New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 164 - ADULT DAY HEALTH SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:164-1.3 - Program participation and evaluation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An adult day health services facility
				shall meet the following requirements in order to participate in the New Jersey
				Medicaid, HCEP or JACC programs:
1. Licensure
				and approval by the Department in accordance with the Standards for Licensure
				of Adult Day Health Services Facilities at N.J.A.C. 8:43F;
2. Completion of the New Jersey Medicaid
				Provider Application PE-1 (chapter Appendix A, incorporated herein by
				reference), the Participation Agreement PE-5 (chapter Appendix B, incorporated
				herein by reference) and a written narrative Statement on the Proposed Adult
				Day Health Services Facility (chapter Appendix C, incorporated herein by
				reference) and approval as a Medicaid adult day health services provider by the
				Department. The New Jersey Medicaid Provider Application (PE-1) and the
				Participation Agreement (PE-5) are also available by contacting Unisys for
				Medicaid participation at (800) 776-6334 and on the Worldwide Web at
www.njmmis.com
. Ongoing
				participation as a provider is contingent upon continued licensure and approval
				by the Department;
i. Adult day health
				services facilities providing services to JACC participants shall also be
				approved as a JACC provider/vendor by the Department.
3. For ADHS facilities, completion of a
				pre-numbered prior authorization request form for every individual or
				beneficiary to whom an ADHS facility intends to provide ADHS under the ADHS
				program prior to the initial provision of ADHS or the continuation of such
				services after an existing prior authorization term ends.
i. Pre-numbered prior authorization request
				forms are available upon request from UNISYS at (800) 776-6334 or on the
				Worldwide Web at
www.njmmis.com
.
ii. A facility shall contact the case or care
				manager for an adult individual or beneficiary who is a participant of any
				program listed at
				N.J.A.C.
				10:164-1.1(b)  that requires
				case or care management to obtain the date that the individual or adult
				beneficiary may begin receiving ADHS and the number of days per week he or she
				may receive such services as identified by his or her case or care manager
				pursuant to (a)3ii(1) below.
(1) The case or
				care manager for an individual or adult beneficiary who is a participant of any
				program listed at
				N.J.A.C.
				10:164-1.1(b)  that requires
				case or care management shall identify for an ADHS facility the number of days
				per week, not to exceed five days per week pursuant to
				N.J.A.C.
				10:164-1.4(a)3, and the date
				the individual or adult beneficiary may begin receiving ADHS if professional
				staff designated by the Department determine the individual or adult
				beneficiary is clinically eligible and the individual or adult beneficiary is
				determined to have obtained prior authorization for ADHS pursuant to
				N.J.A.C.
				10:164-1.5(f).
iii. An ADHS facility shall submit
				a completed pre-numbered prior authorization request form to the Department via
				telefacsimile at (609) 984-3897 or electronically, as specified by the
				Department, to the attention of the Office of Community Choice Options, Adult
				Day Health Services Program.
iv.
				An ADHS facility shall provide the following information on the pre-numbered
				prior authorization request form:
(1) An
				individual's or beneficiary's biographical and contact information, such as
				first and last name, address, telephone number, and social security
				number;
(2) The type of assistance
				an individual or beneficiary requires with regard to the ADLs, skilled
				services, or rehabilitation services, as provided at
				N.J.A.C.
				10:164-1.5(f);
(3) The contact information for the ADHS
				facility completing the pre-numbered prior authorization form, including the
				name and telephone and telefacsimile numbers of the facility, and title of the
				individual completing the form; and
(4) The scope and type of ADHS the facility
				intends to provide to that individual or beneficiary pursuant to
				N.J.A.C.
				10:164-1.5(f).
v. Submission of a pre-numbered
				prior authorization request form is the only mechanism for notifying the
				Department that:
(1) An ADHS facility is
				seeking prior authorization to provide ADHS to an individual or beneficiary who
				requires a clinical eligibility assessment for prior authorization pursuant to
				N.J.A.C.
				10:164-1.5; or
(2) An ADHS facility is seeking prior
				authorization to provide ADHS to a beneficiary who wishes to transfer from
				another adult ADHS facility pursuant to
				N.J.A.C.
				10:164-1.7.
4. Maintenance of a daily attendance record
				that includes the printed name and the arrival and departure times of each
				beneficiary attending on that day, signed by each adult beneficiary in
				acknowledgement of the beneficiary having been present for the time indicated
				and submission to the Department upon request of the Department of a completed
				Day Health Services Monthly Attendance Roster form CSS-11 posted at
www.nj.gov/health/forms
,
				with respect to all beneficiaries who attended at least one day that month.
i. The Day Health Services Monthly Attendance
				Roster form requires ADHS facilities to provide the following information: the
				name of the facility, the applicable month, the name of and Medicaid number for
				each beneficiary and each day the beneficiary attended the facility during the
				month of the roster.
ii. If an
				adult beneficiary is unable to sign the daily attendance record, the
				administrator of the facility or his or her designee shall attest in writing to
				the accuracy of the indicated arrival and departure times of the beneficiary,
				and the signed attestation shall be included as part of the daily attendance
				record maintained by the facility; and
5. Preparation of a complete financial
				statement and a cost report, annually detailing expenditures of the adult day
				health services facility. Adult day health services facility costs shall be
				segregated from other operational costs. (Department reimbursement rates may be
				based on cost report information or on a percentage of nursing facility per
				diem rates.) Cost reports shall be signed by the administrator or an officer of
				the facility. Cost reports shall include a statement that adult day health
				services costs have been verified as to type and amount. Financial statements
				shall be signed by a certified public accountant(s) licensed in accordance with
				N.J.A.C. 13:29. Financial statements shall include a statement that the
				financial statement has been prepared in accordance with generally accepted
				accounting principles and that all adult day health services costs have been
				verified as to type and amount.
i. Cost
				reports and financial statements shall be maintained at the facility and shall
				be available for review by, or submission to, the Department upon
				request.