New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 24 - WORK FIRST NEW JERSEY/GENERAL ASSISTANCE CLAIMS PROCESSING › Section 10:49-24.4 - Services that shall not be processed by the fiscal agent

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Consistent with
				10:90-13.1(a)2,
				the following services shall not be processed by the fiscal agent:
1. Case management for early intervention
				services;
2. Early and periodic
				screening, diagnosis, and treatment (EPSDT) screenings, and any other EPSDT
				services needed to ameliorate a defect if the services are otherwise not
				covered by the WFNJ/GA program;
3.
				EPSDT school-based or early intervention rehabilitation services;
4. Federally qualified health center
				encounter rates;
5. For individuals
				dually eligible for Medicaid and WFNJ/GA, any services that should have been,
				but were not, covered by an HMO to which the Medicaid program has made a
				payment, shall be provided or covered as a medical service;
6. HealthStart maternity and pediatric care
				services;
7. Inpatient or
				outpatient services/care provided by an enrolled hospital provider, either
				in-State or out-of-State, including, but not limited to, psychiatric hospitals,
				acute care hospitals, special hospitals, rehabilitation hospitals,
				non-religious medical institutions and county or State hospitals, except that:
i. Inpatient services provided by Mt. Carmel
				Guild Hospital located in Newark, New Jersey shall be processed by the fiscal
				agent; and
ii. Services provided by
				a hospital when that facility is not providing them as hospital services and is
				not enrolled as a hospital, including, but not limited to, hospital-based home
				health agency services, dental clinic services, end-stage renal dialysis
				services, hospital-based transportation services, and case management services
				for the chronically mentally ill, shall be processed;
8. Intermediate care facility for the
				mentally retarded (ICF/MR) services;
9. Managed care services;
10. Maternity services, including prenatal,
				delivery and postpartum services (through two months), provided by any type
				provider, including, but not limited to, physicians, certified nurse
				specialists/clinical nurse practitioners, certified nurse-midwives and
				clinics;
11. Nursing facility per
				diems;
12. Medical day care
				services;
13. Methadone maintenance
				services, identified by HCPCS Z2006, as set forth at
				10:66-6.3(m);
14. Physician, clinical laboratory, or other
				professional medical services provided while a WFNJ/GA eligible individual is a
				patient in a hospital, including an acute care hospital, special hospital,
				rehabilitation hospital, non-religious medical institution, ICF/MR, an
				inpatient psychiatric hospital, an inpatient psychiatric program for children
				under the age of 21 (residential treatment centers) or services provided to a
				WFNJ/GA eligible individual while in an outpatient hospital department or a
				hospital emergency room;
15.
				Professional services rendered to beneficiaries residing in a residential
				treatment facility for drug or alcohol abuse;
16. Services provided under a home and
				community based services waiver under section 1915(c) of the Social Security
				Act,
				42 U.S.C. §
											1396;
17. Services that would otherwise be covered
				under other health insurance coverage, including services that should have
				been, but were not, provided by an HMO that the WFNJ/GA eligible individual is
				enrolled in; and
18. Transportation
				services provided under contract with a vendor or through a contract with the
				county welfare agency.