices and provider information.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 59 - MEDICAL SUPPLIER MANUAL › Subchapter 1 - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT › Section 10:59-1.14 - Pressure reduction systems

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Pressure reduction systems include:
1. Air fluidized bed systems which employ the circulation of filtered air through silicone-coated ceramic beads creating the characteristics of fluid;
2. Powered low air loss bed systems which incorporate the use of an air-bladder system consisting of a series of interconnected adjustable air sacs designed to allow air escape to reduce support surface pressure. Air to the sacs is supplied by a separate power supply unit; and
3. Low end products which include any powered or non-powered overlay or mattress.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 59 - MEDICAL SUPPLIER MANUAL › Subchapter 1 - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT › Section 10:59-1.15 - Apnea monitor

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Apnea monitors shall require prior authorization (PA) for initial certification and subsequent recertification.
1. To obtain authorization, providers shall complete the "Home Apnea Monitor Certification" form FD-287 which requires the prescriber's signature. The FD-287 may be used in lieu of a prescription by suppliers.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 59 - MEDICAL SUPPLIER MANUAL › Subchapter 2 - HCFA COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:59-2.1 - Introduction

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey Medicaid/NJ FamilyCare Program utilizes the Centers for Medicare & Medicaid Services (CMS) Healthcare Common Procedure Coding System codes for 2006, established and maintained by CMS in accordance with the Health Insurance Portability and Accountability Act, of 1996, 42 USC §
										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, 52:14B-1 et seq. HCPCS follows the American Medical Association's Physicians' Current Procedural Terminology (CPT) architecture, employing a five-position code and as many as two 2-position modifiers. Unlike the CPT numeric design, the CMS-assigned codes and modifiers contain alphabetic characters. HCPCS was developed as a three-level coding system. Level I codes are not applicable to medical supplies and durable medical equipment. The level II and Level III codes are as follows:
1. LEVEL II CODES (Narratives found at 10:59-2.3 ) are assigned by the Centers for Medicare & Medicaid Services (CMS) for physician and non-physician services which are not in the CPT.
2. LEVEL III CODES (Narratives found in 10:59-2.3 ) are assigned by the Division to be used for those services not identified by CPT codes or CMS-assigned codes. Level III codes identify services unique to New Jersey.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 59 - MEDICAL SUPPLIER MANUAL › Subchapter 2 - HCFA COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:59-2.2 - Elements of HCPCS Coding System which require the attention of the provider

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The list of HCPCS procedure codes in 10:55-2.4 is arranged in tabular form with specific information for each code given under columns with the titles "HCPCS Code", "Description", and "Maximum Fee Allowance".
(b) The column titled "Maximum Fee Allowance" indicates the maximum amount of reimbursement or the following symbol:
1. "B.R." (By Report) is listed instead of a dollar amount. It means that additional information will be required in order to properly evaluate the service. Attach a copy of the provider's invoice or manufacturer's price list to the claim form.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:60-1.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this chapter is to explain the rules under which home care services are administered to those individuals determined eligible to receive such services on a fee-for-service basis.
(b) This chapter provides requirements for, and information about, the following services and programs:
1. Home health services;
2. Personal care assistant services;
3. Early and Periodic Screening, Diagnosis and Treatment/Private Duty Nursing (EPSDT/PDN) Services;
4. Home and Community-Based Services Waiver programs, which are administered by the Department of Human Services through 42 U.S.C. § 1915(c) waivers, as follows:
i. Home and Community-Based Services Waiver for Intellectually and/or Developmentally Disabled (DDD-CCW) Individuals; and
5. The New Jersey Comprehensive Waiver demonstration programs (Section 1115): NJ FamilyCare managed long-term services and supports (MLTSS).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:60-1.3 - Providers eligible to participate

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A home care agency or organization, as described at (a)1 through 4 below, is eligible to participate as a New Jersey Medicaid/NJ FamilyCare provider of specified home care services in accordance with N.J.A.C. 10:49-3.2:
1. A home health agency.
i. Out-of-State home health agencies providing services to Medicaid/NJ FamilyCare beneficiaries out of State, must meet the requirements of that state, including licensure, if applicable, and must meet all applicable Federal requirements;
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:60-1.4 - Out-of-State approved home health agencies

Current through Register Vol. 56, No. 14, July 15, 2024
For services rendered on or after January 1, 1999, out-of-State home health agencies shall be reimbursed using the prospective payment rate established pursuant to N.J.A.C. 10:60-2.5. There is no cost filing required. No retroactive settlement shall be made.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:60-1.5 - Limitations on home care services

Current through Register Vol. 56, No. 14, July 15, 2024
When the cost of home care services is equal to or in excess of the cost of institutional care over a protracted period (that is, six months or more), DDS or DMAHS retains the right to limit or deny the provision of home care services on a prospective basis.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:60-1.6 - Advance directives

Current through Register Vol. 56, No. 14, July 15, 2024
All agencies providing home health, private duty nursing, hospice, and personal care participating in the New Jersey Medicaid/NJ FamilyCare program are subject to the provisions of State and Federal statutes regarding advance directives and Practitioner Orders for Life Sustaining Treatment (POLST) forms including, but not limited to: appropriate notification to beneficiaries of their rights, development of policies and practices, as well as communication to and education of staff, community, and interested parties. Detailed information is located at N.J.A.C. 10:49-9.15, and sections 1902(a)(58), and 1902(w)(1) of the Social Security Act (42 U.S.C. §§
										1396a(a)(58) and 1396a(w)) .
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:60-1.7 - Relationship of the home care provider with the Medical Assistance Customer Center (MACC) and the NJ FamilyCare Managed Care Organization or DHS-designated entity

Current through Register Vol. 56, No. 14, July 15, 2024
Prior authorization shall be required for all Medicaid/NJ FamilyCare-eligible individuals and non-Medicaid/NJ FamilyCare eligible individuals applying for nursing facility (NF) services. Managed long-term services and supports (MLTSS) provided under the 1115 New Jersey Comprehensive Medicaid Waiver may require determination of clinical eligibility through the pre-admission screening (PAS) process. Division of Aging Services (DoAS) professional staff will conduct clinical eligibility assessments and/or determinations of individuals in health care facilities and community settings to evaluate eligibility for nursing facility level of care. Counseling on options for care including potential appropriate setting for the delivery of services is conducted by the Office of Community Choice Options (OCCO) or professional staff designated by DoAS.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:60-1.8 - Standards of performance for concurrent and post payment quality assurance review

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An initial visit to evaluate the need for home health services or personal care assistant (PCA) services for a fee-for-service beneficiary shall be made by the provider. For PCA services, the provider agency shall request prior authorization using form FD-365 and a State-approved PCA Assessment tool in accordance with procedures as described at N.J.A.C. 10:60-3.9. PCA services for fee-for-service beneficiaries shall not be rendered until authorization is provided by DDS.
1. On a random selection basis, MACC staff may conduct post-payment quality assurance reviews. At the specific request of the MACC, the provider shall submit a plan of care and other documentation for those Medicaid/NJ FamilyCare fee-for-service beneficiaries selected for a quality assurance review.
2. Upon completing the post-payment quality assurance review, the MACC shall forward a performance report to the provider, based on compliance with the standards described in this section.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:60-1.9 - On-site monitoring visits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For an accredited health care service firm, home health agency, or hospice agency, on-site monitoring visits will be made periodically by DDS or DMAHS staff, or by staff of an accreditation organization, as approved by DMAHS, to the agency to review compliance with personnel, recordkeeping, and service delivery requirements using forms as approved by either Division. The results of such monitoring visits shall be reported to the agency, by DDS or DMAHS, or by staff of an accreditation organization, as approved by DMAHS, and when indicated, a plan of correction shall be required. Continued non-compliance with requirements shall result in such sanctions as curtailment of accepting new beneficiaries for services, suspension, or rescission of the agency's provider agreement.
1. The professional staff from the MACC will use the standards listed in this chapter to conduct a post-payment quality assurance review of home care services as provided to the Medicaid/NJ FamilyCare fee-for-service beneficiary.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:60-1.10 - Provisions for fair hearings

Current through Register Vol. 56, No. 14, July 15, 2024
Providers and Medicaid/NJ FamilyCare-Plan A beneficiaries can request fair hearings as set forth in the Administration chapter at N.J.A.C. 10:49-9.14. NJ FamilyCare-Plan B and C fee-for-service beneficiaries can utilize the grievance board as set forth at N.J.A.C. 10:49-9.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 2 - HOME HEALTH AGENCY (HHA) SERVICES › Section 10:60-2.1 - Covered home health agency services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Home health care services covered by the New Jersey Medicaid/NJ FamilyCare fee-for-service programs are limited to those services provided directly by a home health agency approved to participate in the New Jersey Medicaid/NJ FamilyCare program or through arrangement by that agency for other services.
1. Medicaid/NJ FamilyCare reimbursement is available for these services when provided to Medicaid/NJ FamilyCare fee-for-service beneficiaries in their place of residence, such as a private home, residential hotel, residential health care facility, rooming house, and boarding home.
i. In residential health care facilities, homemaker-home health aide or personal care assistant services are excluded from Medicaid/NJ FamilyCare fee-for-service coverage.
ii. Home health services shall not be available to Medicaid/NJ FamilyCare fee-for-service beneficiaries in a hospital or nursing facility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 2 - HOME HEALTH AGENCY (HHA) SERVICES › Section 10:60-2.2 - Certification of need for home health services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) To qualify for payment of home health services by the New Jersey Medicaid/NJ FamilyCare fee-for-service program, the beneficiary's need for services shall be certified in writing to the home health agency by the attending physician/ practitioner. The nurse or therapist shall immediately record and sign verbal orders and obtain the physician's/practitioner's counter signature, within 30 days of the date of the order.
(b) Except as provided in (b)1 below, home health services shall not be provided or reimbursed, except when provided in accordance with all of the certification and face-to-face encounter provisions of Sections 6407(a) and (d), 3108 and 10605 of the Patient Protection and Affordable Care Act, 111 Pub.L. 148, as amended and supplemented, incorporated herein by reference, 42 U.S.C. §
										1395n, incorporated herein by reference, and 42 CFR 424.22(a) and (b), incorporated herein by reference.
1. Telehealth technology may be used to provide the face-to-face encounter required under (b) above.
2. The "face-to-face encounter" between an authorized physician/practitioner and a NJ Medicaid/ FamilyCare beneficiary for the initial certification for the provision of home care services must occur no more than 90 days prior to the date home care is started or within 30 days of the start of home care, including the date of the encounter.
i. Recertification of the need for home care services shall be done at least every 60 days and must be signed and dated by the physician/practitioner who reviews the plan of care. A face-to-face encounter is not required for recertification.
3. An authorized physician/practitioner must provide the home care provider the date, time, and location of the "face-to-face encounter" and his or her signature confirming that the encounter was conducted.
4. Home care providers are required to maintain proof of a "face-to-face encounter" including the date, time, location, and signature of the authorizing physician/practitioner. Such documentation may be subject to review by the New Jersey Department of Human Services or its authorized agent.
5. Failure to comply with the "face-to-face encounter" and documentation requirements in (b) and (b)2, 3, and 4 above, may result in the recoupment of Medicaid/NJ FamilyCare payments for home care services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 2 - HOME HEALTH AGENCY (HHA) SERVICES › Section 10:60-2.3 - Plan of care

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An interdisciplinary plan of care shall be developed by agency personnel in cooperation with the attending physician/practitioner, and be approved by the attending physician/practitioner. It shall include, but not be limited to, medical, nursing, therapies, nutrition, home health aide services, and social care information. The plan shall be re-evaluated by the nursing staff at least every 60 days and revised as necessary, appropriate to the beneficiary's condition. The following shall be part of the plan of care:
1. The beneficiary's major and minor impairments and diagnoses;
2. A summary of case history, including medical, nursing, and social data;
3. The period covered by the plan;
4. The number and nature of service visits to be provided by the home health agency;
5. Additional health related services supplied by other providers;
6. A copy of physician's/practitioner's initial orders and any subsequent verbal or written orders for changes to the plan of care;
7. Medications, treatments and personnel involved;
8. Equipment and supplies required;
9. Goals, long and short-term;
10. Preventive, restorative, maintenance techniques to be provided, including the amount, frequency and duration;
11. The beneficiary's, family's, and interested person's involvement (for example, teaching); and
12. Discharge planning in all areas of care (coordinated with short and long-term goals);
i. As a significant part of the plan of care, a beneficiary's potential for improvement shall be periodically reviewed and appropriately revised. These revisions shall reflect changes in the medical, nursing, social and emotional needs of the beneficiary, with attention to the economic factors when considering alternative methods of meeting these needs.
ii. Discharge planning shall take the beneficiary's preferences into account when changing the intensity of care in his or her residence, arranging services with other community agencies, and transferring to or from home health providers. Discharge planning also provides for the transfer of appropriate information about the beneficiary by the referring home health agency to the new providers to ensure continuity of health care.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 2 - HOME HEALTH AGENCY (HHA) SERVICES › Section 10:60-2.4 - Clinical records

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Clinical records containing pertinent past and current information, recorded according to accepted professional standards, shall be maintained by the home health agency for each beneficiary receiving home health care services. The clinical record shall include, at a minimum, the following:
1. A plan of care as described in 10:60-2.3;
2. Appropriate identifying information;
3. The name, address, and telephone number of beneficiary's physician/practitioner;
4. Clinical notes by nurses, social workers, and special therapists, which shall be written, signed and dated on the day each service is provided;
5. Clinical notes to evaluate a beneficiary's response to service on a regular, periodic basis, which shall be written, signed and dated by each discipline providing services;
6. Summary reports of pertinent factors from the clinical notes of the nurses, social workers, and special therapists providing services, which shall be submitted to the attending physician/practitioner at least every 60 days; and
7. When applicable, transfer of the beneficiary to alternative health care, which shall include transfer of appropriate information from the beneficiary's record.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 2 - HOME HEALTH AGENCY (HHA) SERVICES › Section 10:60-2.6 - Limitations on home health agency services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When the cost of home care services is equal to or in excess of the cost of institutional care over a protracted period (that is, six months or more), the Division retains the right to limit or deny the provision of home care services on a prospective basis.
(b) For limitations on Personal Care Assistant (PCA) services see 10:60-3.8.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 3 - PERSONAL CARE ASSISTANT (PCA) SERVICES › Section 10:60-3.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Personal care assistant services shall be provided by a certified licensed home health agency, a certified hospice agency or by a health care service firm that is accredited, initially, and on an on-going basis, by an accrediting body approved by DMAHS.
(b) Personal care assistant services include health-related tasks associated with the cueing, supervision, and/or completion of the activities of daily living (ADL), as well as instrumental activities of daily living (IADL) related tasks performed by a qualified individual in a beneficiary's place of residence or place of employment, or at a post-secondary educational or training program, under the supervision of a registered professional nurse, certified as medically necessary by a physician/practitioner in accordance with a written plan of care. These services are available from a home health agency, hospice agency, or a health care services firm. The purpose of personal care assistant services is to accommodate long-term chronic or maintenance health care, as opposed to short-term skilled care required for some acute illnesses.
1. Personal care assistant services are those services described at 10:60-3.3(a)1.
2. Instrumental activities of daily living are those activities described at N.J.A. C. 10:60-3.3(b).
3. Health related tasks are those services described at 10:60-3.3(a)3.
4. A qualified individual is a person who is a personal care assistant, as the term is defined at 10:60-1.2.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 3 - PERSONAL CARE ASSISTANT (PCA) SERVICES › Section 10:60-3.2 - Basis for reimbursement for personal care assistant services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Personal care assistant services shall be reimbursable when provided to Medicaid/NJ FamilyCare beneficiaries in their place of residence or place of employment, or at a post-secondary educational or training program. The term "place of residence" shall include, but is not limited to:
1. A private home;
2. A rooming house;
3. A boarding home (not Class C);
4. A Child Protection and Permanency resource family home;
5. A Division of Developmental Disabilities (DDD) group home, skill development home, supervised apartment, or other congregate living program where personal care assistance is not provided as part of the service package which is included in the beneficiary's living arrangement; or
6. Temporary emergency housing arrangements including, but not limited to, a hotel or shelter.