New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 4 - FEDERALLY QUALIFIED HEALTH CENTER (FQHC) › Section 10:66-4.1 - Federally qualified health center (FQHC) services

Current through Register Vol. 56, No. 14, July 15, 2024
(a)
				Federally qualified health center (FQHC) services are services provided by
				physicians, physician assistants, advanced practice nurses, nurse midwives,
				psychologists, dentists, clinical social workers, and services and supplies
				incident to such services as would otherwise be covered if furnished by a
				physician or as incident to a physician's services.
1. FQHCs shall accommodate an outstationed
				county board of social services (CBOSS) employee(s) for the purpose of
				determining Medicaid and NJ FamilyCare eligibility, pursuant to
				42 U.S.C. §
											1396a(a)(55).
2. A medical encounter is a face-to-face
				contact between a beneficiary and a physician or other licensed practitioner
				acting within his or her respective scope of practice, including a podiatrist,
				optometrist, chiropractor, advanced practice nurse, or nurse midwife.
i. Normally, only one medical encounter is
				covered per beneficiary, per day. More than one medical encounter is covered,
				however, when the beneficiary is seen by more than one licensed practitioner
				for the prevention, treatment or diagnosis of different injuries or illnesses,
				and practitioners of appropriate different specialties are involved.
ii. More than one medical encounter is also
				allowed if a beneficiary leaves the center after having been seen by a
				practitioner, then returns to the center and is seen by another practitioner on
				the same day.
iii. More than two
				medical encounters during a week for a beneficiary require clear documentation
				in the beneficiary's medical record demonstrating the medical necessity of the
				encounter(s).
iv. Interpretation of
				results of tests or procedures not requiring face-to-face contact between a
				beneficiary and a practitioner, and referrals to specialists, do not constitute
				a medical encounter.
3.
				A psychiatric encounter is a face-to-face contact between a beneficiary and a
				licensed mental health professional in which a covered mental health clinic
				service is provided.
4. A dental
				encounter is a face-to-face contact between a beneficiary and a dentist or a
				licensed dental professional in which a covered dental procedure is provided.
				All procedures shall be administered by or under the direct supervision of a
				dentist.
i. Normally, only one dental
				encounter is covered per beneficiary, per day. Only one dental encounter is
				covered when the beneficiary is seen by a licensed general practitioner and a
				dental hygienist or when the beneficiary is seen by two general practitioners
				on the same date of service.
ii.
				More than one dental encounter is covered, however, when the beneficiary is
				seen by a licensed general practitioner and a licensed specialist, such as an
				oral surgeon or an endodontist.
iii. More than two dental encounters during a
				week for a beneficiary require clear documentation in the beneficiary's dental
				record demonstrating the medical necessity for the multiple
				encounters.
iv. Interpretation of
				results of tests or procedure results not requiring face-to-face contact
				between the beneficiary and practitioner and referrals to specialists do not
				constitute a dental encounter.
5. An Early and Periodic Screening, Diagnosis
				and Treatment (EPSDT) medical encounter is a face-to-face contact between a
				beneficiary and a physician or other licensed practitioner acting within his or
				her respective scope of practice, including a podiatrist, optometrist,
				chiropractor, nurse, practitioner, or nurse midwife in which a covered EPSDT
				service is provided.
6. An OB/GYN
				encounter is a face-to-face contact between a beneficiary and a physician or
				other licensed practitioner acting within his or her respective scope of
				practice, including, but not limited to, a certified nurse midwife, in which a
				delivery or approved OB/GYN surgical procedure listed on Table A or Table B on
				the Molina website is performed.
Delivery codes are listed on Table A. OB/GYN surgical codes
				  are listed on Table B. Tables A and B and annual updates are posted on the
				  Molina website:
www.njmmis.com
.