NEW JERSEY ADMINISTRATIVE CODE

                                 TITLE 10. DEPARTMENT OF HUMAN SERVICES                     

CHAPTER 49. ADMINISTRATION MANUAL FOR MEDICAID SERVICES

SUBCHAPTER 1. GENERAL PROVISIONS

10:49-1.1 Scope and purpose

10:49-1.2 Organization 

10:49-1.3 Definitions 

10:49-1.4 Overview of provider manuals

10:49-1.5 (Reserved)

10:49-1.6 (Reserved)

10:49-1.7 (Reserved)

10:49-1.8 (Reserved)

SUBCHAPTER 2. NEW JERSEY MEDICAID BENEFICIARIES

10:49-2.1 Who is eligible for Medicaid? 

10:49-2.2 Persons eligible under the New Jersey Medicaid program 

10:49-2.3 Persons eligible under the Medically Needy program 

10:49-2.4 Persons eligible under Home and Community-Based Services Programs

10:49-2.5 Persons eligible under the NJ FamilyCare program 

10:49-2.7 Applying for Medicaid eligibility for a newborn infant or for an inpatient upon admission to a hospital

10:49-2.8 Presumptive eligibility 

10:49-2.9 Medicaid or NJ FamilyCare-Plan A retroactive eligibility

SUBCHAPTER 3. PROVIDER PARTICIPATION

10:49-3.1 Provider types eligible to participate 

10:49-3.2 Enrollment process

10:49-3.3 Providers with multi-locations  

10:49-3.4 Medicaid or NJ FamilyCare provider billing number 

SUBCHAPTER 4. PROVIDERS' ROLE IN A SHARED HEALTH CARE FACILITY

10:49-4.1 Definitions 

10:49-4.2 Scope

10:49-4.3 Registration of shared health care facilities 

10:49-4.4 Prohibited practices; administrative requirements 

10:49-4.5 Quality of care requirements 

SUBCHAPTER 5. SERVICES COVERED BY MEDICAID AND THE NJ FAMILYCARE PROGRAMS

10:49-5.1 Requirements for provision of services

10:49-5.2 Services available to beneficiaries eligible for, or children who are presumptively eligible for, the regular Medicaid and NJ FamilyCare-Plan A programs 

10:49-5.3 Services available to beneficiaries eligible for the Medically Needy program 

10:49-5.4 Emergency medical services for aliens and prenatal care for specified pregnant alien women 

10:49-5.5 Services not covered by the Medicaid or NJ FamilyCare-Plan A program 

10:49-5.6 Services available and unavailable to beneficiaries eligible for, or who are presumptively eligible for, NJ FamilyCare-Plan B or C 

10:49-5.7 Services available and unavailable to beneficiaries eligible for NJ FamilyCare-Plan D 

10:49-5.8 Services available for beneficiaries eligible for NJ FamilyCare Plan H 

10:49-5.9 Services available for beneficiaries eligible for NJ FamilyCare Plan G

SUBCHAPTER 6. AUTHORIZATIONS REQUIRED BY MEDICAID AND THE NJ FAMILYCARE PROGRAMS

10:49-6.1 Prior and retroactive authorization (general)

10:49-6.2 Out-of-State medical care and services 

SUBCHAPTER 7. SUBMITTING CLAIMS FOR PAYMENT (POLICIES AND REGULATIONS)

 10:49-7.1 General provisions 

10:49-7.2 Timeliness of claim submission and inquiry

10:49-7.3 Third party liability (TPL) benefits 

10:49-7.4 Prohibition of payment to factors 

10:49-7.5 Use of service bureau and/or management agency

SUBCHAPTER 8. PAYMENT FOR SERVICES PROVIDED

10:49-8.1 Fiscal Agent

 10:49-8.2 Claims payment and pricing 

10:49-8.3 Adjustments following payment of claims 

10:49-8.4 Claims payment by direct deposit (electronic funds transfer or EFT)

10:49-8.5 Outstanding checks

SUBCHAPTER 9. PROVIDER AND BENEFICIARY'S RIGHTS AND RESPONSIBILITIES;  ADMINISTRATIVE PROCESS

10:49-9.1 NJ FamilyCare-Plan C personal contribution to care and Plan D copayments

10:49-9.2 NJ FamilyCare-Plan C and D--premiums 

10:49-9.3 Limitation on cost sharing--Plan C 

10:49-9.4 Civil rights 

10:49-9.5 Observance of religious belief

10:49-9.6 Free choice by beneficiary and provider

10:49-9.7 Confidentiality of records 

10:49-9.8 Provider certification and recordkeeping

10:49-9.9 Patient's (beneficiary) certification 

10:49-9.10 Withholding of provider payments 

10:49-9.11 Integrity of the Medicaid and NJ FamilyCare programs; gifts/gratuities prohibited 

10:49-9.12 Fraud and abuse

10:49-9.13 Informing individuals of their rights 

10:49-9.14 Provisions for appeals;  fair hearings 

10:49-9.15 Advance directives

SUBCHAPTER 10. NOTICES, APPEALS AND FAIR HEARINGS

 10:49-10.1 Definitions 

10:49-10.2 Notices

10:49-10.3 Opportunity for fair hearing

10:49-10.4 Advance notice of intent to terminate, reduce, or suspend assistance for Medicaid and NJ FamilyCare-Plan A 

10:49-10.5 Location of hearing 

10:49-10.6 Impartiality of official conducting the hearing 

10:49-10.8 Hearing procedures 

10:49-10.9 Prompt, definitive and final action 

10:49-10.10 Notification to claimants 

10:49-10.11 Action upon favorable decision to claimants 

10:49-10.12 Hearing decision

10:49-10.13 Accessibility of hearing decisions to local agencies and the public 

SUBCHAPTER 11. EXCLUSION FROM PARTICIPATION IN THE NEW JERSEY MEDICAID AND NJ FAMILYCARE PROGRAMS (SUSPENSION, DEBARMENT, AND DISQUALIFICATION)

10:49-11.1 Program participation 

SUBCHAPTER 12. PROVIDER REINSTATEMENT

10:49-12.1 Definitions

10:49-12.2 Requests for reinstatement

10:49-12.3 Petition by debarred, disqualified or suspended person 

10:49-12.5 Provider Reinstatement Committee

10:49-12.6 Criteria for reinstatement 

10:49-12.7 Committee procedures 

SUBCHAPTER 13. PROGRAM CONTROLS

10:49-13.1 Medical review and evaluation

10:49-13.2 Audits 

10:49-13.3 Applicability to DMAHS programs of provisions relating to fraud and abuse, third party liability and administrative and judicial remedies

10:49-13.4 Rewards for information relating to fraud and abuse

SUBCHAPTER 14. RECOVERY OF PAYMENTS AND SANCTIONS

10:49-14.1 Recovery of payments correctly made

10:49-14.2 Sanctions--Special Status Program

10:49-14.3 Authority to adjust, compromise, settle or waive claims, liens, and certificates of debt 

10:49-14.4 Recoveries involving county board of social services (CBOSS)

10:49-14.5 Administrative charges/service fees 

10:49-14.6 Contracts with county boards of social services

SUBCHAPTER 15. AVAILABILITY AND MAINTENANCE OF PROGRAM POLICY ISSUANCES

10:49-15.1 Maintenance of public policy issuances

10:49-15.2 Availability of material

10:49-15.3 Reproduction of policy material

SUBCHAPTER 16. DEMONSTRATION PROJECTS

10:49-16.1 Purpose

10:49-16.2 Definitions 

10:49-16.3 Implementation of projects

10:49-16.4 Necessary criteria for a demonstration project

10:49-16.5 Sanctions related to demonstration projects

SUBCHAPTER 18. EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT)

10:49-18.1 Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

SUBCHAPTER 19. HEALTHSTART

10:49-19.1 HealthStart

SUBCHAPTER 21. THE MEDICAID MANAGED CARE PROGRAM--NJ CARE 2000

 10:49-21.1 Purpose and scope

10:49-21.2 Capitation payment system

10:49-21.3 Medicaid beneficiaries 

10:49-21.4 Medicaid Managed Care Program--New Jersey Care 2000 Services

SUBCHAPTER 22. HOME AND COMMUNITY-BASED SERVICES WAIVER PROGRAMS

 10:49-22.1 Introduction 

10:49-22.2 Approved Waivers 

10:49-22.3 Administration of waivered programs

10:49-22.4 Home and Community-Based Services Waivers 

10:49-22.5 Community Care Program for the Elderly and Disabled (CCPED) 

10:49-22.6 Medicaid's Model Waivers--I, II, and III 

10:49-22.7 AIDS Community Care Alternatives Program (ACCAP) 

10:49-22.8 Traumatic Brain Injury Program

SUBCHAPTER 23. LIFELINE PROGRAMS

10:49-23.1 Purpose and scope 

10:49-23.2 Applications 

SUBCHAPTER 24. WORK FIRST NEW JERSEY/GENERAL ASSISTANCE CLAIMS PROCESSING

10:49-24.1 Introduction 

10:49-24.2 Administrative provisions

10:49-24.3 Services available under the Work First New Jersey/General Assistance (WFNJ/GA) program 

10:49-24.4 Services that shall not be processed by the fiscal agent 

10:49-24.5 Basis for reimbursement 

APPENDIX

 SUBCHAPTER 1. GENERAL PROVISIONS

 10:49-1.1 Scope and purpose 

  (a) The Division of Medical Assistance and Health Services, under the Department of Human Services, is designated in accordance with 42 C.F.R. 412.30, as the single State agency for the administration of the New Jersey Medicaid program. Under the authority of N.J.S.A. 30:4D-1 et seq., as amended and supplemented, N.J.S.A. 30:4D-5, and pursuant to N.J.S.A. 30:4D-4, 30:4I-1 et seq. and 30:4J-1 et seq., the Division of Medical Assistance and Health Services is authorized to administer the Medicaid program as well as other special programs. This chapter provides general and specific information about the regular Medicaid program; special Medicaid services or programs (such as HealthStart, Prepaid Health Plans, and Waivered programs); the NJ FamilyCare programs and other special (State) funded Programs. 

  (b) Governor Whitman's Reorganization Plan No. 001-1996 gives the Department of Health and Senior Services (DHSS) legal authority to administer several components of the Medicaid program.  These components include nursing facility services, medical day care services, PreAdmission Screening (PAS) and PreAdmission Screening and Annual Resident Review (PASARR), the Community Care program for the Elderly and Disabled (CCPED) waiver, the Assisted Living/Alternate Family Care (AL/AFC) waiver, and peer grouping.  Rules for these Medicaid program components are promulgated by DHSS. Accordingly, providers must contact DHSS regarding requirements for these services.

   (c) Pursuant to N.J.S.A. 30:4D-1 et seq., as amended and supplemented, the Division of Medical Assistance and Health Services, under the Department of Human Services, is designated as the State agency responsible for the administration of the NJ FamilyCare program.

   (d) Unless otherwise specified, or clearly indicated otherwise in the context of the rule, the rules of the New Jersey Medicaid program and the rules of the Division of Medical Assistance and Health Services are equally applicable to the NJ FamilyCare program.

10:49-1.2 Organization 

  (a) Regarding the organization of the Division of Medical Assistance and Health Services, the Department of Human Services is the single State Agency for receipt of Federal funds under Title XIX (Medicaid) and Title XXI of the Social Security Act. The Division of Medical Assistance and Health Services, Department of Human Services, administers the New Jersey Medicaid and the NJ FamilyCare program through its Central Office and through Medical Assistance Customer Centers (MACCs) located throughout the State of New Jersey. A listing of the MACCs is provided in the chapter Appendix. The Division may also designate from time to time agencies which will assist in the administration of the NJ FamilyCare program. 

  1. The two programs are jointly financed by the Federal and State governments and administered by the State. The New Jersey Medicaid program is conducted according to the Medicaid State Plan approved by the Secretary, United States Department of Health and Human Services, through the Centers for Medicare & Medicaid Services (CMS). The NJ FamilyCare program is conducted according to the Title XIX and Title XXI State Plans approved by CMS.

10:49-1.3 Definitions 

  The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise. 

  "AFDC" means the former Aid to Families with Dependent Children program. 

  "AFDC-related Medicaid" means medical assistance provided to families who would otherwise qualify for AFDC or would be deemed to qualify for AFDC if the program would be deemed still in existence. 

  "American Indian/Alaska Native (AI/AN)" means a member of a Federally recognized Indian tribe, band, or group; an Eskimo or Aleut or other Alaska Native enrolled by the Secretary of the Interior pursuant to the Alaska Native Claims Settlement Act, 43 C.F.R. 1601 et seq.; or a person who is considered by the Secretary of the Interior as meeting the requirements of tribal membership in accordance with 42 C.F.R. 36a.16. 

  "Beneficiary or eligible beneficiary" means any person meeting the definition of recipient as defined below. 

  "Centers for Medicare and Medicaid Services (CMS)" means the agency of the Federal Department of Health and Human Services which is responsible for the administration of the Medicaid program in the United States. 

  "Commissioner of DHS" means the Commissioner of the Department of Human Services. 

  "Copayment" means a specified dollar amount required to be paid by or on behalf of the beneficiary in connection with benefits as specified in N.J.A.C. 10:49-9.1. 

  "County board of social services (CBOSS)" means that agency of county government which is charged with the responsibility for determining eligibility for public assistance programs including AFDC-Related Medicaid, Temporary Assistance to Needy Families, the Food Stamp program and Medicaid. Depending on the county, the CBOSS might be identified as the Board of Social Services, the Welfare Board, the Division of Welfare, or the Division of Social Services. 

  "Department" or "DHS" means the Department of Human Services.  The Department of Human Services is the single state agency designated by N.J.S.A. 30:4D-3 in accordance with 42 C.F.R. 412.30. 

  "DHSS" means the Department of Health and Senior Services. 

  "Division" or "DMAHS" means the Division of Medical Assistance and Health Services. 

  "DMHS" means the Division of Mental Health Services within the New Jersey Department of Human Services. 

  "DYFS" means the Division of Youth and Family Services within the New Jersey Department of Human Services. 

  "Fiscal agent" means an entity that processes and adjudicates provider claims on behalf of programs administered in whole or part by the Division. 

  "Medicaid" means medical assistance provided to certain persons with low income and limited resources as authorized under Title XIX (Medicaid) of the Social Security Act. 

  "Medicaid Agent" means, under Reorganization Plan No. 001-1996, either DHSS or DMAHS, acting as administrators of the Medicaid program. 

  "Mental health rehabilitation services" means psychiatric and psychological services, including emotional and/or behavioral treatment, drug and alcohol dependency treatment, psychiatric treatment, psychotherapy and related nursing services.

   "NJ FamilyCare" means the health insurance coverage program administered by DMAHS under the provisions of Title XIX and Title XXI of the Social Security Act. 

  "NJ FamilyCare-Plan A" means the State-operated program which provides comprehensive, managed care coverage, including all benefits provided through the New Jersey Care ... Special Medicaid Programs, to eligible children through the age of 18, and adults with family incomes up to and including 133 percent of the Federal poverty level. 

  "NJ FamilyCare-Plan B" means the State-operated program which provides comprehensive, managed care coverage to uninsured children through the age of 18 with family incomes above 133 percent and not in excess of 150 percent of the Federal poverty level. In addition to covered managed care services, eligibles may access mental health and substance abuse services and certain other services which are paid fee-for-service.

   "NJ FamilyCare-Plan C" means the State-operated program which provides comprehensive, managed care coverage to uninsured children through the age of 18 with family incomes above 150 percent and not in excess of 200 percent of the Federal poverty level. In addition to covered managed care services, eligibles may access mental health and substance abuse services and certain other services which are paid fee-for-service. Eligibles are required to participate in cost-sharing in the form of monthly premiums and personal contributions to care for certain services. 

   "NJ FamilyCare-Plan D" means the State-operated program which provides managed care coverage to uninsured children through the age of 18 and adults with gross family incomes above 200 percent and not in excess of 350 percent of the Federal poverty level. In addition to covered managed care services, eligibles may access certain services including mental health and substance abuse services, with limitations, which are paid fee-for-service. Eligibles participate in cost-sharing in the form of monthly premiums and copayments for most services. 

  "NJ FamilyCare Plan D for adults" means the State-operated program which provides a benefit package through managed care organizations, supplemented by services provided on a fee-for-service basis, to specified parents/caretakers of children enrolled in NJ FamilyCare, in accordance with N.J.A.C. 10:49-5.7, 10:78-7.1 and this chapter. 

  "NJ FamilyCare Plan I" means the State-operated program which provides a Plan D benefit package on a fee-for-service basis to specified parents/caretakers of children enrolled in NJ FamilyCare, in accordance with N.J.A.C. 10:78-7.1 and this chapter. 

  "Prepaid health plan" means an entity that provides medical services to enrollees under a contract with DMAHS on the basis of prepaid capitation fees but which does not necessarily qualify as an HMO.  For rules concerning prepaid health care services, see N.J.A.C. 10:49-1.1.  For Medicaid Managed Care Program--New Jersey Care 2000, see N.J.A.C. 10:49-21.

   "Program" means the New Jersey Medicaid program. 

  "Programs" means the New Jersey Medicaid program and the NJ FamilyCare program. 

  "Programs of Assertive Community Treatment (PACT)" means mental health rehabilitative services which are delivered in a self-contained treatment program, provided by a service delivery team and managed by a qualified program director, that merge clinical and rehabilitative expertise to provide mental health treatment, rehabilitation, and support services which are individualized and tailored to the unique needs and choices of the individual receiving the services. 

  "Provider" means any individual, partnership, association, corporation, institution, or any other public or private entity, agency, or business concern, meeting applicable requirements and standards for participation in the New Jersey Medicaid Program, other Special programs, and where applicable, holding a current valid license, and lawfully providing medical care, services, goods and supplies authorized under N.J.S.A. 30:4D-l et seq. and amendments thereto. 

  "Qualified applicant" means a person who is a resident of this State and is determined to need medical care and services as provided under the Medical Assistance and Health Services Act, N.J.S.A. 30:4D-1 et seq., and who meets one of the eligibility criteria set out therein. 

   "Recipient" means a qualified applicant receiving benefits under the Medical Assistance and Health Services Act, N.J.S.A. 30:4D-1 et seq. 

  "Temporary Assistance to Needy Families (TANF)" means that program administered by the Division of Family Development within the Department of Human Services in accordance with N.J.A.C. 10:90. 

10:49-1.4 Overview of provider manuals

   (a) The Medicaid Fiscal Agent and the Division of Medical Assistance and Health Services maintain New Jersey Medicaid and NJ FamilyCare provider manuals. Each is designed for use by a specific type of provider that provides services to Medicaid and/or NJ FamilyCare beneficiaries. Each manual is written in accordance with Federal and State laws, rules, and regulations, with the intent to ensure that such laws, rules, and regulations are uniformly applied. 

  (b) Each provider manual consists of two chapters, broken down into subchapters. The first chapter is referred to as N.J.A.C. 10:49, Administration Manual, and outlines the general administrative policies of the New Jersey Medicaid program and other special programs including NJ FamilyCare. The second chapter of each manual specifies the rules and regulations relevant to the specific provider-type and the services provided. Following the second chapter of the manuals is the Fiscal Agent Billing Supplement. 

  (c) Codification of manual material follows that of the New Jersey Administrative Code (N.J.A.C.). The citation for a particular section of the provider manual reflects the same material under the same citation in the N.J.A.C. The following is an example of a citation in the N.J.A.C. or a provider manual: 

             TABULAR OR GRAPHIC MATERIAL SET AT THIS POINT IS NOT DISPLAYED. 

  (d) There is an individual Program provider manual for each of the following services. These services are listed in the New Jersey Administrative Code (N.J.A.C.) under Title 10 (Department of Human Services) Chapters 10:50 through 10:75, and 10:77 through 10:79 as follows: 

        1.  10:50--Transportation Services Manual

        2.  10:51--Pharmacy Services Manual

        3.  10:52--Hospital Services Manual

        4.  10:53--(Reserved)

        5.  10:53A--Hospice Services Manual

        6.  10:54--Physician Services Manual

        7.  10:55--Prosthetic and Orthotic Services Manual

        8.  10:56--Dental Services Manual

        9.  10:57--Podiatry Services Manual

      10.  10:58--Nurse-Midwifery Services Manual

       11.  10:58A--Certified Nurse Practitioner/Clinical Nurse Specialist

       12.  10:59--Medical Supplier Services Manual

       13.  10:60--Home Care Services Manual

       14.  10:61--Independent Clinical Laboratory Services Manual

       15.  10:62--Vision Care Services Manual

       16.  10:63--Long Term Care Services Manual

       17.  10:64--Hearing Aid Services Manual

       18.  10:65--Medical Day Care Services Manual

       19.  10:66--Independent Clinic Services Manual

       20.  10:67--Psychological Services Manual

       21.  10:68--Chiropractic Services Manual

       22.  10:69 AFDC-Related Medicaid

       23.  10:70 Medically Needy Manual

       24.  10:71 Medicaid Only Manual

       25.  10:72 New Jersey Care ... Special Medicaid Programs Manual

       26.  10:73--Case Management Services Manual

       27.  10:74--Managed Health Care Services for Medicaid Eligibles

       28.  10:75 Programs of Assertive Community Treatment

       29.  (Reserved) 

       30.  10:77 Rehabilitation Services Manual

       31.  10:78 NJ FamilyCare Manual

       32.  10:79 NJ KidCare Manual

  (e) Manual updates, revised pages or additions to the provider manual are issued, as required, for new policy, policy clarification, and/or revisions to the New Jersey Medicaid or NJ FamilyCare program. A newsletter system is utilized to distribute new or revised manual material and to provide any other pertinent information regarding manual updates. Newsletters should be filed at the back of the manual and replacement pages should be added to the manual in accordance with instructions provided. Substantive manual revisions shall be made through the rulemaking process, in accordance with the Administrative Procedure Act, N.J.S.A. 52:14B-1 et seq. 

  (f)  This manual and all subsequent updates are distributed as a guide to assist providers in their participation in the New Jersey Medicaid or NJ FamilyCare program. The provider is ultimately responsible for knowing and abiding by current Federal and State laws and regulations pertaining to this program.

10:49-1.5 (Reserved)

10:49-1.6 (Reserved)

10:49-1.7 (Reserved)

10:49-1.8 (Reserved)

SUBCHAPTER 2. NEW JERSEY MEDICAID BENEFICIARIES

10:49-2.1 Who is eligible for Medicaid? 

  Medicaid beneficiaries are: those eligible for all services under the regular New Jersey Medicaid program (see N.J.A.C. 10:49-2.2 below); those eligible for a limited range of services under the Medically Needy program (see N.J.A.C. 10:49-2.3 below) and those eligible for a limited range of services under the Home and Community-Based Services Waiver Programs, in accordance with N.J.A.C. 10:49-22.

10:49-2.2 Persons eligible under the New Jersey Medicaid program 

  (a) The eligibility rules for persons eligible under the regular New Jersey Medicaid program are included in N.J.A.C. 10:69, 10:70, 10:71, 10:72, 10:78 and 10:79. 

  (b) The following groups may be eligible for medical and health services covered under the New Jersey Medicaid program requirements as outlined in the second chapter of each Provider Services Manual. The list is not all inclusive but is intended to provide an overview of some of the types of individuals who may be eligible for Medicaid benefits, when provided in accordance with the requirements of N.J.A.C. 10:69, 10:70, 10:71, 10:72, 10:78 and 10:79, as appropriate. 

  1. Persons who are eligible to receive Supplemental Security Income (SSI) payments as determined by the Social Security Administration and those persons who meet the SSI standards but apply for the Medicaid Only program through the CBOSS. Those persons are the aged (65 and over), the blind, and the disabled; 

  2. A person who qualifies under the Supplemental Security Income (SSI) program as the "ineligible spouse" of an SSI beneficiary determined by the Social Security Administration; 

  3. For a period of one year, a child born to a woman who is a Medicaid beneficiary, so long as the woman remains eligible for Medicaid, or would remain eligible if pregnant; 

  4. Persons for whom adoption assistance agreements are in effect pursuant to Section 473 of the Social Security Act (42 U.S.C. s 673) or for whom foster or adoption assistance is paid under Title IV-E of the Act; 

  5. Persons ineligible for Supplemental Security Income (SSI) because of requirements that do not apply under Medicaid; 

   6. Persons receiving only mandatory State supplemental payments administered by the Social Security Administration; 

  7. Certain former beneficiaries of Supplemental Security Income (SSI) who would still be eligible for SSI except for entitlement to or increase in the amount of Social Security benefits; 

  8. Persons eligible for but not receiving TANF or an optional State benefit; 

  9. Children under the age of 21 years who meet the income and resource requirements for TANF but do not qualify as dependent children; 

  10. Persons who are in institutions for at least 30 consecutive days and who are eligible under a special income level (the Medicaid "cap") that is higher than the income level for a noninstitutionalized SSI or State supplement beneficiary; 

  11. Pregnant women and children up to the age one whose income is below 185 percent of the Federal poverty level, and children up to the age of six whose income is below 133 percent of the Federal poverty level, codified as 42 U.S.C. s 1396a, or 1902(l) of the Social Security Act; 

  12. Aged, blind, and disabled persons whose income is below 100 percent of the Federal poverty level and whose assets are within 200 percent of the SSI asset limits; 

  13. For a period lasting through the end of the month following the 60th day following delivery, women who have applied for Medicaid benefits before the last day of pregnancy and who are eligible for Medicaid on the last day of pregnancy; and 

  14. Refugees who are eligible under the Refugee Resettlement program.

10:49-2.3 Persons eligible under the Medically Needy program 

  (a) The eligibility rules for persons eligible under the Medically Needy program are included in N.J.A.C. 10:70. 

  (b) A Medicaid beneficiary under the Medically Needy program is limited to those medical services listed in N.J.A.C. 10:49-5.3.  Services shall be provided in conjunction with specific program requirements as outlined in the second chapter of the applicable Provider Services Manual. 

  (c) To be determined Medically Needy under the Medicaid Program, it is necessary for the person to meet categorical eligibility requirements, have income and/or resources in excess of the categorical standards, and have insufficient funds to meet his or her medical expenses.  Medically Needy persons shall be in one of the following groups:

   1. Pregnant women; 

  2. Needy children (under 21 years of age);  or 

  3. The aged (65 years of age or older), the blind or the disabled. 

  (d) There are special income and resource levels established for the Medically Needy.  If a person meets one of the categories listed in (c) above and has income and/or resources above categorical program levels but less than or equal to the Medically Needy income and resource levels, he or she shall be determined as Medically Needy eligible.  However, if a person meets one of the categories listed in (c) above and meets the Medically Needy resource level but has income which exceeds the Medically Needy income level, eligibility may be established through the "spend-down" process. 

  1. "Spend-down" is the process whereby a person may apply incurred medical expenses to offset income above the Medically Needy income level, and thereby adjust his or her income to meet the Medically Needy income limit. 

  (e) Medically Needy eligibility for all groups, including the aged, blind and disabled, shall be determined by the CBOSS for both the retroactive and prospective period. 

  1. Each Medically Needy applicant/beneficiary shall reapply for benefits every six months.  Eligibility may be established the first day of that six-month period or on any date during the six-month period that spend-down is met. 

  2. Eligibility shall be verified by providers on each visit by reviewing the Medicaid Eligibility Identification Card (MEI) (FD-73/l78) (see N.J.A.C. 10:49-2.14--Validation Form). For those cards issued for the month within the six month period in which the spend-down is met, the card will reflect the date that eligibility begins after the spend-down is met. 

  (f) Claims for Medically Needy covered services provided during an eligible period may be submitted to the program for reimbursement using standard Medicaid procedures. Services provided prior to the effective date of eligibility shall be the client's liability, except for certain "special" claims. 

  1. "Special" claims are claims for Medically Needy covered services that were not used to meet the spend-down and were rendered between the first of the month in which eligibility is established and the date of eligibility that appears on the Medicaid Eligibility Identification Card. 

  2. The CBOSS shall identify "special" claims which may be reimbursed under the program and shall provide a Medically Needy Claim Transmittal (Form FD-311, see Appendix, N.J.A.C. 10:49). Such claims shall be submitted hard copy with Form FD-311 attached.

10:49-2.4 Persons eligible under Home and Community-Based Services Programs

   (a) Individuals who may not be eligible for regular Medicaid benefits or Medical Needy may be eligible for selected services under the Home and Community-Based Services Waiver Programs under special eligibility rules.  A brief overview of these programs and their rules may be found at N.J.A.C. 10:49-22.

10:49-2.5 Persons eligible under the NJ FamilyCare program 

  Children under the age of 19 whose family income does not exceed 133 percent of the Federal poverty level may be eligible for NJ FamilyCare--Plan A services pursuant to the eligibility rules at N.J.A.C. 10:78 and 10:79.

10:49-2.6 Eligibility process (variations to routine procedure) 

  There are variations to the routine procedure for determining Medicaid eligibility.  These variations are relevant to applying for eligibility for a newborn infant or for an inpatient upon admission to a hospital (see N.J.A.C. 10:49-2.7);  to determining presumptive eligibility for pregnant women (see N.J.A.C. 10:49-2.8);  and to determining retroactive eligibility (see N.J.A.C. 10:49-2.9).

10:49-2.7 Applying for Medicaid eligibility for a newborn infant or for an inpatient upon admission to a hospital

   (a) There are limited variations to the eligibility process for a newborn infant of a woman who is a Medicaid beneficiary.  The policy and procedures follow: 

  1. Although both the mother and newborn infant may be Medicaid beneficiaries on the date of delivery, the newborn infant is not immediately assigned a Person Number (see N.J.A.C. 10:49-2.12).  In order to expedite payment to any provider before this number is assigned, the provider is permitted to bill for services provided to the newborn using the mother's Medicaid Eligibility Identification Number and Person Number on the claim form. 

  2. The period for which newborn services may be billed under the mother's Medicaid Eligibility Identification Number and Person Number shall extend from the date of birth until the last day of the month in which a 60 day time frame ends, or until the newborn is assigned his or her own Person Number, whichever happens first. 

  Example:  If a newborn's date of birth is January 5th, the 60 day period ends March 6th.  Claims may be submitted for dates of service through March 31st using the mother's Medicaid Eligibility Identification Number and Person Number, provided the newborn has not been assigned his or her own Person Number in the meantime.  Claims for services provided to the newborn after March 31st would be processed only if the required information about the newborn is used (Person Number, name, age, sex, etc.). 

  3. The newborn's Person Number shall be used as soon as it is available to the provider.  The practitioner or any other type of provider shall request the newborn's Person Number from the mother at each encounter. 

  4. Billing instructions for services provided a newborn infant under his or her mother's Medicaid Eligibility Identification Number and Person Number are provided in the Fiscal Agent Billing Supplement following the second chapter of each Provider Services Manual, as applicable. 

  (b) The following procedures shall apply when application is made for Medicaid eligibility for an inpatient upon admission to a hospital: 

    1. A hospital may submit a "Public Assistance Inquiry" (Form PA-1C, see Appendix, N.J.A.C. 10:49) when an individual is admitted to the facility and financial or medical indigency is a factor in the coverage of care. Under this arrangement, if the patient is determined to be eligible for Medicaid, the effective date of eligibility is the date of the hospital inquiry. 

   i. A PA-1C Form should be directed to either the Social Security Administration District Office in the area where the hospital  is located or the CBOSS as follows: 

    (1) The Social Security Administration is responsible for establishing Medicaid eligibility for the aged (persons 65 years and over), for the blind, and for the disabled who apply for Supplemental Security Income (SSI). 

    (2) The CBOSS is responsible for establishing Medicaid eligibility for the individual who applies for AFDC-Related Medicaid (AFDC), or for the individual who is aged, blind, or disabled and applies for "Medicaid Only," or for any individual who applies for New Jersey Care ... Special Medicaid Programs. 

  2. Before preparing a PA-1C Form, the hospital shall screen the patient to determine the following: 

   i. Whether the patient is already eligible for Medicaid or whether the patient's income and/or resources meet the applicable public assistance standard;  and 

   ii. Whether the patient falls into a category of eligibility, for example, aged, disabled, blind, pregnant under 21 years of age, or a member of a family with children under 18 years of age. 

  3. In the event that the date of the Medicaid eligibility which was established by the Social Security Administration or the CBOSS is later than the date of admission, the beneficiary may apply directly to the New Jersey Medicaid program for retroactive Medicaid payment of unpaid bills for allowable medical services within the three month period prior to the month of application (see N.J.A.C. 10:49-2.9).

10:49-2.8 Presumptive eligibility 

  (a) "Presumptive eligibility" means an expedited process whereby selected certified HealthStart Comprehensive Maternity Care providers make preliminary Medicaid eligibility determinations on behalf of pregnant women (see HealthStart in applicable Provider Services Manuals and N.J.A.C. 10:49-19). This is a preliminary process to determine presumptive eligibility prior to the determination of Medicaid eligibility or ineligibility by the CBOSS. 

  1. Approved HealthStart Maternity Care providers (independent clinics and hospital outpatient departments) may determine presumptive eligibility for pregnant women who require ambulatory prenatal services from Medicaid participating providers. 

  (b) A presumptively eligible pregnant woman is entitled to all Medicaid covered services with the exception of inpatient hospital and nursing facility care services.  Although Medicaid HealthStart services must be provided only by a HealthStart provider, other Medicaid covered services may be provided to a presumptively eligible pregnant woman by any appropriate Medicaid provider. 

  (c) A presumptively eligible pregnant woman is eligible for a period of time which will end: 

  1. If the woman has not filed an application with the CBOSS, on or before the last day of the month subsequent to the date of the presumptive eligibility determination; or 

  2. If the woman has filed an application with the CBOSS, by the last day of the month subsequent to the month in which she was determined presumptively eligible, or on the day eligibility or ineligibility for Medicaid benefits is determined by the CBOSS. 

  (d) A presumptively eligible pregnant woman is identified by the two messages which appear on the "Medicaid Eligibility Identification Card" (Form FD-73/178) (see Appendix, N.J.A.C. 10:49). One message is above the woman's name on the upper left side: CLIENTS: YOU MUST CONTACT THE CBOSS FOR FULL BENEFITS; P.E. IS TEMPORARY AND LIMITED. The second message, which appears in the message box on the upper right hand corner instructs the provider to call a toll-free number to verify eligibility before providing services. This card is the only document acceptable for the identification of a presumptively eligible pregnant woman. 

  1. As part of the presumptive eligibility process, a presumptively eligible pregnant woman will be given an FD-334 Form, Certification of Presumptive Eligibility (see Appendix, N.J.A.C. 10:49).  This is not valid proof of eligibility for Medicaid and should not be used by the provider for presumptive eligibility purposes.  A request for reimbursement based solely upon the presentation of the FD-334 form does not guarantee payment. 

  2. Even with the identification through the MEI Card, each time a service is rendered the provider shall verify the presumptive eligibility status of a pregnant woman, prior to the delivery of ambulatory services, by calling the toll free telephone number listed on the MEI Card which is available seven days a week, 24 hours a day. 

  3. A provider's failure to verify eligibility prior to the delivery of services shall result in the denial of payment for those services if the individual was not eligible at that time.  The provider should note that a pregnant woman's presumptive eligibility may be terminated at any time.

10:49-2.9 Medicaid or NJ FamilyCare-Plan A retroactive eligibility 

  (a) Any person applying for Medicaid or NJ FamilyCare-Plan A benefits shall be asked if he or she has unpaid medical bills incurred within the three month period immediately prior to the month of application for Medicaid or NJ FamilyCare-Plan A. 

  1. Medically Needy applicants (see N.J.A.C. 10:49-2.3(f)) shall be evaluated for retroactive eligibility by the county board of social services (CBOSS) when they apply for the Medically Needy program. 

  2. An applicant for NJ FamilyCare-Plan A whose application was processed by the Statewide eligibility determination agency has his or her retroactive eligibility processed by that agency. The applicant must indicate on his or her NJ FamilyCare-Plan A application that unpaid medical bills exist in the retroactive period or shall contact the Statewide eligibility determination agency within six months of his or her application date for NJ FamilyCare-Plan A.

   3. Applicants who applied for Medicaid or NJ FamilyCare-Plan A at a CBOSS other than Essex, Hunterdon or Warren Counties, shall have their retroactive eligibility evaluated and processed at that CBOSS when they apply for Medicaid or NJ FamilyCare-Plan A. If the applicant does not indicate to the CBOSS that unpaid medical bills exist at the time of application, the applicant shall provide that information to the CBOSS within six months of the date of application. If retroactive eligibility is not requested from the CBOSS within six months from the date of application, retroactive eligibility will not be established. 

  4. Medicaid or NJ FamilyCare-Plan A Applicants who applied for benefits at the CBOSS in Essex, Hunterdon or Warren counties or who applied for Supplemental Security Income (SSI) may complete an FD-74 Form, Application for Payment of Unpaid Medical Bills (see Appendix, N.J.A.C. 10:49) and forward the application with required verification and all outstanding unpaid medical bills to the Medicaid Retroactive Eligibility Unit, Division of Medical Assistance and Health Services, PO Box 712, Mail Code #10, Trenton, New Jersey 08625-0712. An application for retroactive eligibility may be obtained by the applicant, or his or her authorized agent, from the CBOSS, the Medical Assistance Customer Center (MACC), the Social Security Administration District Office, or from the Retroactive Eligibility Unit, Division of Medical Assistance and Health Services. The application shall be received by the Retroactive Eligibility Unit within six months from the date of application for public assistance. 

     *29209 5. Applications for retroactive unpaid medical bills cannot be processed for services rendered prior to the effective date of the program. For NJ FamilyCare-Plan A, children eligible under N.J.A.C. 10:79-3.4(b), the effective date is February 1, 1998. For NJ FamilyCare parents, the effective date is September 6, 2000. 

  (b) If the Division of Medical Assistance and Health Services Retroactive Eligibility Unit determines that the person was eligible for Medicaid or NJ FamilyCare-Plan A at the time the service was provided, providers shall be notified directly that the unpaid bills for any service covered by the New Jersey Medicaid program or NJ FamilyCare-Plan A may be reimbursable in accordance with standard Medicaid and NJ FamilyCare reimbursement procedures. 

  1. The provider shall then complete the appropriate claim and submit it to the Fiscal Agent for consideration and authorization of payment within 90 days of the date the provider is notified in writing of the retroactive eligibility. 

  2. When the Retroactive Eligibility Unit approves retroactive eligibility more than one year after the date(s) of service, the Retroactive Eligibility Unit will send a special notification letter to the provider. The provider shall attach the original notification letter to the claim and shall manually submit the claim to the Medicaid fiscal agent at the address listed on the letter. The claim and the attached letter must be received by the Medicaid fiscal agent within 90 calendar days of the date on the special notification letter. 

  3. For any Medically Needy beneficiary, a retroactive eligibility determination shall be completed by the CBOSS (see N.J.A.C. 10:49-2.3 Persons eligible under the Medically Needy program).

SUBCHAPTER 3. PROVIDER PARTICIPATION

10:49-3.1 Provider types eligible to participate 

  (a) The following provider types are eligible to participate as Medicaid/NJ FamilyCare-Plan A providers: 

  1. Case managers; 

  2. Certified nurse practitioners/clinical nurse specialists; 

  3. Chiropractors and/or chiropractic groups; 

  4. Clinics (independent outpatient health care facilities); 

  5. Clinical laboratories; 

  6. Dentists and/or dentist groups; 

  7. Hearing aid dealers;

   8. Health maintenance organizations/managed care organizations; 

  9. Home health agencies; 

  10. Homemaker agencies; 

  11. Hospices; 

  12. Hospitals; 

   i. General; 

   ii. Psychiatric;  and 

   iii. Special; 

  13. Local health departments; 

  14. Nursing facilities, including intermediate care facilities for the mentally retarded; 

  15. Medical suppliers; 

  16. Mental health rehabilitation providers: 

   i. Residential child care facilities (see N.J.A.C. 10:77 and 10:127); 

   ii. Children's group homes (see N.J.A.C. 10:77 and 10:128); 

   iii. Psychiatric community residences for youth (see N.J.A.C. 10:37B and 10:77); and 

   iv. Programs for Assertive Community Treatment (PACT) Agencies/Teams (see N.J.A.C. 10:37J and 10:76). 

  17. Medical day care centers; 

  18. Nurse-midwives; 

  19. Opticians; 

  20. Optometrists; 

  21. Orthotists; 

  22. Pharmacies; 

  23. Physicians and/or physician groups; 

  24. Podiatrists and/or podiatric groups; 

  25. Prosthetists; 

  26. Psychologists and/or psychologist groups; 

  27. Residential treatment facilities; 

  28. Transportation providers;  and 

  29. State and county agencies that have agreed to provide personal care assistant services. 

   (b) In order for professional practices to be eligible to participate in the Medicaid and NJ FamilyCare programs as specific provider entities, such practices shall comply with all applicable State licensing statutes and rules governing their ownership and direction.

10:49-3.2 Enrollment process 

  (a) Providers shall complete a Provider Application and sign a Provider Agreement (see Appendix, N.J.A.C. 10:49) or a specialized agreement, and submit such other information or documentation, including, but not limited to, social security number and date of birth, as the program may require, depending on the nature of the services provided. 

  1. Policies and rules pertaining to shared health care facilities are outlined in N.J.A.C. 10:49-4. 

  2. All practitioners participating in a group practice shall personally sign both the group application and the provider agreement if individual documents, or shall sign a single signature sheet if both documents are contained in a single packet. 

  (b) All providers shall be required to complete Form HCFA-1513, Ownership and Control Interest Disclosure Statement (see Appendix, Form #10) at the time of application or reapplication. In addition, at the time of application or reapplication, all professional practices must certify that they comply with all applicable State licensing statutes and rules governing their ownership and direction (see Appendix, Form #12). Providers prior to 1973 were not required to utilize provider agreement forms; however, they shall comply with all applicable State and Federal Title XIX and Title XXI laws, policies, rules and regulations. 

  1. As a condition of continued participation in the New Jersey Medicaid and NJ FamilyCare programs, a provider may, from time to time, be required to: 

   i. Complete a provider reenrollment application form and sign a provider participation agreement;  and/or 

   ii. Complete a Form HCFA 1513, Ownership and Control Interest Disclosure Statement. 

  2. The New Jersey Medicaid program or NJ FamilyCare program shall terminate any existing agreement or contract if the provider fails to disclose information required by (b)1ii above. 

  3. Enrollment documentation requested by the New Jersey Medicaid or NJ FamilyCare program shall be furnished within 35 calendar days of the date of the written request. 

  (c) An out-of-State provider shall have a current, approved provider agreement with the New Jersey Medicaid or NJ FamilyCare program and hold a current, valid certification and/or license from the appropriate agency under the laws of the respective state in which the provider is located. 

  (d) A provider application may be requested from the fiscal agent of the New Jersey Medicaid and NJ FamilyCare program. An appropriate program enrollment package will be mailed to the requesting provider. The enrollment application must be completed in full and returned to the fiscal agent, along with all the necessary attachments. 

  1. The applicant's eligibility to participate in the New Jersey Medicaid and NJ FamilyCare program will be confirmed in writing. A provider number will be assigned and returned to the applicant along with the appropriate program Provider Manual. 

  2. If the application is denied, the applicant will receive a notification which explains the decision to deny and the applicant's right to appeal the decision (see N.J.A.C. 10:49-10). 

  (e) If a provider is found to be currently enrolled, but has been inactive for at least two (2) years, the applicant will be required to complete a new application. If the application is approved, the provider's existing record on the Provider Master File will be reactivated. 

  (f) The New Jersey Medicaid program or NJ FamilyCare program may refuse to enter into or to renew a provider participation agreement with any applicant or provider who has been suspended, debarred, disqualified, or excluded by the Title XIX or Title XXI program of another state. The program may terminate any existing agreement with a provider, if good cause for exclusion of the provider from program participation exists under any of the provisions of N.J.A.C. 10:49-11.1(d)1 through 27. 

  (g) The New Jersey Medicaid program or NJ FamilyCare program shall not enter into a provider participation agreement with an applicant who has been suspended or excluded from participation in the delivery of medical care or services under Medicare (Title XVIII), Medicaid (Title XIX), or the Social Services Block Grant Act (Title XX) of the Federal Social Security Act, by the Secretary of the United States Department of Health and Human Services.

   (h) The Division may place a moratorium on the enrollment of new providers for particular provider types and/or in particular geographic areas if it determines that beneficiary access to services would not be adversely affected, and: 

  1. That the number of providers already enrolled is sufficient to adequately serve beneficiaries; 

  2. That a moratorium is necessary in order to address fraud and/or abuse; or 

  3. That other compelling reasons warrant a moratorium.

10:49-3.3 Providers with multi-locations 

  (a) All providers participating in the Medicaid or NJ FamilyCare program shall identify all locations from which they are providing services to Medicaid or NJ FamilyCare beneficiaries. 

  (b) Each location shall comply with provider participation requirements and shall be assigned a separate provider number. Services rendered to Medicaid or NJ FamilyCare beneficiaries at a location not approved for participation are not eligible for Medicaid or NJ FamilyCare reimbursement. 

  (c) Billing through a central location for approved multi-location providers shall be allowed; however, providers shall utilize the applicable provider number for each service location. Selection of central or localized billing shall be left to providers, who shall state their preference on the application. The program reserves the right to assign unique provider numbers to maintain the accountability and integrity of the New Jersey Medicaid Management Information System (NJMMIS) and the New Jersey Medicaid or NJ FamilyCare program.

10:49-3.4 Medicaid or NJ FamilyCare provider billing number 

  (a) A seven digit Provider Billing Number shall be assigned by the fiscal agent to all providers approved for participation.  The Provider Billing Number shall be entered upon all claims submitted in accordance with the instructions in the Fiscal Agent Billing Supplement.  The Provider Billing Number should also be referenced in all written and telephone inquiries. 

  (b) Practitioners, as defined in (c)1 below, approved for participation, shall also be assigned a seven digit Provider Servicing Number by the Program fiscal agent.  The Provider Servicing Number is an identification number which shall be entered upon all claim submittals in accordance with the instructions in the Fiscal Agent Billing Supplement.

   (c) Providers who, for billing purposes, need a referring, ordering or prescribing practitioner's individual Provider Servicing Number, shall contact that practitioner or the fiscal agent, or shall access the Provider Servicing Number Directory, to obtain the number. A practitioner who does not participate in the Medicaid or NJ FamilyCare program will not have a Provider Servicing Number. In the absence of the referring, ordering or prescribing practitioner's individual Provider Servicing Number, providers must enter seven fives (5's) for non-participating out-of-State providers or seven sixes (6's) for non-participating in-State providers to indicate non-participation in the New Jersey Medicaid or NJ FamilyCare program. Providers may contact the Medicaid/NJ FamilyCare Fiscal Agent for a copy of the participating provider directory. In addition, providers may obtain servicing and prescribing numbers atwww.njmmis.com.

   1. Each participating practitioner (that is, physician, certified nurse midwife, certified nurse practitioner/clinical nurse specialist, chiropractor, dentist, optometrist, podiatrist, or psychologist) shall supply his or her individual Provider Servicing Number to other providers when referring a Medicaid or NJ FamilyCare beneficiary for services, or ordering or prescribing on his behalf.

   (d) A shared health care facility (SHCF) (see N.J.A.C. 10:49-4.1) is assigned a registration code (Shared Health Care Facility Number), which must appear on a claim form submitted to the fiscal agent by every member of the SHCF. In addition, each practitioner rendering a service in a shared health care facility must indicate his or her Provider Billing Number and individual Provider Servicing Number on the claim form (see Fiscal Agent Billing Supplement following the second chapter of each Provider Services Manual).

SUBCHAPTER 4. PROVIDERS' ROLE IN A SHARED HEALTH CARE FACILITY

10:49-4.1 Definitions 

  The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise. 

  "Discipline" means a branch of instruction or learning, such as medicine, dentistry, chiropractic, and so forth. 

  "Patient" means anyone eligible to receive benefits from the program. 

  "Purveyor" means any person, firm, corporation or other entity other than a provider who, whether or not located in a building which houses a shared health care facility, directly or indirectly, engages in the business of supplying to ultimate users or providers within the shared health care facility any medical supplies, equipment and/or services for which reimbursement under the program is received, including, but not limited to, clinical laboratory services or supplies;  diagnostic radiology services;  sick room supplies;  physical therapy services or equipment;  orthopedic or surgical appliances or supplies;  drugs, medication or medical supplies;  eyeglasses, lenses or other optical supplies or equipment;  hearing aids or devices;  and any other goods, services, supplies, equipment or procedures prescribed, ordered, recommended or suggested for medical diagnosis, care or treatment, and which amount to $10,000 per year.

   "Shared health care facility" (SHCF) means four or more providers, two or more of whom are practicing within different specialties and/or disciplines, either independently or in association with each other, within a single structure;  and 

  1. Two or more of whom share any of the following: 

   i. Common waiting areas; 

   ii. Examining rooms; 

   iii. Treatment rooms;

    iv. Equipment; 

   v. Supporting staff;

   vi. Common records;  and 

  2. One or more of whom receives payment on a fee-for-service basis, and where the gross Medicaid income for the facility meets or exceeds $80,000 per year. 

  "Specialty" means a health care practice within a discipline such as pediatrics, obstetrics/gynecology, orthodontics, periodontics, and so forth.

10:49-4.2 Scope 

  (a) This subchapter shall apply to shared health care facilities as defined herein and to providers located in a specific health care facility. 

  (b) This subchapter shall apply to purveyors, whether or not located in a building which houses a shared health care facility. 

  (c) Nothing in this subchapter shall apply to an association of health care providers delivering health services on other than a fee-for-service basis. 

  (d) This subchapter shall not apply to hospitals participating in the Medicaid program.

10:49-4.3 Registration of shared health care facilities 

  (a) No shared health care facility shall be operated under the program unless it has been registered with the Division.  The Office of Quality Management and Program Integrity, PO Box 712, Mail Code #7, Trenton, New Jersey 08625-0712 is responsible for registration. 

  1. Providers within the shared health care facility shall designate one provider member who shall be responsible for registration: 

   i. Said responsibility and liability by the designated provider, shall be limited to timely filing of accurate reports required   under this section. 

  (b) Registration shall be made on forms furnished by the Division and shall contain the information required therein, including, but not limited to: 

  1. The name of the owner or owners of the facility; 

  2. The name, residence address and professional license number of every provider and purveyor working in the shared health care facility; 

  3. The name, residence address and curriculum vitae of the individual designated to assume responsibility for the central coordination and management of the shared health care facility's activities, if so designated; 

  4. The owner, lessor or lessee shall furnish to the Division a copy of the lease agreement upon request; 

  5. The name of any person, firm or corporation providing administrative, clerical or billing services to providers in shared health care facilities, other than employees of providers;  and 

  6. The name and address of lessor of any space or equipment in the shared health care facility. 

  (c) The registrant shall re-register on the June 1 next following initial registration, and annually thereafter on June 1. 

  (d) The Division shall be notified, in writing, within 30 calendar days of any change in: 

  1. The owner or owners of the facility; 

  2. The termination of the services of the individual designated to assume responsibility for coordination and management of the shared health care facility's activities.  The Division shall also be notified within 30 calendar days of the name, residence address and professional qualifications of any new individual appointed to assume such central administrative responsibility;  and

  3. Any addition or termination of any provider or purveyor in the shared health care facility.  Such notification shall include the name, residence address and license number of each person appointed in place of such individual.

10:49-4.4 Prohibited practices; administrative requirements 

  (a) The Division shall not enter into any agreement of Medicaid or NJ FamilyCare participation, nor shall any payment be made to any provider in a shared health care facility where the rental fee for the letting of space or supportive professional or clerical services to a provider in a shared health care facility is calculated in whole or in part, directly or indirectly, as a percentage of earnings or billings of the provider for services rendered on the premises in which the shared health care facility is located. 

  (b) No purveyor or provider, whether or not located in a building which houses a shared health care facility, shall directly or indirectly offer, pay or give, or permit or cause to be offered, paid or given to any provider or purveyor, and no provider or purveyor shall directly or indirectly solicit, request, receive or accept from any purveyor or provider any sum of money, credit or other valuable consideration for: 

  1. Recommending or procuring goods, services or equipment of such purveyor or provider to any other person; 

  2. Directing patronage or clientele to such purveyor or provider;  or 

  3. Influencing any person to refrain from using or utilizing goods, services or equipment of any purveyor or provider. 

  (c) Patient referral requirements follow: 

  1. No provider in a shared health care facility or person employed in such facility shall refer a patient to another provider located in such a facility, unless the records of the referring provider pertaining to such patient clearly sets forth the justification for such referral; 

  2. Every provider practicing in a shared health care facility who treats a patient referred to him or her by another provider practicing in the same facility shall communicate in writing to the referring provider, the diagnostic evaluation and the therapy rendered.  The referring provider shall incorporate such information into the patient's permanent record;  and 

  3. The claim submitted to the program by the provider to whom such patient has been referred shall contain the full name and individual Provider Servicing Number of the referring provider, and shall identify the medical problem that necessitated the referral. 

 (d) Any pharmacy maintaining a business in the same building in which a shared health care facility is located shall prominently post a notice informing patients that all pharmaceuticals prescribed in the program may be obtained at any pharmacy of the beneficiary's choice. 

  (e) No purveyor or provider other than a physician, dentist, podiatrist, optometrist or chiropractor, who maintains a business in the building in which a shared health care facility is located, shall maintain a door or window opening into the offices or waiting room of the shared health care facility. 

  (f) All provider claims submitted for services rendered at a shared health care facility shall contain the registration code (SHCF Number) of the facility at which the service was performed.  The individual Provider Servicing Number of the practitioner rendering the service must also be entered on the claim form.  The practitioner who rendered the service or his or her authorized representative must sign and date the claim form. 

  (g) The requirements set forth in the Program Provider Services Manuals for each respective discipline shall apply to services rendered at a shared health care facility. 

  (h) It shall be unlawful for any provider to pay a bonus, commission or fee to any other provider based on business supplied or referred.

10:49-4.5 Quality of care requirements 

  (a) To ensure quality, continuity and proper coordination of medical care, each shared health care facility shall: 

  1. Where feasible, designate an individual who, on a full-time basis, shall coordinate and manage the facility's activities; 

  2. Devise an appropriate means of insuring that patients shall be scheduled to return for appropriate follow-up care and shall be treated by a provider familiar with patient's medical history; 

  3. Post conspicuously the names and scheduled office hours of all providers practicing in the facility; 

  4. Maintain proper records.  Such records shall contain at least the following information: 

   i. The full name, address and Program Number of the patient; 

   ii. The dates of all visits to all providers in the shared health care facility; 

   iii. The chief complaint for each visit to each provider in the shared health care facility; 

   iv. Pertinent history and all physical examinations rendered by each provider in the shared health care facility; 

   v. Diagnostic impressions for each visit to any provider in the shared health care facility; 

   vi. All medications prescribed at each visit by any provider in the shared health care facility who is qualified to issue prescriptions; 

   vii. The precise dosage and prescription regimens for each medication prescribed by a provider in the shared health care facility; 

   viii. All x-ray, laboratory work and electrocardiograms ordered at each visit by any provider in the shared health care facility; 

   ix. The results of all x-ray, laboratory work and electrocardiograms ordered as in (a)4viii above; 

   x. All referrals by providers in the shared health care facility to other medical providers and the reason for such referrals, and date of referral;  and 

   xi. A statement as to whether or not the patient is expected to return for further treatment. 

  5. The Division shall have the right to inspect the business records, patient records, leases and other contracts executed by any provider in a shared health care facility.  Such inspections may be by site visits to the shared health care facility.

SUBCHAPTER 5. SERVICES COVERED BY MEDICAID AND THE NJ FAMILYCARE PROGRAMS

10:49-5.1 Requirements for provision of services

   (a) The services listed in N.J.A.C. 10:49-5.2 are available to beneficiaries eligible for the regular New Jersey Medicaid or the NJ FamilyCare-Plan A programs. Services available to Medically Needy beneficiaries are listed in N.J.A.C. 10:49-5.3. The services listed in N.J.A.C. 10:49-5.2 and 5.3 shall be provided in conjunction with program requirements specifically outlined in the second chapter of each Provider Services Manual. 

  1. Any service limitations imposed will be consistent with the medical necessity of the patient's condition as determined by the attending physician or other practitioner and in accordance with standards generally recognized by health professionals and promulgated through the New Jersey Medicaid program.  Some services require prior authorization from the program before the services are provided (see N.J.A.C. 10:49-6--Authorization Required).  

 10:49-5.2 Services available to beneficiaries eligible for, or children who are presumptively eligible for, the regular Medicaid and NJ FamilyCare-Plan A programs 

  (a) The services listed below are available to beneficiaries eligible for the Medicaid or NJ FamilyCare-Plan A program: 

  1. Case management services (Mental Health Program);

   2. Certified nurse practitioner/clinical nurse specialist services; 

  3. Chiropractic services; 

  4. Religious non-medical health care services, (see Hospital Services Manual); 

  5. Clinic services such as services in an independent outpatient health care facility, other than hospital, that provides services such as Mental Health, Family Planning, Dental, Optometric, Ambulatory Surgery, FQHCs;

   6. Dental services; 

  7. Environmental lead inspection services-rehabilitative services; 

  8. Early and Periodic Screening, Diagnosis, and Treatment for beneficiaries under age 21 (EPSDT):  A preventative health care program for beneficiaries under age 21 designed for early detection, diagnosis and treatment of correctable abnormalities.  This program supplements the general medical services otherwise available; 

  9. Family planning services including medical history and physical examination (including pelvic and breast), diagnostic and laboratory tests, drugs and biologicals, medical supplies and devices, counseling, continuing medical supervision, continuity of care and genetic counseling. 

   i. Services provided primarily for the diagnosis and treatment of infertility, including sterilization reversals, and related   office (medical and clinic) visits, drugs, laboratory services, radiological and diagnostic services and surgical procedures are   not covered by the New Jersey Medicaid or NJ FamilyCare-Plan A program. 

  10. HealthStart maternity and pediatric care services include packages of comprehensive medical and health support services provided by independent clinics;  hospital outpatient departments;  local health departments meeting New Jersey Department of Health and Senior Services' improved pregnancy outcome criteria;  physicians;  and nurse midwives;  either directly or through linkage with other HealthStart care providers.  (See N.J.A.C. 10:49-19 for HealthStart services, policies and requirements for provider participation;) 

  11. Hearing aid services; 

  12. Home care services (home health care and personal care assistant services); 

  13. Hospice services including room and board services in a nursing facility (available to dually eligible Medicare/Medicaid or dually eligible Medicare/NJ FamilyCare-Plan A beneficiaries); 

  14. Hospital services--inpatient: 

   i. General hospitals; 

   ii. Special hospitals; 

   iii. Psychiatric hospitals (inpatient):  Limited to persons age 65 or older and children 21 years of age and under;  and 

   iv. Inpatient psychiatric programs for children 21 years of age and under; 

  15. Hospital services--outpatient; 

  16. Laboratory (clinical);

   17. Medical day care services; 

  18. Medical supplies and equipment; 

  19. Mental health services, including mental health rehabilitation services provided in: 

   i. Residential child care facilities (see N.J.A.C. 10:77 and 10:127); 

   ii. Children's group homes (see N.J.A.C. 10:77 and 10:128); 

   iii. Psychiatric community residences for youth (see N.J.A.C. 10:37B and 10:77); and 

   iv. Programs for Assertive Community Treatment (PACT) Services (see N.J.A.C. 10:37J and 10:76), except that adults with no children who are covered under NJ FamilyCare-Plan A are not eligible for PACT services. These beneficiaries are identified with a "70" as the third and fourth digits of their 12 digit NJ FamilyCare eligibility identification number. 

  20. Nursing facility services, including intermediate care facilities for the mentally retarded; 

   i. Any additional Intermediate Care Facility/Mental Retardation (ICF/MR) beds or new ICF/MR facilities shall be approved by the   Division of Developmental Disabilities (DDD) prior to application for reimbursement as a Medicaid/NJ FamilyCare provider;

   21. Nurse-midwifery services;

   22. Optometric services;

   23. Optical appliances; 

  24. Pharmaceutical services;

   25. Physician services; 

  26. Podiatric services; 

  27. Prosthetic and o