reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 6 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:54-6.2 - Scope of services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) HealthStart maternity care services shall include all medical services recommended by the American College of Obstetricians and Gynecologists (ACOG) and the American College of Nurse Midwives (ACNM), as well as a program of health support services. HealthStart pediatric care services shall include the nine preventive visits recommended by the American Academy of Pediatrics and all of the necessary immunizations. This subchapter includes provisions for provider participation, standards for service delivery, procedure codes from the CMS Healthcare Common Procedure Coding System (HCPCS) and directions for submitting claims.
(b) HealthStart Comprehensive Maternity Care includes two components; Maternity Medical Care Services and Health Support Services as follows:
1. Maternity Medical Care Services include, but are not limited to:
i. Ambulatory prenatal services;
ii. Admission arrangements for delivery;
iii. Obstetrical delivery services; and
iv. Postpartum medical services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 6 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:54-6.3 - HealthStart provider participation criteria

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Providers that are eligible to participate as HealthStart providers shall be: independent clinics (including local health departments meeting the New Jersey Department of Health and Senior Services Improved Pregnancy Outcome criteria); hospital outpatient departments; Federally Qualified Health Centers; physicians; certified nurse midwives; advanced practice nurses (APNs); and physician and/or practitioner groups, approved as providers in the New Jersey Medicaid/NJ FamilyCare program in accordance with N.J.A.C. 10:49 and 10:54-6.3.
(b) In addition to New Jersey Medicaid program rules applicable to provider participation, HealthStart providers shall:
1. Sign an Addendum to the New Jersey Medicaid Program Provider Agreement;
2. Have a valid "HealthStart Maternity Care Certificate" or a "HealthStart Maternity Medical Care Certificate" and/or a Pediatric Care Certificate; and
3. Provide maternity medical care and/or health support services, if applicable, or pediatric care services, in accordance with the requirements for issuance of "HealthStart Comprehensive Maternity Care Certificate" or "HealthStart Maternity Medical Care Certificate," and/or a "HealthStart Pediatric Care Certificate," and in accordance with the New Jersey State Department of Health and Senior Services Guideline for HealthStart Maternity Care Providers and HealthStart Pediatric Care Providers at N.J.A.C. 10:66-3.
4. Shall participate in program evaluation and training activities, including, but not limited to, site monitoring, agency and patient record review, and submission of required summary information on each patient according to the "New Jersey State Department of Health and Senior Services Guidelines for HealthStart Providers," as delineated in N.J.A.C. 10:66-3; and
5. Determine presumptive eligibility for the New Jersey Medicaid program, if approved to perform such determinations by the Division of Medical Assistance and Health Services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 6 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:54-6.4 - Termination of HealthStart certificate

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey State Department of Health and Senior Services will be 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.
1. Failure to comply with HealthStart Certificate Standards shall be cause for termination of the HealthStart provider certificate. Providers who are terminated shall have the right to request a hearing pursuant to the procedures in 10:49-10.10.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 6 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:54-6.5 - Standards for a HealthStart comprehensive maternity care provider certificate

Current through Register Vol. 56, No. 14, July 15, 2024
(a) HealthStart maternity care services shall be integrated and coordinated.
(b) HealthStart Maternity Care providers shall provide for comprehensive maternity care services, that is, maternity medical and health support services, as follows:
1. Providers shall provide directly or through approved agreements, at one contiguous site, the following services:
i. Ambulatory prenatal and postpartum care;
ii. Case coordination services;
iii. Nutrition assessment;
iv. Guidance and counseling services;
v. Health education assessment and instruction; and
vi. Social-psychological assessment, guidance and counseling.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 6 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:54-6.6 - HealthStart maternity care certificate; physicians or nurse midwives in private practice

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Physicians and certified nurse midwives in private practice shall meet the requirements in 10:54-6.5, except they may provide just the medical care component as long as they have entered into a written agreement with a single HealthStart provider who shall provide the HealthStart Health Support Services component. This agreement shall delineate which party shall take primary responsibility for the provision of all HealthStart services.
1. Separate certificates for each component shall be issued.
2. Two sites may be utilized only when one site for the provision of services is not feasible.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 6 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:54-6.7 - Access to service

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All HealthStart services shall be accessible to patients.
(b) HealthStart Maternity Care providers shall facilitate patient access to services by scheduling appointments for the HealthStart enrollment visit, the initial antepartum maternity medical care and other health support assessments within two weeks of the patient's first request for services. The initial antepartum maternity medical care visit shall be completed within two weeks of the patient's first visit and shall include, at a minimum, the following:
1. The medical history;
2. A risk assessment;
3. Collection of laboratory specimens;
4. A plan for continuing services;
5. A comprehensive physical examination; and
6. Routine counseling and treatment.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 6 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:54-6.8 - Plan of care

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Definition: A Plan of Care is a written document available to and used by all providers for the purpose of assuring the provision of comprehensive and coordinated care. The Plan of Care documents: the identified patient needs for medical, nutritional, social/psychological services (including financial assessment/Medicaid eligibility status); and health education services. It also shall document what services are to be provided and by whom; when the services are to be provided; and document when the services are completed.
(b) A Plan of Care shall be initiated during the first visit. The initial Plan of Care shall be completed after a case conference by the case coordinator and no later than one month after the initial maternity medical care visit.
(c) A Plan of Care shall include but not be limited to: identification of risk conditions and/or problems; prioritization of needs; outcome objectives; planned interventions; time frames; referrals and follow-up activities; and the identification of staff persons responsible for the services and for executing the Plan of Care.
(d) The Plan of Care shall be developed and maintained by the case coordinator for each patient in consultation with the patient and staff providing services.
(e) The Plan of Care shall be reviewed, updated and revised throughout the pregnancy, but at least once during each trimester and in the postpartum period.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 6 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:54-6.9 - HealthStart Maternity Medical Care Services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Maternity medical care services shall include antepartum, intra-partum and postpartum care provided by the obstetrical care practitioner(s) in accordance with the "New Jersey State Department of Health and Senior Services Guidelines for HealthStart Maternity Care Providers."
(b) Prenatal services are as follows:
1. The frequency of prenatal visits for an uncomplicated pregnancy shall be every four weeks during the first 28 weeks; then every two weeks until 36 weeks; and weekly thereafter; or in accordance with the standards recommended by the American College of Obstetrics and Gynecologists (ACOG) and/or the American College of Nurse Midwives (ACNM). Additional prenatal visits for complications should be scheduled as needed.
2. Initial prenatal visit content shall include, but not be limited to, the following:
i. History;
ii. Review of systems;
iii. Comprehensive physical examination;
iv. Risk assessment;
v. Patient counseling;
vi. Routine laboratory tests;
vii. Development of the Plan of Care;
viii. Special tests and/or procedures as medically indicated; and
ix. Determination of and arrangements for the delivery site.
3. Subsequent prenatal visit content shall include, but not be limited to, the following:
i. Review and revision of the patient Plan of Care;
ii. Interim history;
iii. Physical examination;
iv. Patient counseling and treatment;
v. Laboratory tests;
vi. Special tests and/or procedures which are medically indicated;
vii. Identification of new or developing problems;
viii. Management, including the transfer of any new or persistent problems;
ix. Review and update of the arrangements for the delivery site.
4. Transfer of prenatal records to the labor and delivery unit no later than 34 weeks gestation.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 6 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:54-6.10 - HealthStart health support services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Case coordination services shall facilitate the delivery of continuous, coordinated and comprehensive services for each patient in accordance with the "New Jersey State Department of Health and Senior Services Guidelines for HealthStart Maternity Care Providers," as follows:
1. A permanent case coordinator shall be assigned to each patient no later than two weeks after the HealthStart enrollment visit.
2. Prenatal case coordination responsibilities shall be clearly defined and shall include the accountability of the case coordinator for the provision of all services. These responsibilities shall include, but not be limited to, the following:
i. Orienting the patient to all services;
ii. Developing, maintaining and coordinating the Plan of Care in consultation with the patient and appropriate medical practitioners;
iii. Coordinating and monitoring the delivery of all services and referrals;
iv. Monitoring and facilitating the patient entry into and continuation with maternity services;
v. Facilitating and providing advocacy for obtaining referral services;
vi. Reinforcing health teachings and providing support;
vii. Providing vigorous follow-up for missed appointments and referrals;
viii. Arranging home visits;
ix. Meeting with the patient and coordinating patient care conferences;
x. Reviewing, monitoring and updating the patient's complete record;
xi. Vigorous follow-up for referrals; and
xii. Vigorous follow-up for final Medicaid eligibility determination.
3. Postpartum case coordination activities shall include, but not be limited to, the following:
i. Arranging and coordinating the postpartum visit and any home visit;
ii. Arranging with the obstetrical care provider to obtain the labor, delivery and postpartum hospital summary record information no later than two weeks after delivery;
iii. Linking the patient to appropriate service agencies including: the Special Supplemental Food Program for Woman, Infants and Children Program (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;
iv. Arranging for the transfer of pertinent information and records to the pediatric care and/or future family planning service providers when authorized by the patient;
v. Coordinating referrals and following up on missed appointments and referrals; and
vi. Reinforcing health instruction for mother and baby.
4. The case coordinator shall complete at the time of the termination of services and submit a Maternity Services Summary Data form to the New Jersey State Department of Health and Senior Services, HealthStart Program, per beneficiary for each pregnancy. Copies of this form are available from the New Jersey State Department of Health and Senior Services, HealthStart Program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 6 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:54-6.11 - Professional staff requirements for HealthStart comprehensive maternity services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All HealthStart Maternity Care services shall be delivered through an integrated approach by qualified professionals.
(b) Physicians and/or certified nurse midwives shall be Medicaid providers and have obstetrical admitting privileges at a licensed maternity care facility.
(c) Case coordinators shall have, as a minimum, a license as a registered nurse; or a Bachelor's degree in social work, health, or a behavioral science.
(d) Case coordinators shall discharge their responsibilities as defined in the "New Jersey State Department of Health and Senior Services Guidelines for HealthStart Maternity Care Providers" (N.J.A.C. 10:66-3 ).
(e) Health professionals shall have a valid license to practice their professions as required by the State.
(f) All other professionals, for whom no license to practice is required, shall meet generally accepted professional standards for qualification.
(g) Paraprofessionals must be familiar with the local community, have knowledge and/or skill in maternal and child health services and work under the direction of a health professional.
(h) Prenatal, delivery, and postpartum medical services must be delivered by physicians and/or certified nurse midwives.
(i) Nutrition, social-psychological and health education assessment and portions of the Plan of Care must be completed by the appropriate professionals in each of the specialty areas, or by case coordinators or maternity medical care professionals in accordance with the "New Jersey State Department of Health and Senior Services Guidelines for HealthStart Maternity Care Providers" (N.J.A.C. 10:66-3 ).
(j) Nutrition and social-psychological basic counseling shall be provided by case coordinators with at least one year experience providing care to maternity patients or by an appropriate specialist in each of the areas, or by registered nurses, or obstetrical care providers.
(k) Short-term specialized social-psychological and nutrition counseling services shall be provided by social workers and nutritionists, respectively. Social workers and nutritionists shall be available on site during patient visits.
(l) There shall be adequate professional, paraprofessional and clerical staff to provide, in a timely manner, maternity care services as described herein. Maternity medical care services which meet the needs of the patients shall be provided in accordance with the "New Jersey State Department of Health and Senior Services Guidelines for HealthStart Maternity Care Providers."
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 6 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:54-6.12 - Records: documentation, confidentiality and informed consent for HealthStart maternity care providers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) HealthStart Maternity Medical Care providers must have policies and procedures which protect patient confidentiality, provide for informed consent and document prenatal, labor, delivery and postpartum services in accordance with the "New Jersey State Department of Health and Senior Services Guidelines for HealthStart Maternity Care Providers" (N.J.A.C. 10:66-3 ).
(b) An individual record must be maintained for each patient throughout the pregnancy.
(c) Each record must be confidential and must include at least the following: history and physical examination findings; assessment; a Plan of Care; treatment services; laboratory reports; counseling and health instructions; documentation of referral and follow-up services; and the Medicaid eligibility status, including presumptive eligibility determination and follow-up, as appropriate.
(d) There shall be policies and procedures for appropriate informed consent for all HealthStart services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 6 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:54-6.13 - Standards for HealthStart pediatric care certificate

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Pediatric care services shall be comprehensive, integrated and coordinated.
(b) HealthStart Pediatric Care providers shall be Medicaid providers and shall:
1. Directly provide preventive, well-child care, maintenance of complete patient history, outreach for preventive care, initiation of referrals for appropriate medical, educational, social, psychological and nutrition services, and follow-up of referrals and sick care.
2. Directly provide or arrange for non-emergency room based, 24-hour physician telephone access to patients.
3. Directly provide or arrange for sick care and emergency care.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 6 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:54-6.14 - Professional requirements for HealthStart pediatric care providers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) HealthStart Pediatric Care Providers shall be primary care physicians or have a physician on staff who possesses a knowledge of pediatrics. This may be demonstrated by eligibility for board certification by the American Academy of Pediatrics, and/or having hospital admitting privileges in pediatrics, or by documentation of a formal arrangement with a physician who is board certified in pediatrics or family practice.
(b) Any HealthStart advanced practice nurse pediatric provider shall be a primary care provider who possesses a certificate as an APN with a specialization in pediatrics issued by the New Jersey State Board of Nursing, and by having hospital admitting privileges in pediatrics, or by the documentation of a formal arrangement with a physician who is board certified in pediatrics or family practice.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 6 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:54-6.15 - Preventive care services for 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 the New Jersey State Department of Health and Senior Services Guidelines for HealthStart Pediatric Care (N.J.A.C. 10:66-3 ). The schedule shall include a two to four week visit, two month visit, four month visit, six month visit, nine month visit, 12 month visit, 15 month visit, 18 month visit and 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. The HealthStart Child Health Preventive Visit form shall be completed for each HealthStart preventive visit.
(b) Each provider shall provide or arrange for sick care and twenty-four hour telephone physician access during non-office hours. If not directly provided by the HealthStart provider, sick care and twenty-four 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 shall not be permitted. Referral to the emergency room shall 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, encouraging the follow through of the referral. All of the activity shall be recorded on the patient's chart.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 6 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:54-6.16 - Referral services for HealthStart pediatric care providers

Current through Register Vol. 56, No. 14, July 15, 2024
All HealthStart 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 nutrition services. This may include, but is not limited to: the Supplemental Special Food Program for Women, Infants and Children program (WIC), the Division of Youth and Family Services, Special Child Health Services Case Management Units and Child Evaluation Centers, the early intervention programs, County Welfare Agencies/Board of Social Services, certified home health agencies, community mental health centers, local and county health departments.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 6 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:54-6.17 - 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 which protect patient confidentiality, provide for informed consent and document comprehensive care services in accordance with New Jersey State Department of Health and Senior Services Guidelines for HealthStart Pediatric Care Providers.
(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 54 - PHYSICIAN SERVICES › Subchapter 6 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:54-6.18 - Policy for reimbursement for HealthStart providers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The HealthStart HCPCS procedure codes listed in this subchapter are governed by the same policies and rules that appear in the HCPCS subchapter of each chapter concerning non-institutional provider services. (See the Chapters on Independent Clinic Services, (N.J.A.C. 10:66), Physician Services, (N.J.A.C. 10:54)) and the Nurse Midwivery Services, (N.J.A.C. 10:58). The maximum fee allowance schedule and reimbursement requirements for HCPCS HealthStart Maternity Codes (Medical Care and Health Support Services) and HCPCS HealthStart Pediatric Codes are listed under N.J.A.C. 10:49-8.19 and 8.20 respectively.
(b) A HealthStart Provider shall submit the same claim form presently in use for the type of service provided.
Physician services CMS 1500 Claim Form
Nurse Midwifery services CMS 1500 Claim Form
Independent clinics CMS 1500 Claim Form
Local Health Departments CMS 1500 Claim Form
Hospital Outpatient Departments--Use present procedure for billing except for HealthStart Health Support Services (W9040-W9043) and the HealthStart Pediatric Continuity of Care (W9070), which are billed on the CMS 1500 Claim Form.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 6 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES › Section 10:54-6.19 - HealthStart maternity care code requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) HealthStart Maternity Care code requirements are as follows:
1. Separate reimbursement shall be available for Maternity Medical Care Services and Maternity Health Support Services;
2. Maternity Medical Care Services shall be billed as a total obstetrical package, when feasible, but may be billed as separate procedures;
3. 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 Medical or Health Support Service;
4. The modifier "WM" in the HCPCS list of procedure codes refers to those services provided by certified nurse midwives who shall include the modifier at the end of each code; and
5. Laboratory and other diagnostic procedures and all necessary medical consultations shall be eligible for separate reimbursement.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 7 - PHYSICIAN SERVICES PROVIDED IN HOSPITALS AND NURSING FACILITIES › Section 10:54-7.2 - Pre-admission Screening and Resident Review (PASRR); Level I

Current through Register Vol. 56, No. 14, July 15, 2024
(a) PASRR Level I Identification Screens shall be required for individuals diagnosed as mentally ill, mentally retarded or with related conditions.
(b) An individual is considered to have a mental illness if he or she has a "serious mental illness such as: schizophrenia; mood disorder; paranoia; panic or other severe anxiety disorder;" listed in the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV), incorporated by reference herein, as amended and supplemented, which leads to a chronic disability and which meet the PASRR requirements on Diagnosis, Level of Impairment and Duration of Illness found in the PASRR Identification Criteria for Serious Mental Illness (SMI) and MR at 10:54-7.3.
1. An individual is considered to have dementia if he or she has a primary diagnosis of dementia, as described in the Diagnostic and Statistical Manual of Mental Disorders (Latest Edition).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 7 - PHYSICIAN SERVICES PROVIDED IN HOSPITALS AND NURSING FACILITIES › Section 10:54-7.3 - PASRR Level I; PASRR Identification criteria for serious mental illness (SMI) and mental retardation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The criteria for serious mental illness includes:
1. A diagnosis of a mental illness that may lead to chronic disability, such as, schizophrenia, mood disorder, paranoia, panic or other severe anxiety disorder, somataform disorder, personality disorder, or other psychotic disorder.
2. A disability showing that within the past 3 to 6 months, mental disorder has resulted in functional limitations in major life activities that would be appropriate for the client's developmental stage.
3. During the past two years and due to a mental illness, either or both of the following have occurred:
i. There were two or more treatment episodes of greater intensity than outpatient services, such as, inpatient, emergency or partial hospitalization care (include also single episodes lasting three months or more); and/or
ii. The normal living situation has been disrupted to the point that supportive services were required to maintain that client in that home or residence, or housing or law enforcement officials intervened.
NOTE: Psychotic drug use no longer constitutes a mandatory criteria for a PASRR Screen.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 7 - PHYSICIAN SERVICES PROVIDED IN HOSPITALS AND NURSING FACILITIES › Section 10:54-7.4 - PASRR Level II Screens

Current through Register Vol. 56, No. 14, July 15, 2024
(a) PASRR Level II screens shall be conducted for mentally ill or mentally retarded individuals only if the RSN's assessment or the assessment by the professional staff designated by the DHSS results in authorization for NF placement.
(b) Level II screens require that a psychiatric examination be performed by a Medicaid/NJ FamilyCare participating psychiatrist to determine the need for specialized services. (See 10:52-1.9(e).)
(c) Level II screens for mentally retarded individuals will be performed by the Division of Developmental Disabilities (DDD) to determine the need for specialized services. (See 10:52-1.9(d).)
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 7 - PHYSICIAN SERVICES PROVIDED IN HOSPITALS AND NURSING FACILITIES › Section 10:54-7.5 - PASRR Level II; Readmission following psychiatric hospitalization

Current through Register Vol. 56, No. 14, July 15, 2024
Readmission of an individual to a nursing facility following hospitalization in a psychiatric unit of an acute care hospital or from a psychiatric hospital for treatment of an acute episode of a serious mental illness is exempt from preadmission NF and Specialized Services screens. If the Minimum Data Set (MDS), which must be completed on admission, indicates a significant change in the resident's mental or behavioral status, the NF must immediately secure a resident review. If the resident's mental condition is stabilized, the resident review may be performed in the normal 12 cycle. In addition, if a resident is transferred from one NF to another, the discharging NF must forward to the admitting facility a copy of the most recent MDS, a copy of the most recent PASRR NF authorization letter and Specialized Services determination outcome.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 7 - PHYSICIAN SERVICES PROVIDED IN HOSPITALS AND NURSING FACILITIES › Section 10:54-7.6 - PASRR Level II; Alzheimer's or related dementias

Current through Register Vol. 56, No. 14, July 15, 2024
For individuals diagnosed with Alzheimer's or related dementias, documentation must be provided to the admitting Medicaid certified nursing facility for the individual's clinical record on the history, physical examination and diagnostic workup to support the diagnosis of dementia, Alzheimer's disease or related dementias.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 7 - PHYSICIAN SERVICES PROVIDED IN HOSPITALS AND NURSING FACILITIES › Section 10:54-7.7 - PASRR and PAS Screens; Necessity for nursing facility services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The determination of the necessity for NF services shall be performed through Pre-admission Screening (PAS) as mandated by 30:4D-17.1 0. The Regional Staff Nurse (RSN) or other professional staff designated by the DHSS shall determine the necessity for nursing facility services for Medicaid/NJ FamilyCare program beneficiaries and for individuals who may become Medicaid/NJ FamilyCare program beneficiaries within six months following admission to a Medicaid certified facility and for individuals identified as meeting PASRR Level I criteria.
(b) The PASRR Level II Screen prior to NF admission shall be performed by a psychiatrist and forwarded to the Division of Mental Health Services (DMHS) for final determination of the need for specialized services.
1. The hospital discharge planning unit and/or social services department shall immediately arrange through the individual's attending physician, a consultation by a board eligible or board certified hospital staff psychiatrist, who shall also be a Medicaid/NJ FamilyCare participating provider, to conduct the active treatment review and complete the "Psychiatric Evaluation" form. (The "Psychiatric Evaluation" form is not to be completed until such time as the RSN or other professional staff designated by the DHSS has approved placement in an NF.)
2. Within 48 hours of the psychiatrist's review of the beneficiary or potential Medicaid/NJ FamilyCare program beneficiary, the completed "Psychiatric Evaluation" form shall be sent to the Division of Mental Health Services, PO Box 727, Trenton, New Jersey 08625-0727, Attention: PASRR Coordinator.
i. A supply of the "Psychiatric Evaluation" form may be ordered from the PASRR Coordinator in the Division of Mental Health Services or downloaded from the Department's website. (See 10:54-7.2(e)  )
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 7 - PHYSICIAN SERVICES PROVIDED IN HOSPITALS AND NURSING FACILITIES › Section 10:54-7.8 - Physician services to the hospital patients

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Physician services that are rendered to a patient registered in the hospital outpatient department that are reimbursed as part of hospital costs shall not be billed directly by the physician to the Medicaid/NJ FamilyCare program. Any arrangement, contractual, employment, grant or otherwise, for payment of the physician(s) providing a service(s) to such a registered clinic patient is between the hospital and the physician(s). Physician services provided in the hospital outpatient department to Medicaid/NJ FamilyCare program beneficiaries that are not included in hospital costs may be billed by the physician directly to the New Jersey Medicaid/NJ FamilyCare program.
(b) For the hospital based physician providing services to an ambulatory non-registered (private) patient, the following applies:
1. This type of patient shall be considered to be the private ambulatory patient of a physician who has referred the patient to the hospital for the services provided, in part or whole, by a hospital based physician (for example, radiologist, pathologist, electrocardiographer, and so forth);
2. Such specific services are considered hospital costs when provided by the physician who is customarily reimbursed directly by the hospital, contractually or otherwise, and are not reimbursable directly to the referring physician.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 7 - PHYSICIAN SERVICES PROVIDED IN HOSPITALS AND NURSING FACILITIES › Section 10:54-7.9 - Psychiatric services; inpatient services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey Medicaid/NJ FamilyCare program recognizes as a covered service, a medically necessary inpatient service that is provided to a Medicaid/NJ FamilyCare program beneficiary in an approved private psychiatric hospital or the psychiatric section of an approved general hospital with the following limitation. (See 10:49-2.3(b)  for the Medically Needy program and the Hospital Services Chapter, 10:52-1.15, 2.9 and 4.2 for policies and procedures for hospital outpatient psychiatric services).
1. Reimbursement for either a psychiatric consultation, individual psychotherapy, family or group psychotherapy, or shock therapy shall be considered as inclusive for all psychiatric services performed on that day.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 7 - PHYSICIAN SERVICES PROVIDED IN HOSPITALS AND NURSING FACILITIES › Section 10:54-7.10 - Psychiatric services (including prior authorization); hospital outpatient and other settings

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following policies and procedures were developed to help ensure the appropriate utilization of hospital outpatient psychiatric services. These include the role of the evaluation team in relation to the patient's treatment regimen, with emphasis placed on intake evaluation, development of a Plan of Care (PoC), performance of periodic review for evaluation purposes, and supportive documentation for services rendered. (See 10:52-2.3 Recordkeeping and 10:66-2.5 for more specific policies and procedures for psychiatric (mental health services).
(b) Psychiatric services that are medically necessary rendered in an approved hospital outpatient department or in other settings, to a registered patient who is a Medicaid/NJ FamilyCare program beneficiary, shall not require prior authorization, except in the following situations:
1. Authorization for partial hospitalization and/or acute partial hospitalization services shall be provided in accordance with N.J.A.C. 10:52A, Psychiatric Adult Acute Partial Hospital and Partial Hospital Services.
2. Prior authorization is required for mental health services exceeding $ 900.00 in reimbursement to the physician rendered to a Medicaid/NJ FamilyCare program beneficiary in any 12-month service year, commencing with the patient's initial visit, when provided in other than an inpatient hospital setting. Reimbursement shall not be paid by the program for physician psychiatric services rendered to a registered hospital outpatient.
3. Prior authorization shall be required for mental health services exceeding $ 400.00 in payments in any 12-month service year rendered to a Medicaid/NJ FamilyCare program beneficiary residing in either a nursing facility or a residential health care facility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 8 - PHARMACEUTICAL SERVICES › Section 10:54-8.1 - Pharmaceutical; conditions for participation as provider of pharmaceutical services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All covered pharmaceutical services shall be provided under the New Jersey Medicaid program shall be provided to Medicaid/NJ FamilyCare program beneficiaries within the scope of N.J.A.C. 10:49, Administration; 10:51, Pharmaceutical Services; and this subchapter.
(b) All drugs shall be prescribed.
1. "Prescribed drugs" means simple or compound substances or mixtures of substances prescribed for the cure, mitigation, or prevention of disease, or for health maintenance, that are:
i. Prescribed by a practitioner licensed or authorized by the State of New Jersey, or the state in which he or she practices, to prescribe drugs and medicine within the scope of his or her license and practice;
ii. Dispensed by licensed pharmacists in accordance with rules promulgated by the New Jersey Board of Pharmacy, N.J.A.C. 13:39; and
iii. Dispensed by licensed pharmacists on the basis of a written prescription that is maintained in the pharmacist's records.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 8 - PHARMACEUTICAL SERVICES › Section 10:54-8.3 - 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, Pharmaceutical Services)
(b) The MEP shall be administered by a contractor, referred to as the MEP contractor, under a 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 54 - PHYSICIAN SERVICES › Subchapter 8 - PHARMACEUTICAL SERVICES › Section 10:54-8.4 - Pharmaceutical; Physician-administered drugs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey Medicaid/NJ FamilyCare program shall reimburse physicians 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:
1. Physician-administered medications shall be reimbursed directly to the physician. For this methodology, the physician is required to bill the appropriate "J" code in conjunction with the appropriate HCPCS procedure code as described below.
i. A "J" code may be billed in conjunction with an office, home, or independent clinic visit when the criteria for an office or home visit is met and the procedure code for the method of drug administration. The HCPCS 90799 may be billed for intradermal, subcutaneous, intramuscular, or intravenous drug administration. Other HCPCS procedure codes may be billed for the administration of allergy, chemotherapy or inhalation drugs.
ii. The New Jersey Medicaid/NJ FamilyCare program has assigned HCPCS procedure codes and Medicaid maximum fee allowances to certain, selected drugs for which reimbursement to the physician is based on the Average Wholesale Price (AWP) of a single dose of an injectable or inhalation drug or the physician's acquisition cost, whichever is less.
iii. Unless otherwise indicated in Subchapter 8 or under the exception listed in (a)2 and 3 below, the Medicaid maximum fee allowance is determined based on the AWP per unit which equals one cubic centimeter (cc) or milliliter (ml) of drug volume for each unit. For drug vials with a volume equal to one cubic centimeter (cc) or milliliter (ml), the Medicaid maximum fee allowance shall be based on the cost per vial.
iv. When a physician office, home, or independent clinic visit is for the sole purpose of administering a drug, the reimbursement shall include the cost of the drug and administration. In these situations, there is no reimbursement for a physician office, home, or independent clinic visit. If, in addition to the physician administration of a drug, the criteria of an office, home, or independent clinic visit is met, the cost of the drug and administration may, if medically indicated, be reimbursed in addition to the visit.
v. No reimbursement will be made for vitamins, liver or iron injections or combination thereof; except in laboratory-proven deficiency states requiring parenteral therapy.
vi. No reimbursement will be made for placebos or any injections containing amphetamines or derivatives thereof.
vii. No reimbursement will be made for injection given as a preoperative medication or as a local anesthetic which is part of an operative or surgical procedure, since this injection would normally be included in the prescribed fee for such a procedure.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 8 - PHARMACEUTICAL SERVICES › Section 10:54-8.5 - 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-Children's Program services. Medicaid and NJ FamilyCare-Children's Program will 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," effective March 9, 2009, 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-Children's 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.