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 orthotic devices; 

   28. Psychological services; 

  29. Radiological services; 

  30. Rehabilitative services (Payments are made to eligible Medicaid/NJ FamilyCare-Plan A providers only. No payment is made to privately practicing therapists); 

   i. Physical therapy, as provided by a home health agency, independent clinic, nursing facility, hospital outpatient department,  or in a physician's office; 

   ii. Occupational therapy, as provided by a home health agency, independent clinic, nursing facility, or hospital outpatient department;

    iii. Speech-language pathology services, as provided by a home health agency, independent clinic, nursing facility, hospital outpatient department, or in a physician's office; 

   iv. Audiology services provided in the office of a licensed specialist in otology or otolaryngology, or as part of independent clinic or hospital outpatient services; and 

   v. School based rehabilitation services under EPSDT; and 

  31. Transportation services which include ambulance, mobility assistance vehicle, and other transportation provided by  independent clinics or through arrangements with a county board of social services. 

  (b) All Medicaid and NJ FamilyCare Plan A beneficiaries shall be eligible to receive all of the services specified in (a) above fee-for-service during the presumptive eligibility period, and through the time that they select and are enrolled into a managed care organization, if managed care is applicable.

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

  (a) Regular Medicaid services are available to Medically Needy beneficiaries except for the following services which are not available or are only available to certain eligible Medically Needy groups:  (See the service code next to the beneficiary's name on the Medicaid Eligibility Identification Card to ascertain the Medically Needy group under which the beneficiary's eligibility was established;  that is, Group A--pregnant women, Group B--needy children, and Group C--aged, blind and disabled.) 

  1. Chiropractic services are available only to pregnant women (Group A). 

  2. EPSDT services are not available to any Medically Needy group. 

  3. Hospital services (inpatient) are available only to pregnant women (Group A). 

  4. Nursing facility services are available to Medically Needy beneficiaries.  For purposes of the Medically Needy program, nursing facility services include pharmacy services under Title XIX. 

  5. Medical day care services are available only to pregnant women, the aged, the blind and the disabled (Groups A and C). 

  6. Pharmaceutical services are available only to pregnant women and needy children (Groups A and B);  and aged, blind or disabled beneficiaries who reside in Medicaid participating nursing facilities (see N.J.A.C. 10:51-2.10).  Pharmaceutical services are not available to other aged, blind and disabled beneficiaries (Group C). 

  7. Podiatric services are available only to pregnant women, the aged, the blind and the disabled (Groups A and C). 

  8. Rehabilitative services are not available for reimbursement when provided through a hospital or nursing facility, except to pregnant women as part of their inpatient hospital services. 

  9. Case management services for the mentally ill are available to Medically Needy pregnant women only. 

  10. Services provided primarily for the diagnosis and treatment of infertility, including sterilization reversals, and related office (medical or clinic), drugs, laboratory services, radiological and diagnostic services and surgical procedures are not available to the Medically Needy group.

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

  (a) Most legal aliens who entered the United States on or after August 22, 1996 are restricted in their entitlement to emergency services for five years from their date of entry. Undocumented aliens and temporarily documented aliens, that is visitors, workers, and students, are also restricted in their entitlement to emergency services. These emergency medical services are only available to individuals who, except for their alien status, would be eligible for Medicaid, Medically Needy, New Jersey Care ... Special Medicaid Programs, AFDC-related Medicaid, or NJ FamilyCare-Plan A. Applicants who would otherwise be eligible for NJ FamilyCare-Plans B, C and D are not eligible for these emergency medical services for aliens. 

  1. Except as noted in (a)2 below, emergency services are defined as care provided in an acute care general hospital (emergency outpatient services and/or inpatient services) for a medical condition (including labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: 

   i. Placing the patient's health in serious jeopardy; 

   ii. Serious impairment to bodily functions;  or 

   iii. Serious dysfunction of any bodily organ or part. 

  2. For labor and delivery services, the place of service is not limited to an acute care general hospital.  Services provided in birth centers are also eligible for reimbursement under this program. 

  3. Diagnoses are classified as emergency or non-emergency services in accordance with the above definition of an emergency.  Those diagnoses that correspond with emergency care are defined as emergencies and thus do not require any authorization by the attending physician.  Those diagnoses that correspond with urgent care require a Certification of Treatment of Emergency Medical Condition signed by the attending physician confirming the emergency nature of the encounter to be attached to the claim when submitted for reimbursement. 

   i. Emergency care is provided for life-threatening or organ threatening, or potentially life or organ threatening condition that requires immediate care. 

   ii. Urgent care is provided for a condition that is potentially harmful to a patient's health and determined by the physician to be medically necessary for treatment within 12 hours to prevent deterioration. 

  4. To be eligible for emergency services, an alien meeting the medical criteria listed in (a)1 above must also meet all financial and categorical eligibility requirements for NJ FamilyCare-Plan A, Medicaid, Medically Needy, New Jersey Care ... Special Medicaid Programs or AFDC-related Medicaid. 

  (b) Lawfully admitted aliens who entered the United States prior to August 22, 1996 and other aliens who are refugees, asylees, Cuban/Haitian entrants, American Indians born in Canada, Amerasian immigrants, and aliens who are honorably discharged or are on active duty in the Armed Forces of the United States and their spouses and unmarried dependent children, may qualify for full NJ FamilyCare-Plan A, Medicaid, Medically Needy, New Jersey Care ... Special Medicaid Programs or AFDC-related Medicaid, if they meet all other programmatic eligibility requirements. These aliens should be referred to the appropriate eligibility determination agency of their choice to apply for full benefits. See N.J.A.C. 10:70-3.2(a), 10:71-3.3(c), 10:72-3.2(a), and 10:79-3.2(b). 

  (c) Legally admitted pregnant alien women who entered the United States on or after August 22, 1996, who would otherwise be eligible for New Jersey Care . . . Special Medicaid Programs, except for the alien requirements are also eligible for routine prenatal care services.  Prenatal care includes services provided in the outpatient hospital department, or by a physician, certified nurse practitioner or certified nurse midwife, as well as laboratory, radiological and pharmaceutical services.

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

  (a) Listed below are some general services and items excluded from payment under the New Jersey Medicaid and NJ FamilyCare-Plan A program. There are additional specific exclusions and limitations detailed in the second chapter of each Provider Services Manual. Payment is not made for the following: 

  1. Any service, admission, or item, which is not medically required for diagnosis or treatment of a disease, injury, or condition; 

  2. Services provided to all persons without charge;  these services shall not be billed to the Medicaid program when provided for a Medicaid beneficiary.  Services and items provided without charge through programs of other public or voluntary agencies (for example, New Jersey State Department of Health and Senior Services, New Jersey Heart Association, First Aid Rescue Squads, and so forth) shall be utilized to the fullest extent possible;

   3. Any service or items furnished in connection with elective cosmetic procedures; 

   i. There are certain exceptions to this rule, but the exceptions require prior authorization.  A written certification of   medical necessity and a treatment plan shall be submitted by the physician to the appropriate Medicaid District Office for   consideration; 

  4. Private duty nursing services (except for beneficiaries under EPSDT, Model Waiver III, ACCAP and ABC programs); 

  5. Services or items furnished for any sickness or injury occurring while the covered person is on active duty in the military; 

  6. Services provided outside the United States and territories; 

  7. Services or items furnished for any condition or accidental injury arising out of and in the course of employment for which any benefits are available under the provisions of any workers' compensation law, temporary disability benefits law, occupational disease law, or similar legislation, whether or not the Medicaid beneficiary claims or receives benefits thereunder, and whether or not any recovery is obtained from a third-party for resulting damages; 

  8. That part of any benefit which is covered or payable under any health, accident, or other insurance policy (including any benefits payable under the New Jersey no-fault automobile insurance laws), any other private or governmental health benefit system, or through any similar third-party liability, which also includes the provision of the Unsatisfied Claim and Judgment Fund; 

  9. Services or items furnished prior to or after the period for which the beneficiary presents evidence of eligibility for coverage. 

   i. Payment is made for inpatient hospital services (excluding governmental psychiatric hospitals) when ineligibility occurs   after admission to hospital as an inpatient.  Payment is also made for certain services that were authorized and initiated before loss of eligibility such as dental, vision care, prosthetics and orthotics, and durable medical equipment.  Also, see   "Retroactive Eligibility" at N.J.A.C. 10:49-2.7(c); 

  10. Any services or items furnished for which the provider does not normally charge; 

  11. Any admission, service, or item, requiring prior authorization, where prior authorization has not been obtained or has been denied (see N.J.A.C. 10:49-6, Authorizations required); 

  12. Services furnished by an immediate relative or member of the Medicaid beneficiary's household; 

  13. Services billed for which the corresponding health care records do not adequately and legibly reflect the requirements of the procedure described or procedure code utilized by the billing provider, as specified in the Provider Services Manual;
 

   i. Final payment shall be made in accordance with a review of those services actually documented in the provider's health care  record.  Further, the medical necessity for the services must be apparent and the quality of care must be acceptable as  determined upon review by an appropriate and qualified health professional consultant. 

   ii. All such determinations will be based on rules and regulations of the New Jersey Medicaid Program, the minimum requirements described in the appropriate New Jersey Medicaid Provider Services Manual, to include those elements required to be documented in the provider's records according to the procedure code(s) utilized for payment, and on accepted professional standards.  (See N.J.A.C. 10:49-9.5, Provider Certification and Recordkeeping.) 

   iii. Any other evidence of the performance of services shall be admissible for the purpose of proving that services were rendered only if the evidence is found to be clear and convincing. "Clear and convincing evidence" of the performance of services includes, but is not limited to, office records, hospital records, nurses notes, appointment diaries, and beneficiary statements. 

   iv. Therefore, any difference between the amount paid to the provider based on the claim submitted and the Medicaid Agent's value of the procedure as determined by the Medicaid Agent's evaluation, may be recouped by the Medicaid Agent. 

   14. Any claim submitted by a provider for service(s) rendered, except in a medical emergency, to a Medicaid or a NJ FamilyCare-Plan A beneficiary whose Medicaid or NJ FamilyCare Eligibility Identification Card has a printed message restricting the beneficiary to another provider of the same service(s). (See N.J.A.C. 10:49-2.13(e)2, Special Status program); 

  15. Services or items reimbursed based upon submission of a cost study when there are no acceptable records or other evidence to substantiate either the costs allegedly incurred or beneficiary income available to offset those costs. In the absence of financial records, a provider may substantiate costs or available income by means of other evidence acceptable to the Medicaid Agent or the Division. If upon audit, financial records or other acceptable evidence are unavailable for these purposes: 

   i. All reported costs for which financial records or other acceptable evidence are unavailable for review upon audit are deemed  to be non-allowable;  and/or

   ii. Beneficiary income shall be presumed to equal the maximum income allowable for a Medicaid or NJ FamilyCare beneficiary for those beneficiaries whose records relating to income are completely unavailable; 

   iii. The Medicaid Agent or the Division shall seek recovery of any resulting overpayments; 

  16. Services provided primarily for the diagnosis and treatment of infertility, including sterilization reversals, and related office (medical or clinic), drugs, laboratory services, radiological and diagnostic services and surgical procedures; 

  17. Claims for services, goods or supplies which are furnished, rendered, prescribed or ordered in violation of Federal or State civil or criminal statutes, or in violation of licensure statutes, rules and/or regulations; and 

  18. Any item or service (other than an emergency item or service, not including items or services furnished in an emergency room of a hospital) furnished at the direction or on the prescription of a physician, individual or entity, during the period when such physician, individual or entity is excluded from participation in the Medicaid and NJ FamilyCare programs, and when the physician, individual or entity furnishing such item or service has received written notice from the Division that the physician, individual or entity has been excluded from participation in the Medicaid and NJ FamilyCare programs.

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

  (a) Except for the exceptions at N.J.A.C. 10:79-6.5, which concern services for newborns enrolling into NJ FamilyCare-Plan C, the services listed below are available to beneficiaries eligible for NJ FamilyCare-Plan B or C, through an HMO selected by the NJ FamilyCare-Plan B or C beneficiary. 

  1. Audiology services;

   2. Certified nurse practitioner services; 

  3. Chiropractic services; 

  4. Clinic services (services in an independent outpatient health care facility, other than hospital, that provides services such as, dental, optometric, ambulatory surgery, etc.); 

  5. Clinical nurse specialist services; 

  6. Dental services; 

  7. Durable medical equipment; 

  8. Early and periodic screening, and diagnosis examinations, dental, vision and hearing services.  Includes only those treatment services identified through the examination that are available under the HMO contract or covered fee-for-service program; 

  9. Emergency room services; 

  10. 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 program. 

  11. Federally qualified health center primary care services; 

  12. HealthStart maternity services, which is a package of comprehensive medical and health support services provided by the HMO; 

  13. Hearing aid services; 

  14. Home health care services; 

   i. Exception:  personal care assistant services; 

   15. Hospice services; 

  16. Hospital services--inpatient: 

   i. General hospitals; 

   ii. Special hospitals;  and 

   iii. Rehabilitation hospitals; 

  17. Hospital services--outpatient; 

  18. Laboratory (clinical); 

  19. Medical supplies and equipment; 

  20. Nurse-midwifery services; 

  21. Optometric services; 

  22. Optical appliances; 

  23. Organ transplant services, except the inpatient hospital services.  Inpatient hospital services for organ transplants are covered fee-for-service; 

  24. Prescription drug services; 

  25. Physician services; 

  26. Podiatric services; 

  27. Prosthetic and orthotic devices; 

  28. Private duty nursing; 

  29. Radiological services; 

  30. Rehabilitative services, including physical, occupational and speech therapy, limited to 60 days per type of therapy per year;  and 

  31. Transportation services, limited to ambulance, MICU's and invalid coach. 

  (b) The services listed below are available to beneficiaries eligible for NJ FamilyCare-Plan B or C under fee-for-service: 

  1.  Religious non-medical health care institution care and services; 

  2. Clinic services (services in an independent outpatient health care facility, other than hospital) for family planning services, mental health or substance abuse treatment services; 

  3. Elective/induced abortion services; 

  4. Emergency room services for treatment of mental health disorder or for substance abuse; 

  5. 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; 

  6. Hospital services--inpatient; 

   i. Psychiatric hospitals; 

   ii. Inpatient psychiatric programs for children 19 years of age and under; 

   iii. Acute care or special hospital services if provided for mental health or substance abuse services; 

   iv. Organ transplant hospital services; 

    (1) All other transplant services are covered by HMO; 

   7. Mental health services provided by practitioners, such as physicians, psychologists, and certified nurse practitioners/clinical nurse specialists;

   8. Nursing facility services, limited to the Medicare Part A copayments for the first 30 days of skilled nursing care; 

  9. Outpatient hospital services for family planning, mental health and substance abuse treatment services; 

  10. Substance abuse services provided by practitioners, including physicians, psychologists, certified nurse practitioners/clinical nurse specialists;  and 

  11. Targeted case management services for the chronically ill. 

  (c) Services not covered under Plan B and C are as follows: 

  1. Unless listed in (a) and (b) above, no other services are covered by NJ FamilyCare-Plan B or C. 

  2. Services not covered include, but are not limited to: 

   i. Nursing facility services, except the Medicare Part A copayments for the first 30 days of skilled nursing care; 

   ii. Intermediate care facilities for mental retardation (ICFs/MR); 

   iii. Personal care services;

    iv. Medical day care services;

    v. Lower mode transportation; 

   vi. Mental health rehabilitation services provided in residential child care facilities (as defined in N.J.A.C. 10:127 and licensed by DYFS), children's group homes (as defined in N.J.A.C. 10:128 and licensed by DYFS), or psychiatric community residences for youth (as defined in N.J.A.C. 10:37B and licensed by DMHS); 

   vii. Any item or service (other than an emergency item or service, not including items or services furnished in an emergency room of a hospital) furnished at the direction or on the prescription of a physician, individual or entity, during the period when such physician, individual or entity is excluded from participation in the Medicaid and NJ FamilyCare programs, and when the physician, individual or entity furnishing such item or service has received written notice from the Division that the physician, individual or entity has been excluded from participation in the Medicaid and NJ FamilyCare programs; and 

   viii. Programs for Assertive Community Treatment (PACT) services. 

  (d) All presumptively eligible NJ FamilyCare-Plan B and C beneficiaries shall be eligible to receive all the services specified in (a) and (b) above fee-for-service during the presumptive eligibility period, which shall include the services that are otherwise only available through the managed care organizations. The provision of the managed care services fee-for-service shall be limited to the presumptive eligibility period.

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

  (a) Except as indicated at N.J.A.C. 10:79-2.5, which concerns services for newborns enrolling into NJ FamilyCare Plan C and D, the services listed below are available to beneficiaries eligible for NJ FamilyCare Plan D and Plan D for Adults, when medically necessary and provided through the network of an HMO selected by the NJ FamilyCare Plan D beneficiary.

   1. Certified nurse practitioner and clinical nurse specialist services; 

  2. Clinic services (services in an independent outpatient health care facility, other than hospital, that provides covered ambulatory care services); 

  3. Preventive dental services for children under the age of 12 years, including oral examinations, oral prophylaxis and topical application of fluorides; 

  4. Emergency room services; 

  5. 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 FamilyCare program; 

  6. Federally qualified health center primary care services; 

  7. Home health care services, limited to skilled nursing for a home bound beneficiary which is provided or supervised by a registered nurse, and home health aide when the purpose of the treatment is skilled care, medical social services which are necessary for the treatment of the beneficiary's medical condition and short-term physical, speech or occupation therapy with the same limitations described in (a)22 below; 

   i. Personal care assistant services are not covered; 

  8. Hospice services; 

  9. Hospital services--inpatient; 

  10. Hospital services--outpatient; 

  11. Laboratory (clinical); 

  12. Nurse-midwifery services; 

  13. Optometric services, including one routine eye examination per year; 

  14. Optical appliances, limited to one pair of glasses or contact lenses per 24 month period; 

  15. Organ transplant services which are non-experimental or non-investigational; 

  16. Prescription drug services; 

   i. Exception:  Over-the-counter drugs are not covered; 

  17. Physician services; 

  18. Podiatric services; 

   i. Exception:  Coverage excludes routine foot care; 

  19. Prosthetic appliances, limited to initial provision of prosthetic device that temporarily or permanently replaces all or part of an external body part lost or impaired as a result of disease or injury or congenital defect; 

   i. Coverage includes repair and replacement when due to congenital growth; 

  20. Outpatient surgery; 

  21. Radiological services;

  22.  Inpatient rehabilitative services, including physical, occupational and speech therapy for non-chronic conditions and acute illnesses and injuries;

  23. Transportation services, limited to ambulance for medical emergency only; 

  24. Well child care including immunizations, lead screening and treatments; 

  25. Maternity and related newborn care;  and 

  26. Diabetic supplies and equipment. 

  (b) The services listed below are available to beneficiaries eligible for NJ FamilyCare-Plan D under fee-for-service. 

  1. Services for mental health or behavioral conditions;

    i. Inpatient hospital services, including psychiatric hospitals, limited to 35 days per year;

   ii. Outpatient benefits for short-term, outpatient evaluative and crisis intervention or home health mental health services, limited to 20 visits per year; 

    (1) When authorized by the Division of Medical Assistance and Health Services, inpatient benefit exchanges are allowed.  One mental health inpatient day may be exchanged for up to four outpatient services, including partial care.  This is limited to an exchange of up to a maximum of 10 inpatient days for a maximum of 40 additional out patient visits.

     (2) When authorized by the Division of Medical Assistance and Health Services, inpatient benefit exchanges are allowed.  One mental health inpatient day may be exchanged for two days of treatment in partial hospitalization up to the maximum number of covered inpatient days. 

   iii. Inpatient and outpatient services for substance abuse are limited to detoxification;

   2. Outpatient rehabilitative services, including physical, occupational and speech therapy for non-chronic conditions and acute illnesses and injuries. Outpatient rehabilitation benefits are limited to treatment over a period of 60 consecutive business days per incident of illness or injury beginning with the first day of treatment per contract year, except that: 

   i. Speech therapy services rendered for treatment of delays in speech development, unless resulting from disease, injury or congenital defects are not covered; and 

  3. Elective/induced abortion services. 

  (c) Services not covered under Plan D are as follows: 

  1. Unless listed in (a) and (b) above, no other services are covered by NJ FamilyCare-Plan D. 

  2. Services not covered include, but are not limited to: 

   i. Services that are not medically necessary; 

   ii. Private duty nursing unless authorized by the HMO; 

   iii. Intermediate care facilities for mental retardation (ICF/MR); 

   iv. Personal care assistant services; 

   v. Medical day care services; 

   vi. Chiropractic services; 

   vii. Dental services except for preventive dentistry for children under age 12; 

   viii. Orthotic devices;

    ix. Targeted case management for the chronically ill; 

   x. Inpatient psychiatric programs for children age 19 years and under; 

   xi. Religious non-medical health care institution care and services; 

   xii. Durable medical equipment; 

   xiii. EPSDT services; 

    (1) Refer to (a)24 above concerning the coverage of well child care including immunizations, lead screening and treatments; 

   xiv. Routine transportation, including nonemergency ambulance, invalid coach and lower mode transportation; 

   xv. Hearing aid services; 

   xvi. Blood and blood plasma; 

    (1) Administration, processing of blood, processing fees and fees related to autologous blood donations are covered; 

   xvii. Cosmetic services; 

   xviii. Custodial care; 

   xix. Special and remedial educational services; 

   xx. Experimental and investigational services;

    xxi. Infertility services; 

   xxii. Medical supplies; 

    (1) Diabetic supplies are a covered service; 

   xxiii. Rehabilitative services for substance abuse; 

   xxiv. Weight reduction programs or dietary supplements; 

   (1) Surgical operations, procedures or treatment of obesity, shall not be covered, except when specifically approved by   the HMO; 

   xxv. Acupuncture and acupuncture therapy, except when performed as a form of anesthesia in connection with covered surgery; 

   xxvi. Temporomandibular joint disorder (TMJ) treatment, including treatment performed by prosthesis placed directly in the teeth; 

   xxvii.  Nursing facility (long term care) services; 

   xxviii. Recreational therapy; 

   xxix. Sleep therapy; 

   xxx. Court ordered services; 

   xxxi. Thermograms and thermography; 

   xxxii. Biofeedback; 

   xxxiii. Radial keratotomy; 

   xxxiv. Mental health rehabilitation services provided in residential child care facilities (as defined in N.J.A.C. 10:127 and licensed by DYFS), children's group homes (as defined in N.J.A.C. 10:128 and licensed by DYFS), or psychiatric community residences for youth (as defined in N.J.A.C. 10:37B and licensed by DMHS); and 

   xxxv. Respite care; 

   xxxvi. Any item or service (other than an emergency item or service, not including items or services furnished in an emergency room of a hospital) furnished at the direction or on the prescription of a physician, individual or entity, during the period when such physician, individual or entity is excluded from participation in the Medicaid and NJ FamilyCare programs, and when the physician, individual or entity furnishing such item or service has received written notice from the Division that the physician, individual or entity has been excluded from participation in the Medicaid and NJ FamilyCare programs; and 

   xxxvii. Programs for Assertive Community Treatment (PACT) services.

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

  (a) Childless adults whose income is below 100 percent of the Federal poverty level and who do not qualify for WFNJ/GA and who are enrolled in NJ FamilyCare on July 1, 2002 shall be eligible to receive the NJ FamilyCare Plan H service package. 

  (b) Out-of-plan community-based mental health services shall be limited to 60 service days per calendar year and shall be eligible for payment on a fee-for-service basis. 

  (c) No behavioral health out-of-plan service of any kind, where the place of service is a hospital, shall be a covered service. 

  (d) The services listed below shall be available to beneficiaries eligible for NJ FamilyCare Plan H, when medically necessary and when provided through the network of an HMO selected by the beneficiary; 

  1. Ambulance--emergency; 

  2. Ambulatory surgery; 

  3. Certified nurse practitioner/clinical nurse specialist;

   4. Clinic services (free standing)--ambulatory; 

  5. Clinic services (free standing)--ESRD; 

  6. Clinic services (free standing)--family planning; 

  7. Diabetic supplies/equipment; 

  8. Emergency room; 

  9. Family planning services; 

  10. Federally qualified health centers (FQHC) encounters; 

  11. HealthStart maternity; 

  12. HMO services not otherwise specified herein; 

  13. Home health care services (limited benefits); 

  14. Hospice services--non-nursing facility based; 

  15. Inpatient hospital (non-behavioral health related); 

  16. Laboratory services; 

  17. Maternity services; 

  18. Nurse midwifery--nonmaternity; 

  19. Nurse midwifery services--maternity; 

  20. Organ transplantation; 

  21. Outpatient hospital (non-mental health related); 

  22. Optometric services (limited benefits); 

  23. Optical appliances (limited benefits); 

  24. Physician services; 

  25. Podiatric services; 

  26. Prescription drugs (excludes over the counter medications); 

   27. Private duty nursing (when authorized); 

  28. Prosthetic devices (limited benefits); 

  29. Psychological services (up to a maximum of 60 days of mental health services per calendar year); and 

  30. Radiological services. 

  (e) The following services shall be available to NJ FamilyCare Plan H beneficiaries on a fee-for-service basis: 

  1. Abortion (elective/induced);

   2. Mental health services in the community, including psychological services, up to a maximum of 60 days per calendar year; 

  3. Outpatient rehabilitative services: speech therapy, occupational therapy and physical therapy, in an office, a hospital based clinic, an independent clinic, or by a home health agency; and 

  4. Skilled nursing services (limited benefits). 

   i. For individuals admitted to a skilled nursing facility, managed care shall be terminated in the month of admission, which   shall result in the termination of eligibility for Plan H.

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

   General Assistance-eligible individuals shall receive Plan G services, which shall be those services delineated at N.J.A.C. 10:49-24.3.

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

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

   (a) Under the Programs, payment for certain services shall require prior authorization except in an emergency. It is the responsibility of the provider to obtain prior authorization before furnishing or rendering a service. Specific instructions are detailed in the appropriate Provider Services chapter. 

  1. Prior authorization should not be construed as a guarantee that a person is eligible for the New Jersey Medicaid or NJ FamilyCare program. At the time the service is to be provided, it is the provider's responsibility to verify eligibility. 

  2. "Medical emergency" means a critical illness or injury status for which prompt medical care may be crucial to saving life and limb or sparing the beneficiary significant or intractable pain.  Services provided for a medical emergency are exempt from prior authorization.  Any service classified as a medical emergency that would have been subject to prior authorization had it not been so classified, must be supported by a practitioner's statement which describes the nature of the emergency, including relevant clinical information, and must state why the emergency services rendered were considered to be immediately necessary.  To simply state that an emergency did exist is not sufficient. 

  3. In addition to services that must be prior authorized under the previous subsections, a provider may be required to submit some or all services for prior authorization if in the judgment of the Medicaid Agent or DMAHS the provider has engaged in conduct which would constitute good cause for suspension, debarment or disqualification under N.J.A.C. 10:49-11.1(d).  Prior authorization under this subsection may be imposed prior to a hearing under the same conditions applicable to suspensions under N.J.A.C. 10:49-11.1(j), except that the approval of the Attorney General shall not be necessary. 

  (b) Retroactive authorization may be granted under certain circumstances provided that the service is a part of continuing beneficiary care and, on the basis of medical judgment, would have been authorized at the time the service was rendered.  Each case is considered on its own merit.  Retroactive authorization is an exceptional measure granted only under the following unusual circumstances: 

   1. "Other coverage" (Medicare, Third-Party liability, other insurance, etc.) has denied or made only partial payment of a claim for services or items requiring prior authorization and it would have been unreasonable to expect the provider to have requested authorization prior to rendering the service; 

  2. Retroactive determination of eligibility; 

  3. An "administrative emergency" existed because communication between the provider and the staff of the New Jersey Medicaid program could not be established (for example, during a weekend, holiday or evening) and provision of the service should not have been delayed.  This differs from a medical emergency in that the beneficiary's condition would not be impaired if the service was not provided (see example below). In such instances, the request for retroactive authorization, including an explanation of the circumstances as well as the medical documentation supporting the services, shall be submitted to the Medicaid District Office or Central Office, as appropriate, within five calendar days after the service was provided or initiated.  If verbal authorization was obtained, confirming written documentation shall follow. 

  Example:  A physician orders a Medicaid beneficiary home from the hospital on a Friday evening.  The beneficiary requires an electrical hospital bed, but the Medical Supplier is unable to contact the Medicaid District Office to obtain prior authorization.  It is advantageous to the Medicaid program, the hospital and the patient to discharge the beneficiary and not wait until authorization for the bed is requested on Monday;  or 

  4. In situations not covered by (b)1, 2, and 3 above, the New Jersey Medicaid program follows the doctrine of reasonableness which asks, "Is it reasonable to conclude that the situation presented warrants waiver of procedural rules?"

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

  (a) Any covered service that requires prior authorization as a prerequisite for reimbursement to New Jersey Medicaid providers shall also require prior authorization if it is to be provided in any other state. 

  1. Services which require prior authorization are described in the specific Medicaid Provider Services Manual.

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

 10:49-7.1 General provisions 

  (a) The following information outlines the policies and regulations of the New Jersey Medicaid program that the provider shall adhere to when submitting a claim and requesting payment for services provided to a New Jersey Medicaid recipient. (To identify a Medicaid recipient, see N.J.A.C. 10:49-2). 

  1. Each Provider Services Manual has information relevant to the basis of payment for services and items of payment provided that is usually found in the second chapter of each manual. 

  2. For requirements of the Division of Medical Assistance and Health Services and the New Jersey State Department of Health and Senior Services when submitting a claim to be considered for the charity care component of the disproportionate share subsidies for hospital services and other rules regarding eligibility for these services, see N.J.A.C. 10:52-11, 12 and 13. 

  (b) In addition to information in this subchapter about submitting claims for payment, a Fiscal Agent Billing Supplement is included following each Provider Services Manual.  Included in the Supplement are prior authorization forms and instructions;  information for the proper completion and submission of claim forms;  the procedure to follow when claims are rejected and returned to the provider by the Fiscal Agent during the adjudication process;  third party liability verification, procedure for submitting crossover claims, and examples of timely submission of claims;  electronic media claims (EMC) submission;  Remittance Advice Statements;  procedures for Electronic Funds Transfer (EFT);  adjustments for overpayment of claims, and adjustments by Medicare;  procedure to follow when a claim is paid in error (voids);  procedure for inquiries about claims;  procedure for ordering forms;  information about provider services;  and item-by-item instructions for completing the claim form and other forms. 

  1. The Fiscal Agent Billing Supplement is not published in the New Jersey Administrative Code (N.J.A.C.) but is referenced as an appendix and is thus, not a legal description of the New Jersey Medicaid program's rules.  Should there be any conflict between the Fiscal Agent Billing Supplement and the pertinent laws or rules governing the Medicaid program or the charity care program, the laws and rules of the Medicaid program and the charity care program, as appropriate, take precedence.

10:49-7.2 Timeliness of claim submission and inquiry

   (a) A claim is defined as a request for payment from the New Jersey Medicaid program for a Medicaid reimbursable service provided to a Medicaid recipient. For disproportionate share data collection purposes only, a claim is defined as a request for the New Jersey charity care program to price the services rendered and consider those services when determining the amount of subsidy to be afforded to New Jersey hospitals. The charity care claim properly identifies the hospital, the service(s) rendered, the recipient of the service(s), the date(s) of the service, and any other data required by the State. 

  1. For a Medicaid claim, the claim for payment from the Medicaid program may be submitted hard copy or by means of an approved method of automated data exchange.  A claim for pricing of charity care hospital services is a request to the New Jersey charity care program, which shall be submitted by an approved method of automated data exchange within 180 days of the charity care determination.  In order for a Medicaid claim to be considered, all appropriate documentation shall be included with the claim form. 

  2. It is the responsibility of each provider to ensure that each Medicaid/NJ FamilyCare-Plan A claim submitted by that provider is received by the New Jersey Medicaid/NJ FamilyCare program's Fiscal Agent within the time periods indicated in this section. Providers shall reconcile their claims submission records with the Remittance Advice they receive from the Division's Fiscal Agent in order to verify that the Division's Fiscal Agent has received their claims. Providers shall resubmit any claims for reimbursement which the provider determines have been submitted previously, but which do not appear on the Remittance Advice. 

   i. The New Jersey Medicaid program shall not reimburse for a claim received outside the prescribed time periods.  This policy also applies to inquiries concerning a claim or claim related information received outside the prescribed time periods. 

   ii. For retroactive eligibility cases, a claim associated with a retroactive eligibility application, that was submitted to the Medicaid Assistance and Health Services' Retroactive Eligibility Unit will be considered as received on the date of receipt of the application on behalf of the applicant. For information about retroactive eligibility, see N.J.A.C. 10:49-2.9. 

 (b) "Prospective" medical bill(s) are bills submitted to the Retroactive Eligibility Unit with an Application for Retroactive Medicaid Eligibility (FD-74) on the assumption that they were incurred during the retroactive eligibility period but were actually incurred during the month of application for Medicaid or later. These bills were incurred during a time period when Medicaid eligibility already existed or should have existed (except that the individual experienced a delayed determination of Medicaid eligibility). 

  (c) Under the circumstances in (c)1 through 3 below, the Division of Medical Assistance and Health Services' Retroactive Medicaid Eligibility Unit will generate letters to providers whose bills were included with an Application for Retroactive Medicaid Eligibility, allowing the one-year timely submission requirements to be bypassed. 

  1. These "prospective" claims must not have already been submitted to the Fiscal Agent within one-year of the date that services were rendered; 

  2. The Application for Retroactive Medicaid Eligibility that these "prospective" bills are associated with must have been received at the Retroactive Eligibility Unit within 60 days of the date of the above mentioned letter (with the original letter attached); and 

  3. In order for payment to be made, these claims must remain outstanding and any collection action against the Medicaid beneficiary must be withdrawn. 

  (d) An institutional claim is a claim submitted by a hospital;  home health agency;  nursing facility;  intermediate care facility/mental retardation (ICF/MR);  residential treatment center;  or governmental psychiatric hospital.  The time requirements for submitting an institutional claim is as follows: 

  1. For claims submitted by home health agencies and hospitals (excluding governmental psychiatric hospitals), a claim for payment of a service provided to any Medicaid beneficiary shall be received by the New Jersey Medicaid Fiscal Agent within: 

   i. One year of the date of discharge on an inpatient hospital claim; 

   ii. One year of the date of service entered on an outpatient hospital claim or home health claim; 

   iii. One year of the earliest date of service entered on an outpatient hospital claim or home health claim, if the claim carries more than one date of service;  or 

   iv. For early and Periodic Screening, Diagnosis and Treatment (EPSDT) including pediatric HealthStart services, claims must be submitted to the Fiscal Agent within 30 days of the provision of services. 

  2. For claims submitted by a nursing facility;  an intermediate care facility for the mentally retarded;  a residential treatment center;  or a governmental psychiatric hospital, a claim for payment for services shall be received by the fiscal agent no later than one year after the "from date of service" as indicated on the claim. 

  (e) A non-institutional claim is a claim submitted by all providers except a hospital, home health agency, nursing facility, intermediate care facility/mental retardation (ICF/MR), residential treatment center, or governmental psychiatric hospital.  The time requirements for submitting a non-institutional claim are as follows: 

  1. A claim for payment of a non-institutional service provided to any Medicaid beneficiary shall be received by the New Jersey Medicaid Fiscal Agent within: 

   i. One year of the date of service; 

   ii. One year of the earliest date of service entered on the claim if the claim carries more than one date of service; 

   iii. One year (365 days) of the dispensing date on a pharmacy claim;  or 

   iv.  For early and Periodic Screening, Diagnosis and Treatment (EPSDT) including pediatric HealthStart services, claims must be submitted to the Fiscal Agent within 30 days of the provision of services. 

  (f) The time requirements for submitting a combination Medicare/Medicaid or Medicare/NJ FamilyCare claim are as follows (Under Federal regulations this applies only to Medicare/Medicaid or Medicare/NJ FamilyCare claims and does not extend to claims involving any other third party insurance.): 

  1. A combination Medicare/Medicaid claim is defined as a request for payment from the New Jersey Medicaid program for a medical service provided to any Medicare/Medicaid beneficiary. 

   i. The claim shall contain the Medicaid Eligibility Identification Number, the Medicare three digit carrier/payor code, and the   Medicare HIC Number. 

  2. A combination Medicare/Medicaid claim shall be received by the Medicare Intermediary/Carrier within the applicable Medicaid timely submission period (see (d) and (e) above) to be considered for further payment by the New Jersey Medicaid program. 

   i. The provider shall continue to have one year from the date of service for a claim to be received by the Medicaid Fiscal   Agent.  A claim received by the Medicaid Fiscal Agent after Medicare adjudication and within one year from the date of service   shall be considered timely submitted. 

   ii. For combination Medicare/Medicaid claims received by the Medicare Intermediary/Carrier within the applicable Medicaid timely submission period and where Medicare adjudication occurs beyond the one year of the date of service, the provider shall submit a claim to be received by the Medicaid Fiscal Agent within 90 days of the date of the Medicare adjudication. 

   iii. For Medicare/Medicaid claims where the Medicare adjudication occurs within one year from the date of service, but less than 90 days remain within the timely filing period, the provider shall submit the claim to be received by Medicaid within the one year timely filing period or 90 days, whichever is later. 

   iv. A combination Medicare/Medicaid claim received outside the applicable Medicaid timely submission period shall not be reimbursed by the New Jersey Medicaid program. 

   3. In most cases, when a beneficiary is eligible for both Medicare and Medicaid, or Medicare and NJ FamilyCare, a Medicare/Medicaid approved claim will crossover from the Medicare Carrier/Intermediary to the program's Fiscal Agent. The provider is requested to allow 45 days from Medicare adjudication for the Medicaid or NJ FamilyCare program to receive and process crossover claims. Failure to allow the 45 days for the transition from Medicare to Medicaid or NJ FamilyCare will result in claim denials due to duplicate claim errors. There are instances, however, where claims will not cross over from Medicare. In those instances, or when a Medicare/Medicaid or Medicare/NJ FamilyCare crossover is not reflected on the provider's Medicaid Remittance Advice within 45 days of the Medicare Explanation of Benefits (EOB), the provider shall follow the billing instructions in the Fiscal Agent Billing Supplement following the second chapter of the provider services manual. 

  (g) If additional information is required in order to process a claim, the provider shall supply the information as soon as possible but not more than 30 days after the end of the timely submission period. 

  (h) Regarding a claim submitted timely that has been adjudicated and denied, a provider may resubmit the claim within one year of the date of service or 30 days of the date of adjudication as indicated in the Remittance Advice Statement, whichever is later.

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

  (a) "Third party liability" (TPL) exists when any person, institution, corporation, insurance company, absent parent, Medicare program, public, private, or governmental entity is or may be liable in contract, tort, or otherwise by law or equity to pay all or part of the cost of medical assistance payable by the Medicaid or NJ FamilyCare program. 

  1. It is a violation of section 1902(a)(25)(D) of the Federal Social Security Act to refuse to furnish covered services to any Medicaid beneficiary because of a third party's potential liability to pay for services. 

  (b) Medicaid and NJ FamilyCare benefits are last-payment benefits. All TPL, for example, health insurance, Medicare, CHAMPUS, prepaid health plans, workers' compensation and auto insurance, shall, if available, be used first and to the fullest extent in meeting the cost of the medical needs of the Medicaid or NJ FamilyCare beneficiary, subject to the exceptions listed in (h) below. 

  (c) The New Jersey Medicaid program and the NJ FamilyCare program will supplement the amount paid by a third party, but the combined total paid to the provider shall not exceed the total amount payable under the program in the absence of any TPL. The following exceptions should be noted: 

  1. Medicare: The program will make payment in the full amount of the Medicare Part A deductible and co-insurance for inpatient hospital services, and for Part B outpatient hospital services. For services rendered on or after July 20, 1998, payment for Part B coinsurance and deductible for other non-hospital services shall be paid only up to the Medicaid or NJ FamilyCare maximum allowable. 

  2. Contracting practitioners:  No program payments shall be made when the third party calls for a contracting or participating practitioner to accept the TPL as payment in full. 

  (d) Medicaid and NJ FamilyCare participating providers are prohibited from billing Medicaid or NJ FamilyCare beneficiaries for any amount, except: 

  1. For services, goods, or supplies not covered or authorized by the New Jersey Medical Assistance and Health Services Act (N.J.S.A. 30:4D-1 et seq.), as amended and supplemented, or not covered or authorized by the Division of Medical Assistance and Health Services under this chapter or N.J.A.C. 10:74, if the beneficiary elected to receive the services, goods, or supplies with the knowledge that they were not covered or authorized; 

  2. For payments made to the beneficiary by a third party on claims submitted to the third party by the provider; 

  3. For NJ FamilyCare-Plan C enrollee's contribution to care responsibility; or 

  4. For NJ FamilyCare-Plan D enrollee's required copayment. 

  (e) When a Medicaid or NJ FamilyCare-Plan A beneficiary has other health insurance, the program requires that such benefits be used first and to the fullest extent, subject to the exceptions in (h) below. Supplementation may be made by the program, but the combined total paid shall not exceed the amount payable under the program in the absence of other coverage. The program shall not supplement covered services rendered by a participating or contracting practitioner with any private health coverage program where the private plan calls for the practitioner to accept that plan's payment as payment in full. When other health insurance is involved, supplementation claims shall not be filed with the program unless accompanied by a statement of payment, Explanation of Benefits (EOB), or denial from the other carrier. Attachment of such information will expedite Medicaid and NJ FamilyCare claim processing. 

  1. Medicare is a health insurance program which covers certain aged and disabled persons. When rendering Medicare-covered services to any Medicaid or NJ FamilyCare beneficiary, providers shall inquire about Medicare eligibility especially if the third digit of the Eligibility Identification Number is a 1, 2, 5, or 7. Medicaid or FamilyCare supplementation of available Medicare benefits shall be as follows: 

   i. Medicare (Title XVIII): For any Medicaid or NJ FamilyCare beneficiary who is covered under Medicare, responsibility for payment by the New Jersey Medicaid Agent or the NJ FamilyCare program for non-hospital Part B services shall be limited to the   unsatisfied deductible and/or coinsurance to the extent that the combined total of payments does not exceed the maximum allowable  under the Medicaid or NJ FamilyCare program in the absence of other coverage for services rendered on or after July 20, 1998. 

  (f) When a Medicaid or NJ FamilyCare beneficiary has benefits available, such as those described above or from any other liable third party, an approved Medicaid or NJ FamilyCare provider shall be authorized to sign an insurance claim for the Commissioner, based on the third party assignment of rights, in order to receive direct payment from the insurer. This is done pursuant to N.J.S.A. 30:4D-7.1(c). The following language shall be used by the provider when completing insurance claims: "(signature of authorized provider), Assignee for the Commissioner, New Jersey Department of Human Services." 

 (g) When recovery of benefits is sought by the Medicaid or NJ FamilyCare program from a liable third-party, the Commissioner shall authorize the Director or his designee(s) to sign the recovery demand. 

  (h) TPL may be exhausted, but is not required to be, before a claim is submitted for Medicaid or NJ FamilyCare payment in any of the following circumstances: 

  1. The TPL benefits are derived from a parent whose obligation to pay support is being enforced by the State Title IV-D agency;

  2. The claim is for prenatal care for a pregnant woman or for preventive pediatric services (including EPSDT services) that are covered by the program; 

  3. The claim is for labor, delivery, and post-partum care and does not involve hospital costs associated with the inpatient hospital stay; 

  4. The claim involves a service for which CMS has granted a waiver of the TPL cost avoidance requirements in accordance with 42 C.F.R. 433.139(e). Waivers have been granted for services covered by Medicare Part B which are rendered at State and county governmental psychiatric hospitals, State and private ICFs/MR, and Vineland Special Hospital; or 

  5. Rehabilitation services provided by a local school district under a child's Individualized Education Program (IEP). 

  (i) In those situations where a health insurance payment is received after Medicaid or NJ FamilyCare has been billed and has made payment, the provider must reimburse the Medicaid or NJ FamilyCare payment to the Medicaid or NJ FamilyCare program and not to the Medicaid or NJ FamilyCare beneficiary. Reimbursement must be made immediately to comply with Federal regulations. In the event a provider is apprised or otherwise is on notice that a duplicate or excessive payment has been made by the Division as a result of the provider's receipt of a Medicare or health insurance payment, the provider shall have 60 days to refund such overpayments to the Division. To initiate the process, providers must submit an MMIS Claim Adjustment Request Form. (See Fiscal Agent Billing Supplement following the second chapter of each Provider Services Manual). 

  1. In situations involving tort matters where liability has not been established at the time of billing, providers may elect to bill the Medicaid program. However, if they choose to do so, they are precluded from returning Medicaid payments for their services, and may not seek reimbursement from any proceeds resulting from the tort matter. Conversely, providers may elect not to bill the Medicaid program, and await the outcome of the tort matter. However, should the tort matter not result in an award to the beneficiary, and the deadline for timely filing of a Medicaid claim by the provider passes, the provider shall not bill either the Medicaid program or the beneficiary. 

  2. This subsection in no way precludes the Division from seeking reimbursement for Medicaid payments made on behalf of the beneficiary or from any third party liability source, including a tort liability recovery, which may be awarded the beneficiary. 

  (j) Regardless of the status of a provider's claim with other third parties, all claims for Medicaid or NJ FamilyCare reimbursement must be received by the Fiscal Agent within the time frames specified in N.J.A.C. 10:49-7.2, Timeliness of claim submission. 

  (k) Any individual who undertakes to legally represent any Medicaid or NJ FamilyCare beneficiary in an action for damages against any third party when medical expenses have been paid by the Division shall be required to give written notice to the Division within 20 days of filing or commencing the action. 

  1. The term "legal representative" shall include, but not be limited to, an attorney, administrator/administratrix, executor/executrix, conservator, guardian or guardian ad litem.

10:49-7.4 Prohibition of payment to factors 

  (a) A "factor" means an individual or an organization, such as a collection agency or service bureau, that advances money to a provider for accounts receivable that the provider has assigned, sold or transferred to the individual organization for an added fee or deduction of a portion of the accounts receivable. 

  (b) Payment for any covered services furnished to any Medicaid or NJ FamilyCare beneficiary by an approved provider may not be made to or through a factor, either directly or by power-of-attorney.

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

  (a) Payment may be made to a business agent, such as a billing service or an accounting firm, that furnishes statements and receives payment in the name of the provider if the agent's compensation for this service is: 

  1. Related to the cost of processing the billing; 

  2. Not related on a percentage or other basis to the amount that is billed or collected;  and 

  3. Not dependent upon the collection of the payment. 

  (b) If a NJ Medicaid or FamilyCare participating provider wishes to designate a business agent to perform management, clerical and/or other services related to the claims payment process, approval is required from the New Jersey Medicaid or NJ FamilyCare program. 

  (c) In order to obtain approval the provider/agent shall submit a copy of the signed agreement and power-of-attorney, if any, between the provider and the agent which shall contain a detailed statement of the powers and duties of the agent (including the power to sign Medicaid or NJ FamilyCare claims on behalf of the provider and the compensation arrangement) to Provider Enrollment, New Jersey Medicaid or NJ FamilyCare program. 

  (d) Approval shall be obtained for each provider/agent agreement.  Approval of an agent agreement with one provider does not confer an automatic approval of any additional provider/agent agreement. 

  (e) Standard Medicaid or NJ FamilyCare hard-copy claim forms shall be used unless the provider has been authorized for electronic media claims submission; however, in some instances hard-copy claims are required. These instances are detailed, as applicable, in the appropriate Provider Services Manual. 

  1. If standard Medicaid or NJ FamilyCare claim forms are not utilized, the provider/agent shall obtain approval from the New Jersey Medicaid or NJ FamilyCare program. 

  2. In order to obtain approval, the provider/agent shall submit a printer's prototype of an exact replica of the Medicaid or NJ FamilyCare claim form and the programming instructions for completion of the form to the Fiscal Agent. 

  3. The provider/agent shall assume the entire cost of printing duplicate forms at all times. 

 (f) The New Jersey Medicaid or NJ FamilyCare program in approving any provider/agent agreement, assumes no responsibility for the performance of the provider or agent. In the event that any error of the provider/agent requires special programming to be made by the Fiscal Agent in order to have claims paid correctly, the provider/agent shall assume the entire cost of the special program.

SUBCHAPTER 8. PAYMENT FOR SERVICES PROVIDED

10:49-8.1 Fiscal Agent

  The State of New Jersey uses a fiscal agent for the processing of Medicaid claims, the pricing of charity care claims, and payment to providers.

10:49-8.2 Claims payment and pricing 

  (a) The Fiscal Agent will process claims daily and produce provider payments and associated Remittance Advice (RA) statements once each week. The RA is the provider's account statement and reflects the status of all claims currently entered into the Medicaid Management Information System. Provider payments in the form of checks and electronic funds transfers will be released following approval by the New Jersey Medicaid program. For charity care claims pricing information, see N.J.A.C. 10:52-11, 12 and 13. 

  1. The Remittance Advice (RA) is the major vehicle for communicating to the provider the status of all Medicaid claims received by the fiscal agent. All of the provider's claims are processed and supporting records are updated during each payment cycle. RA statements are generated as a result of a payment cycle. All claims processed (entered into the Medicaid Management Information System) fall into one of three classifications: paid; in process; or denied. 

   i. A claim that is correctly completed for a covered service provided to a Medicaid beneficiary by an approved provider will be   paid.  The claim will appear on the RA Claims Status page, or pages, along with all other claims for which a provider is being   paid in that payment cycle.  If the amount differs from the billed charges, an explanation will appear on the RA. 

   ii. In process claims or processed but unpaid claims are those claims held for prepayment review by the Division or by the Fiscal Agent. The review will result in a claim or group of claims being paid, denied, or additional information being requested. If additional information is required, a letter and/or a Claim Correction Form (CCF) will be forwarded to the provider. (Additional billing information is provided in the Fiscal Agent Billing Supplement following the second chapter of each Provider Services Manual). 

   iii. Reasons for denial of a claim will be provided on the RA in the form of an error/edit code. 

    (1) Messages explaining all codes reflected on the Remittance Advice will be printed on a separate page. 

   (b) A unique 13 digit Internal Control Number (ICN) is assigned to each Medicaid claim received by the Fiscal Agent.  The ICN is reflected on the RA and can be used to track the status of a claim.  For more information about the ICN, see Fiscal Agent Billing Supplement following the second chapter of each Provider Services Manual. 

  (c) For each claim processed in a payment cycle, the ICN, beneficiary name, dates of service and other claim information is printed on the RA. On the line immediately below this information, a code is printed representing a denial reason, and other information that might be useful to the provider and payment reduction reasons, if any.  Messages explaining all codes found on the RA will be found on a separate page following the status listing of all claims.  For more information about Remittance Advice see the Fiscal Agent Billing Supplement following the second chapter of each Provider Services Manual. 

  (d) Claims may be paid beyond 12 months of the date of receipt with Federal financial participation (FFP) in the following situations: 

  1. When the claim invoice or retroactive adjustment is paid to a provider reimbursed under a retrospective payment system; 

  2. For a Medicare/Medicaid claim or Medicare/NJ KidCare claim, timely filed, payment may be made for services within six months after the program or provider receives notice of the Medicare claim disposition for a timely filed Medicare/Medicaid or Medicare/NJ KidCare claim;

  3. For claims from providers under investigation for fraud or abuse; or 

  4. For claims associated with administrative or legal actions pursuant to a hearing action or agency corrective action mandate, whether for an eligible individual or for all those eligibles affected in a similar manner. 

10:49-8.3 Adjustments following payment of claims 

  (a) If a claim is incorrectly paid and the provider receives an overpayment or underpayment, within 60 days of such receipt, the provider shall notify the Fiscal Agent in writing. (For the procedure to follow, see Fiscal Agent Billing Supplement, MMIS Claim Adjustment Request Form, (FD-999(9/91) following the second chapter of each Provider Services Manual). 

  (b) On occasion, a claim will be paid that should not have been paid. If a claim is paid in error, within 60 days of such receipt, the provider shall notify the Fiscal Agent by requesting that the claim be voided. (For the procedure to follow, see the Fiscal Agent Billing Supplement following the second chapter of each Provider Services Manual.) 

  (c) Any adjustment made by Medicare will not cross over to Medicaid. If Medicare makes an adjustment that results in an overpayment or underpayment by Medicaid, within 60 days of receipt of any such overpayment or under payment, the provider shall notify the Fiscal Agent. (For the procedure to follow, see the Fiscal Agent Billing Supplement following the second chapter of each Provider Services Manual).

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

   (a) Through electronic funds transfer, a provider has the option of receiving claims payment automatically as a direct deposit to his or her checking account. 

  1. To enroll in the EFT payment program, the provider must complete an EFT Enrollment Request/Authorization form.  A voided check displaying the provider's account number must accompany the complete authorization form.  The enrollment form must be signed by the provider or an authorized official such as the business manager, owner, or facility administrator.  Any change to the EFT information (for example, a change of account number, ownership, or authorized official) requires the completion of a new EFT Enrollment Request/Authorization form.  (For detailed instructions about enrollment in the EFT payment program, see the Fiscal Agent Billing Supplement following the second chapter of each Provider Services Manual.)

10:49-8.5 Outstanding checks

   (a) After Medicaid checks are outstanding for a period of six months, a follow-up letter shall be sent to the payee.  This procedure shall only apply to checks of $5.00 or more. 

  (b) All Medicaid checks remaining outstanding after 12 months shall be cancelled in monthly lots rather than check by check.  Listings of cancelled checks shall be in sufficient detail to identify providers and amounts of payment.  These records shall be retained for audit.

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

   (a) Under NJ FamilyCare-Plan C, personal contribution to care in the amounts indicated below shall be collected by the provider for the services indicated below: 

  1. Outpatient hospital clinic services:  $5.00 personal contribution to care for outpatient visits.  No personal contribution to care shall be charged for well-child visits in accordance with the schedule recommended by the American Academy of Pediatrics;  lead screening and treatment;  age-appropriate immunizations;  prenatal care;  preventive services;  family planning services;  or substance abuse treatment services.  Specific policies are set forth at N.J.A.C. 10:52-4.7.

  2. $10.00 personal contribution to care for each covered emergency room services visit which does not result in an inpatient hospital stay.

   3. Physician services:  $5.00 personal contribution to care per visit.  No personal contribution to care shall be charged for well-child visits in accordance with the schedule recommended by the American Academy of Pediatrics;  lead screening and treatment;  age-appropriate immunizations;  prenatal care;  preventive or for family planning services, or substance abuse treatment services.  Policies specific to physician personal contribution to care services are set forth at N.J.A.C. 10:54-4.1. 

  4. Clinic services:  $5.00 personal contribution to care for clinic visits.  No personal contribution to care shall be charged for well-child visits in accordance with the schedule recommended by the American Academy of Pediatrics;  lead screening and treatment;  age-appropriate immunizations;  prenatal care;  preventive or for family planning services, or substance abuse treatment services.  Policies specific to clinic personal contribution to care policies are set forth at N.J.A.C. 10:66-1.6. 

  5. Podiatric services:  $5.00 personal contribution to care for office visits.  Specific policies regarding podiatric personal contribution to care are set forth at N.J.A.C. 10:57-1.7. 

  6. Optometric services:  $5.00 personal contribution to care for professional vision care services.  Specific policies are set forth at N.J.A.C. 10:62-1.6. 

  7. Chiropractic services:  $5.00 personal contribution to care.  Covered for spinal manipulation only. 

  8. Prescription drugs:  $1.00 personal contribution to care for generics and $5.00 for brand name drugs.  Includes insulin, needles and syringes.  Specific policies regarding personal contribution to care for prescription drugs are set forth at N.J.A.C. 10:51-1.12. 

  9. Psychological services:  $5.00 personal contribution to care.  Specific policies for psychologists are set forth at N.J.A.C. 10:67-1.6. 

  10. Certified nurse-midwife services:  $5.00 personal contribution to care.  No personal contribution to care shall be charged for prenatal care, preventive care, or for family planning services.  See N.J.A.C. 10:58-1.8 for specific policies related to certified nurse-midwife services. 

  11. Clinical nurse practitioner:  $5.00 personal contribution to care.  No personal contribution to care shall be charged for well-child visits in accordance with the schedule recommended by the American Academy of Pediatrics;  lead screening and treatment;  age-appropriate immunizations;  prenatal care;  preventive or for family planning services, or substance abuse treatment services.  Specific policies are set forth at N.J.A.C. 10:58A-1.6. 

  12. Dental services:  $5.00 personal contribution to care applies, unless the visit is for preventive dentistry services.  Specific policies are set forth at N.J.A.C. 10:57-1.7. 

  (b) Providers are required to collect the personal contribution to care for the NJ FamilyCare-Plan C services set forth in (a) above if the NJ FamilyCare Identification card indicates that a personal contribution to care is required and the beneficiary does not have a NJ FamilyCare letter which indicates that the beneficiary has reached his or her cost share limit and no further personal contributions to care are required until further notice. Personal contributions to care can not be waived. 

  (c) Under NJ FamilyCare-Plan D, copayments in the amounts indicated below shall be collected by the provider for services as follows, if copayment is indicated on the beneficiary's HMO card: 

  1. A $5.00 copayment per visit shall be required for the following services: 

   i. Primary care provider office visit; 

    (1) A $10.00 copayment shall apply for services rendered during non-office hours and for home visits. 

    (2) The $5.00 copayment shall apply only to the first prenatal visit; 

   ii. Specialist and other practitioner office visit; 

   iii. Outpatient rehabilitation services, including physical therapy, occupational therapy and speech therapy; 

   iv. Hospital outpatient department visits and diagnostic testing; 

   v. Routine eye examinations; 

   vi. Prescription drugs; 

    (1) If greater than a 34-day supply of a prescription drug is dispensed, a $10.00 copayment shall apply;  and 

   vii. Outpatient substance abuse services for detoxification; 

  2. A $25.00 copayment per visit shall be required for outpatient mental health visits;  and 

  3. A $35.00 copayment per visit shall be required for outpatient emergency services, including services provided in an outpatient hospital department or an urgent care facility. 

   i. No copayment shall be required if the beneficiary was referred to the emergency room by his or her primary care provider for   services that should have been rendered in the primary care physician's office, or if the beneficiary is admitted into the   hospital. 

  4. No copayment shall be charged for the following services: 

   i. Emergency ambulance services; 

   ii. Outpatient surgery; 

   iii. Home health services; 

   iv. Hospice services; 

   v. Inpatient hospital services; 

   vi. Inpatient mental health services; or 

   vii. Inpatient substance abuse detoxification services. 

  (d) Personal contributions to care under NJ FamilyCare-Plan C and copayments under NJ FamilyCare-Plan D shall be effective upon date of enrollment. 

  1. Exception:  A personal contribution to care or copayment shall not apply to services rendered to a newborn until the newborn is enrolled in a managed care program. 

  (e) No personal contribution to care under NJ FamilyCare-Plan C shall be charged for well-child visits in accordance with the schedule recommended by the American Academy of Pediatrics; lead screening and treatment; age-appropriate immunizations; preventive dental services; prenatal care; for family planning services; or for substance abuse treatment services. 

  (f) No copayment under NJ FamilyCare-Plan D will be charged for well-child visits in accordance with the schedule recommended by the American Academy of Pediatrics; nor for lead screening and treatment; for age-appropriate immunizations; or for preventive dental services. 

 (g) No cost sharing shall be imposed on children who are American Indians/Alaska Natives. Proof of Federally recognized AI/AN tribal status shall be provided in the form of a tribal card or letter, in accordance with 42 C.F.R. 36a.16.

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

  (a) For children in families with income at or below 150 percent of the Federal poverty limit, there shall be no premiums under NJ FamilyCare-Plan B. 

  (b) Effective February 1, 2003, for families with gross income above 150 percent and at or below 200 percent of the Federal poverty level (NJ FamilyCare Plan C), a monthly premium shall be required to be paid for enrollment, as follows: 

  1. For children, there shall be a premium of $16.50 per family per month that applies to all families, regardless of the number of children in the family; 

  2. For parents/caretakers, there shall be a premium of $27.50 for the first parent and $11.00 for the second parent/caretaker. 

  (c) Under NJ FamilyCare-Plan D, effective February 1, 2003, the following premiums shall apply: 

  1. For children in families with gross income above 200 percent and at or below 250 percent of the Federal poverty level, a single monthly premium of $33.00 per family per month that applies to all families, regardless of the number of children in the family. 

  2. For children in families with gross income above 250 percent and at or below 300 percent of the Federal poverty level, a single monthly premium of $66.00 per family per month that applies to all families, regardless of the number of children in the family. 

  3. For children in families with gross income above 300 percent and at or below 350 percent of the Federal poverty level, a single monthly premium of $110.00 per family per month that applies to all families, regardless of the number of children in the family. 

  (d) Families shall be billed in advance of the coverage month. Failure to submit the full contribution will result in termination of coverage for the month following the coverage month that the premium has not been received by the NJ FamilyCare program. 

  (e) The premiums required in accordance with (b) through (d) above shall be adjusted each July 1, in accordance with the change in the Consumer Price Index published by the U.S. Department of Labor. The amounts in (b) through (d) above will be revised annually by a notice of administrative change published in the New Jersey Register.

  (f) No cost sharing shall be imposed on children who are American Indians/Alaska Natives. Proof of Federally recognized AI/AN tribal status shall be provided in the form of a tribal card or letter, in accordance with 42 C.F.R. 36a.16.

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

  (a) There shall be a family limit on cost-sharing equal to 5 percent of household income for Plan C beneficiaries. 

  (b) The cost-sharing limit shall be calculated annually starting with the date of initial enrollment of any children in the family or the annual reenrollment date.  For ease of administration, the annual premium should be calculated by the Statewide eligibility determination agency and used to reduce the family cost from the first day of enrollment. 

  (c) Once the limits have been met, the Statewide eligibility determination agency shall issue a certification indicating that the Plan C member has met their cost share limit, and the provider shall not collect a personal contribution to care until further notice. 

  (d) No cost sharing shall be imposed on children who are American Indians/Alaska Natives. Proof of Federally recognized AI/AN tribal status shall be provided in the form of a tribal card or letter, in accordance with 42 C.F.R. 36a.16. 

10:49-9.4 Civil rights 

  Federal regulations require that services provided to any Medicaid beneficiary shall be given without discrimination on the basis of race, color, national origin, or handicap.  Therefore, payments shall be limited to providers of service who are in compliance with the nondiscrimination requirements of Title VI of the Civil Rights Act and Section 504 of the Rehabilitation Act of 1973.

10:49-9.5 Observance of religious belief

   (a) Nothing in the Medicaid program shall be construed to require any beneficiary to undergo any medical screening, examination, diagnosis, or treatment, or to accept any other health care or services provided under the program for any purpose (other than for the purpose of discovering and preventing the spread of infection or contagious disease or for the purpose of protecting environmental health) if such person or his or her parent or guardian objects thereto on religious grounds, except as specified in (b) below. 

  (b) If a physical examination is necessary to establish eligibility based on disability or blindness, the Medicaid Program may not find an individual eligible for Medicaid unless he or she undergoes the examination.

10:49-9.6 Free choice by beneficiary and provider

   (a) The concept of freedom of choice shall apply to both provider and beneficiary. 

  1. A Medicaid fee-for-service beneficiary shall be free to choose providers of service who meet program standards and who elect to participate in the Medicaid program. The MACC shall assist any beneficiary in obtaining services if the beneficiary cannot locate a provider. Exception: See N.J.A.C. 10:49-14.2, Special Status programs. 

  2. A Medicaid provider who accepts a Medicaid beneficiary as a patient under the Medicaid program shall accept the program's policies and reimbursement for all covered services and/or items provided or delivered during that period when, by mutual agreement, the beneficiary is under the provider's care.  In the provision of professional services, the provider shall be bound by the code of ethics governing his or her profession.

10:49-9.7 Confidentiality of records 

  (a) All information concerning applicants and beneficiaries acquired under this program shall be confidential and shall not be released without the written consent of the individual or his or her authorized representative.  If, because of an emergency situation, time does not permit obtaining consent before release, the program shall notify the individual, his or her family, or authorized representative, immediately after releasing the information.

   (b) The restriction on the disclosure of information shall not preclude the release of statistical or summary data or information in which applicants or beneficiaries are not, and cannot be, identified;  nor shall it preclude the exchange of information among providers furnishing services, Fiscal Agent of the program, and State or local government agencies, for purposes directly connected with administration of the program.  Disclosure without the consent of the applicant or beneficiary shall be limited to purposes directly connected with the administration of the program in accordance with Federal and State law and regulations. 

  1. Purposes directly connected with the administration of the program shall include but are not limited to: 

   i. Establishing eligibility; 

   ii. Determining the amount of medical assistance; 

   iii. Providing services for beneficiaries;  and 

   iv. Conducting or assisting an investigation, prosecution, or civil or criminal proceeding related to the administration of the program. 

  (c) The type of information about applicants and beneficiaries that shall be safeguarded by the program includes, but is not limited to:

   1. Name and address; 

  2. Medical services provided; 

  3. Social and economic conditions or circumstances; 

  4. Program evaluations of personal information; 

  5. Medical data, including diagnosis and past history of disease or disability; 

  6. Any information received for verifying income eligibility and amount of medical assistance payments.  Income information received from SSA or the Internal Revenue Service shall be safeguarded according to the requirements of the agency that furnished the data;  and 

  7. Any information received in connection with the identification of legally liable third party resources as required under applicable Federal Regulations (42 C.F.R. 433.138).

10:49-9.8 Provider certification and recordkeeping

   (a) All program providers, except institutional, pharmaceutical, and transportation providers, shall be required to certify that the services billed on any claim were rendered by or under his or her supervision (as defined and permitted by program regulations);  and all providers shall certify that the information furnished on the claim is true, accurate, and complete. 

  1. All claims for covered services must be personally signed by the provider or by an authorized representative of the provider (for example, hospital, home health agency, independent clinic) unless the provider is approved for electronic media claims (EMC) submission by the Fiscal Agent.  The provider must apply to the Fiscal Agent for EMC approval and sign an electronic billing certificate. 

   i. The following signature types are unacceptable: 

    (1) Initials instead of signature; 

    (2) Stamped signature;  and 

    (3) Automated (machine-generated) signature. 

  (b) Providers shall agree to the following: 

  1. To keep such records as are necessary to disclose fully the extent of services provided, and, as required by N.J.S.A. 30:4D-12(d), to retain individual patient records for a minimum period of five years from the date the service was rendered; 

  2. To furnish information for such services as the program may request; 

  3. That where such records do not document the extent of services billed, payment adjustments shall be necessary; 

  4. That the services billed on any claim and the amount charged therefore, are in accordance with the requirements of the New Jersey Medicaid and/or NJ FamilyCare programs; 

  5. That no part of the net amount payable under any claim has been paid, except that all available third party liability has been exhausted, in accordance with program requirements; and 

  6. That payment of such amount, after exhaustion of third party liability, will be accepted as payment in full without additional charge to the Medicaid or NJ FamilyCare beneficiary or to others on his behalf. 

  (c) When a Medicaid or NJ FamilyCare provider employs, contracts or subcontracts with an individual or entity that is not an enrolled Medicaid or NJ FamilyCare provider, the services provided to Medicaid or NJ FamilyCare beneficiaries by that employee, contractor or subcontractor shall meet all the requirements of the Medicaid or NJ FamilyCare programs as defined at N.J.A.C. 10:49-5 and 6 and 10:49-9.8(a) and (b), and the pertinent provider chapters of the New Jersey Administrative Code, which requirements include, but are not limited to, availability of services, range of services, quality of care, licensure, non-exclusion under N.J.A.C. 10:49-11.1 and completeness of documentation. Failure to do so may result in either or both of the following consequences: 

  1. The Division may recover from the enrolled Medicaid or NJ FamilyCare provider the Medicaid or NJ FamilyCare reimbursement paid by the Program to the provider for any service rendered by an employee, contractor, subcontractor or a contractor's or subcontractor's employee not meeting such requirements; and/or 

  2. The provider, contractor, subcontractor or other responsible party may be subject to any applicable civil or criminal sanctions and/or penalties. 

  (d) A Medicaid or NJ FamilyCare provider shall ensure that any individuals or entities employed by or under contract to a contractor or subcontractor performing services for the provider, fully satisfy all applicable State, Federal, and any other licensure and certification requirements. This shall include, but not be limited to, any equipment and/or vehicles relating to services provided to Medicaid or NJ FamilyCare beneficiaries. Failure to assure that all such requirements are met may result in either or both consequences specified in (c)1 and 2 above.

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

  (a) Except as provided in (e) below, a beneficiary shall sign a certification, authorization to release information and payment request after the services identified on the claim are provided and before the provider submits a claim for payment. The beneficiary is: 

  1. Certifying that the service(s) covered by a claim has been received; 

  2. Requesting payment for those services made on his or her behalf;  and 

  3. Authorizing any holder of medical or other information to release to the New Jersey Medicaid or NJ FamilyCare program or its authorized agents any information needed for this or a related claim. 

  (b) A provider shall obtain the beneficiary or representative's certification on the Medicaid or NJ FamilyCare hard-copy claim (appropriate to the provider), except as noted in (c) below, on the standard Patient Certification (Form FD-197) or on a similar form of the provider's choosing (referred to in this section as a certification log), as long as the form identifies the beneficiary by name and Medicaid or NJ FamilyCare Eligibility Identification Number, provides the date of service, contains a brief, non-technical description of the service(s) provided, and provides the certification and signature described in (a) above in a legible and readily understandable format. A provider who chooses to use Form FD-197 to obtain patient certification information shall use the column headed "Other Comments" to record the description of the service(s) provided. The provider shall keep this certification on file for each service rendered and shall make the form available upon request to representatives of the New Jersey Medicaid or NJ FamilyCare program. Initials instead of a signature are unacceptable on the certification form. 

  1. If a signed Patient Certification Form is not on file for each service, Medicaid and/or NJ FamilyCare reimbursement for the service shall be subject to recoupment. 

  (c) Certain providers may be required to use an individualized certification form that calls for information in addition to that described in

  (b) above, as indicated in the specific service chapter of the Division's rules. 

  (d) A provider shall complete a Medicaid or NJ FamilyCare hard-copy claim, Patient Certification Form, or certification log before it is presented to the beneficiary for signature. A Medicaid or NJ FamilyCare beneficiary shall not sign a blank Medicaid or NJ FamilyCare hard-copy claim, Patient Certification Form, or certification log, nor shall he or she sign the form prior to receiving services or as a condition for receiving services. 

  (e) When the beneficiary's signature is unobtainable, the following procedures shall be used: 

  1. An illiterate beneficiary shall make his or her mark (x), and the mark shall be witnessed by another person who signs his or her name on the Patient Certification Form (FD-197), certification log, or on the Medicaid or NJ FamilyCare hard-copy claim. 

  2. If a beneficiary is physically or mentally incapable of signing, or is deceased, the form(s) may be signed on his or her behalf by: 

   i. A parent; 

   ii. A legal guardian; 

   iii. A relation; 

   iv. A friend; 

   v. An individual provider; 

   vi. A representative of an institution providing care or support; 

   vii. A representative of a governmental agency providing assistance;  or 

   viii. An administrator or executor. 

  3. A brief explanation of the reason the beneficiary was not personally able to sign the form(s) and the relationship of the signer to the beneficiary shall be noted directly on the hard-copy claim, certification log, or the Patient Certification Form (FD-197).

10:49-9.10 Withholding of provider payments 

  (a) When the Division, in accordance with 42 C.F.R. 455.23, receives reliable evidence of fraud or willful misrepresentation by a provider, including an HMO, as well as a practitioner or entity participating in an HMO's network (whether or not the HMO practitioner or entity is also enrolled as a Medicaid or NJ FamilyCare provider), the Medicaid Agent or the Division shall withhold Program payments, in whole or in part, upon approval by the Division Director or the Assistant Director, Office of Program Integrity Administration, or their designee. Further, a practitioner or entity participating in an HMO's network subject to a withholding action under this section shall have any payments for services rendered to Medicaid and NJ FamilyCare beneficiaries withheld by the HMO. 

  (b) "Reliable evidence" shall include, but not necessarily be limited to: 

  1. Receipt of information from a Division unit or from the Department of Health and Senior Services, Department of Banking and Insurance or a law enforcement, investigatory, or prosecutorial agency that indicates fraud or willful misrepresentation has occurred or is occurring; 

  2. Information from any other local, county, State or Federal agency indicating fraud or willful misrepresentation has occurred or is occurring;  or 

  3. Indications that a violation of those subsections of N.J.A.C. 10:49-11.1 that pertain to fraud or willful misrepresentation may have occurred or is occurring, including, but not necessarily limited to, overutilization or misutilization;  any unexplained increase in the number of claims rejected by the claims processing system;  or any other reliable grounds to believe that fraud or willful misrepresentation may have occurred or is occurring. 

  (c) Withholding may be total or partial, and if partial, may be predicated upon withholding by specific claim type, practitioner, procedure code, diagnosis, or other factors. 

  (d) The Division shall send notice of its withholding to the affected provider, practitioner or entity within five days of taking such action. The notice shall also be sent to all participating HMOs to enable them to identify if the affected provider, practitioner or entity is also part of their network. The HMOs shall be required to implement the provisions of this section within their network. The notice shall set forth the general allegations as to the nature of the withholding action, but need not disclose specific information concerning any ongoing civil or criminal investigation. The notice shall: 

  1. State that payments are being withheld in accordance with this regulation and with 42 C.F.R. 455.23; 

  2. State that withholding is for a period initially not to exceed six months, after which the withholding action shall be reviewed to determine if an additional period of withholding is warranted.  Withholding shall be terminated when the Division determines there is insufficient evidence of fraud or willful misrepresentation, or legal proceedings relating to the fraud or willful misrepresentation are completed; 

  3. Specify, when appropriate, to which type or types of claims withholding is effective; 

  4. Inform the provider, practitioner or entity of the right to submit written evidence for consideration by the Medicaid Agent or the Division;  and 

  5. Set forth the provider's, practitioner's or entity's right to submit to the Division, within 20 days of the provider's receipt of the withholding notice, a request for an administrative hearing, consistent with N.J.A.C. 10:49-10.3. Immediately upon receipt of such a request, the Division shall request the Office of Administrative Law to schedule a hearing on an expedited basis.  

  (e) Regular, periodic meetings shall be held to review all parties from whom payments are being withheld under this section.  Also, in a case involving any party against which withholding is being imposed, where circumstances indicate that the reason for the withholding may no longer exist, said case shall be brought before a committee to be comprised of staff of the Division of Medical Assistance and Health Services, or their designees, for consideration of cessation of withholding of payment, upon the request of any of the specified officials.

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

  The Division, in order to maintain the integrity of the programs it administers in whole or in part, strictly prohibits its employees, or representatives of its contractors, subcontractors or fiscal agents, from accepting gifts or gratuities of any kind and of any value from representatives of providers or provider-related individuals, entities, organizations or institutions if receipt of such gifts or gratuities would violate the rules of the New Jersey Executive Commission on Ethical Standards (N.J.A.C. 19:61), the New Jersey Conflicts of Interest Law (N.J.S.A. 52:13D-12 et seq.), Executive Order No. 189 (July 20, 1988), and/or Executive Order No. 2 (January 18, 1994). This includes the prohibition of offers of special employment, consultation fees and all other gratuities by a provider, individual or facility.

10:49-9.12 Fraud and abuse

   The New Jersey Medicaid and NJ FamilyCare programs shall employ methods to identify situations in which a question of fraud and/or abuse in the program may exist. The Division shall refer to law enforcement officials situations in which there is valid reason to suspect that fraud has or may have been committed.

10:49-9.13 Informing individuals of their rights 

  (a) All Medicaid and NJ FamilyCare-Plan A claimants shall be informed of the following, in writing, at the time of application and at the time of any action affecting their claim: 

  1. Of their right to a fair hearing; 

  2. Of the method by which they may obtain a hearing; 

  3. That they may be represented by legal counsel or by a relative, friend, or other spokesperson, or they may represent themselves;  and 

  4. Of legal services within the community from which they may receive legal aid. 

  (b) NJ FamilyCare-Plan B, C and D enrollees are entitled to use the grievance procedure established by the Division of Medical Assistance and Health Services or the administrative law hearing process established at N.J.A.C. 10:79-6.5 and 6.6, as appropriate.

10:49-9.14 Provisions for appeals;  fair hearings 

  (a) Pursuant to N.J.A.C. 10:49-10, Notices, Appeals, and Fair Hearings, providers, Medicaid beneficiaries and NJ FamilyCare-Plan A beneficiaries shall have the right to file for fair hearings. 

  (b) A provider may be granted a hearing because of the denial of a prior authorization request or issues involving the provider's status;  for example, termination, debarment, suspension, and so forth, as described in N.J.A.C. 10:49-11.1, or issues arising out of the claims payment process. 

  (c) A Medicaid or NJ FamilyCare-Plan A beneficiary may be granted a fair hearing in accordance with N.J.A.C. 10:49-10 if his or her claim for medical assistance is denied or is not acted upon with reasonable promptness, or because the beneficiary is aggrieved by any other agency action resulting in non-eligibility, denial, termination, reduction or suspension of such assistance. A NJ FamilyCare-Plan B, C and D beneficiary shall be afforded the opportunity for grievance review in accordance with N.J.A.C. 10:78-8. 

  (d) In order to obtain a fair hearing, the provider or the beneficiary shall submit a request in writing to the Medicaid Agent at the address as specified in the notice. 

  (e) Any nursing facility whose certification or Medicaid Provider Agreement is denied, terminated, or not renewed, may request a hearing in accordance with the appeals procedure described in the Nursing Facilities Services chapter.

10:49-9.15 Advance directives

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

  "Advance directive" means a written expression of a patient's preferences regarding the provision, withholding or withdrawal of a medical service, treatment or procedure in the event that the patient subsequently lacks decision making capacity. An advance directive may include a proxy directive or an instruction directive, or both. 

  "Decision making capacity" means a patient's ability to understand and appreciate the nature and consequences of health care decisions, including the benefits and risks of each, and alternatives to any proposed health care, and to reach an informed decision. A patient's decision making capacity is evaluated relative to the demands of a particular health care decision. 

  "Declarant" means a competent adult 18 years of age or older who executes an advance directive. 

  "Health care decision" means a decision to accept or to refuse any treatment, service or procedure used to diagnose, treat or care for a patient's physical or mental condition, including life-sustaining treatment. "Health care decision" also means a decision to accept or to refuse the services of a particular physician, nurse, other health care professional or health care institution, including a decision to accept or to refuse a transfer of care. 

  "Health care institution" means institutions, facilities, and agencies licensed, certified, or otherwise authorized by State law to administer health care in the ordinary course of business, including hospitals, nursing homes, residential health care facilities, home health care agencies, personal care service agencies, and hospice programs operating in this State, mental health institutions, facilities or agencies, or institutions, facilities and agencies for the developmentally disabled. For purposes of this section, "health care institution" also means a managed care organization contracted pursuant to N.J.A.C. 10:74 to provide medical services to beneficiaries of the New Jersey Medicaid/NJ KidCare/NJ FamilyCare program. 

   "Health care professional" means an individual, as opposed to a health care institution, licensed by this State to administer health care in the ordinary course of business or practice of a profession. 

  "Health care representative" means the individual designated by a declarant pursuant to the proxy directive part of an advance directive for the purpose of making health care decisions on the declarant's behalf, and includes an individual designated as an alternate health care representative who is acting as the declarant's health care representative in accordance with the terms and order of priority stated in an advance directive.

   "Instruction directive" means a writing which provides instructions and direction regarding the declarant's wishes for health care in the event that the declarant subsequently lacks decision making capacity. 

  "Life-sustaining treatment" means the use of any medical device or procedure, artificially provided fluids and nutrition, drugs, surgery or therapy that uses mechanical or other artificial means to sustain, restore or supplant a vital bodily function, and thereby increase the expected life span of a patient.

   "Nurse" means a person currently licensed to practice as a registered professional nurse who is certified by the New Jersey State Board of Nursing in accordance with N.J.A.C. 13:37-7, and with N.J.S.A. 45:11-23 et seq., or similarly licensed and certified by a comparable agency of the state in which he or she practices. 

  "Other health care professionals" means licensed health care professionals other than physicians and nurses. 

  "Patient" means an individual who is under the care of a physician, nurse or other health care professional. 

  "Physician" means an individual licensed to practice medicine and surgery in this State. 

  "Proxy directive" means a writing which designates a health care representative in the event the declarant subsequently lacks decision making capacity. 

  (b) Participating health care institutions shall establish written policies and procedures concerning the rights of patients to make decisions regarding their medical care and their right to execute advance directives. In addition to policies affirming patients' rights:

   1. Private religiously-affiliated health care institutions may develop institutional policies and practices defining circumstances under which they will decline to participate in the withholding or withdrawing of specific measures to sustain life. Such policies and practices shall be written, and shall be properly communicated to patients and their families and health care representatives before or at the time of the patient's admission or enrollment. If the institution's policies and practices appear to conflict with the legal rights of a patient wishing to forego health care, the health care institution shall attempt to resolve the conflict. If a mutually satisfactory accommodation cannot be reached, the health care institution shall take all reasonable steps to effect the appropriate, timely and respectful transfer of the patient to the care of another health care institution appropriate to the patient's needs, and shall assure that the patient is not abandoned or treated disrespectfully; and 

   2. Health care institutions shall include in their policies a statement informing physicians, nurses and other health care professionals of their rights and responsibilities, to assure that such rights and responsibilities are understood, including the right to decline to participate in withholding or withdrawing life-sustaining treatment, in accordance with sincerely held personal or professional convictions, and to provide a forum for discussion and consultation on the subject of such rights. 

  (c) Nothing in this section shall be construed as restricting, modifying or replacing the requirements established for health  care institutions by the Department of Health and Senior Services (see N.J.A.C. 8:36, 8:39, 8:42, 8:43, 8:43C and 8:43G for specific requirements). 

  (d) In addition to developing the written policies referred to in (b) above, health care institutions shall: 

  1. Furnish patients with written information about their rights to accept or refuse treatment, and to formulate advance

directives. This information shall also be made available on request to patients' health care representatives, families and other interested parties; 

  2. Note in each patient's medical record whether that patient has executed an advance directive; 

  3. Provide (individually or with others) for education of staff and the community on issues concerning advance directives; 

  4. Provide care or other services without discrimination based on whether or not the individual has executed an advance directive; and 

  5. Ensure compliance with State law regarding advance directives (see N.J.S.A. 26:2H-53 et seq.). 

  (e) Health care institutions shall distribute written information concerning advance directives to individuals: 

  1. In the case of a hospital, at the time of the individual's admission as an inpatient; 

  2. In the case of a nursing facility, at the time of the individual's admission as a resident; 

  3. In the case of a provider of home health care, personal care assistant services or private duty nursing services, in advance of the individual coming under the provider's care; 

  4. In the case of a hospice program, at the time the individual initially receives hospice care from the program; and 

  5. In the case of a managed care organization, at the time the individual enrolls in the program. 

  (f) A physician, nurse, or other health care professional may decline to participate in the withholding or withdrawing life-sustaining treatment, in accordance with sincerely held personal or professional convictions, consistent with the provisions of N.J.S.A. 26:2H-62(b) and (c).

SUBCHAPTER 10. NOTICES, APPEALS AND FAIR HEARINGS

 10:49-10.1 Definitions 

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

  "Applicant" means any person who has made application for purpose of becoming a "qualified applicant." 

  "Claimant," when used within these rules, means applicant, qualified applicant or beneficiary as defined in this section. 

  "Notice" means an announcement of a policy decision by the Title XIX or Title XXI agency that may adversely affect the Medicaid or NJ FamilyCare-Plan A beneficiary. 

  "Qualified applicant" means any person who is determined to be eligible to receive benefits in accordance with N.J.S.A. 30:4D-1 et seq., as amended and supplemented.

10:49-10.2 Notices

   (a) The New Jersey Medicaid or NJ FamilyCare program may print a notice of prospective policy changes affecting Medicaid or NJ FamilyCare beneficiaries or providers generally in one or more newspapers in New Jersey. 

  1. This public notice will be accompanied by a proposed rulemaking on the subject of the notice in the New Jersey Register. 

  2. The public notice may precede or be subsequent to the Register publication. 

  3. The Department of Human Services, or the Department of Health and Senior Services where authorized by Reorganization Plan No. 001-1996, may proceed to adopt the regulatory changes pursuant to N.J.S.A. 52:14B-4 without providing further notice.

10:49-10.3 Opportunity for fair hearing

   (a) An opportunity for a fair hearing may be granted to any provider requesting a hearing on any valid complaint or issue arising out of the Medicaid or NJ FamilyCare claims payment process: 

  1. Such issues shall include, but not be limited to, denials of prior authorization and denial of claims submitted for payment. 

  2. Such requests for hearing shall be made in writing within 20 days from the date of the notice of the agency action giving rise to said complaint or issue. 

  3. For claim denial or payment adjustment, the 20 days' notice starts from the date in the right hand corner of the Remittance Advice Claims Status returned to providers with the Remittance Advice cover page (see the Fiscal Agent Billing Supplement following the second chapter of each Providers Services Manual regarding the Remittance Advice cover page and Claims Status explanations and examples). Providers should include a photocopy of the applicable Claims Status page, highlighting the beneficiary and applicable edit code(s) when submitting a hearing request.

   (b) An opportunity for a fair hearing shall be granted to all claimants requesting a hearing because their claims for medical assistance are denied or are not acted upon with reasonable promptness, or because they believe the Medicaid Agent or NJ FamilyCare-Plan A program has erroneously terminated, reduced or suspended their assistance. The Medicaid Agent or NJ FamilyCare program need not grant a hearing if the sole issue is one of a Federal or State law requiring an automatic termination, reduction or suspension of assistance affecting some or all claimants. Under this requirement: 

  1. A request for hearing shall be defined as any clear expression (submitted in writing) by claimants (or someone authorized to act on behalf of claimants) to the effect that they desire the opportunity to present their case to higher authority; 

  2. The freedom to make such a request shall not be limited or interfered with in any way, and the Medicaid Agent or NJ FamilyCare-Plan A program emphasis shall be on helping claimants to submit and process their case if needed; 

  3. Claimants shall have 20 days from the date of notice of Medicaid Agent or NJ FamilyCare program action in which to request a hearing; 

  4. The fair hearing shall include consideration of: 

   i. Any Medicaid Agent or NJ FamilyCare-Plan A program action, or failure to act with reasonable promptness, on a claim for medical assistance, which includes undue delay in reaching a decision on eligibility, suspension of assistance or denial of such assistance in whole or in part; 

   ii. Medicaid Agent's or NJ FamilyCare-Plan A program's decision regarding: 

    (1) Eligibility for medical assistance in both initial and subsequent determinations; 

    (2) Amount of medical assistance or change in such assistance; 

  5. The Medicaid Agent or DMAHS may respond to a series of individual requests for fair hearings by arranging for a single group hearing.  A consolidation of cases by the Medicaid Agent or DMAHS may be allowed only in cases which the sole issue involved is one of Federal or State law or policy; 

  6. In all group hearings, whether initiated by the Medicaid Agent or DMAHS or by claimants, the policies governing fair hearings shall be followed.  Thus, each individual claimant shall be permitted to present his or her own case and be represented in accordance with the provisions of N.J.A.C. 10:49-9.13(a)3;  and

7. The Medicaid Agent or DMAHS shall not deny or dismiss a request for a hearing except where it has been withdrawn by claimant in writing or abandoned. 

  (c) For purposes of these rules, the right to a hearing is considered abandoned if claimants or their representative fail to appear at a scheduled hearing and, within five days after receipt of an inquiry as to whether they desire any furtheraction on their request, no reply is received.  Refusal of acceptance of a registered letter inquiring into contemplated further action by claimants shall constitute abandonment effective the date of refusal.

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

  (a) In cases of any proposed action to terminate, reduce or suspend assistance, the Medicaid Agent or DMAHS shall give the claimant timely and adequate notice detailing the reasons for the proposed action.  Under these requirements: 

  1. "Timely" means that the notice is dated at least 10 days before the action is to be taken;  and 

  2. "Adequate advance notice" means a written notice that includes a statement of the action the Medicaid Agent or DMAHS intends to take, reasons for the proposed departmental action, the specific regulations that support, or the change in Federal or State law that requires the action, the claimant's right to request a fair hearing, or in cases of a departmental action based on a change in law, the circumstances under which a hearing shall be granted, and the circumstances under which assistance shall be continued if a fair hearing is requested. 

  (b) In cases in which there is a request for a fair hearing within the advance notice period: 

  1. Assistance shall be continued until a decision is rendered unless: 

   i. It is determined at the hearing that the sole issue is one of Federal or State law or policy;  and 

   ii. The Medicaid Agent or DMAHS promptly informs the claimant in writing that services shall be terminated or reduced pending the hearing decision. 

  2. If the Medicaid Agent's or DMAHS's action is sustained by the hearing decision, the Medicaid Agent or DMAHS may institute recovery procedures against claimants to recoup the cost of any services furnished claimants to the extent the services were furnished solely by reason of this section. 

  (c) The Medicaid Agent or DMAHS may reinstate services if a claimant requests a hearing not more than 10 days after the effective date of the termination, suspension or reduction of eligibility or covered services. 

  1. If services are reinstated, they shall continue until a hearing decision is made unless it shall be determined at the hearing that the sole issue is one of Federal or State law or policy. 

  (d) The Medicaid Agent or DMAHS shall reinstate and continue services until a decision is rendered after a hearing if: 

  1. An action is taken to terminate, suspend or reduce eligibility or covered services without affording claimants adequate advance notice as defined herein; 

  2. Claimants request a hearing within 10 days of the date of the notice of action;  and 

  3. The Medicaid Agent or DMAHS determines that the action to terminate, reduce or suspend assistance resulted from reasons other than the application of Federal or State law or policy. 

  (e) If a claimant's whereabouts are unknown, as indicated by the return of unforwardable departmental mail directed to them, any discontinued services shall be reinstated if their whereabouts become known during the time they are eligible for services.

10:49-10.5 Location of hearing 

  The hearing shall be conducted at a reasonable time, date and place after adequate written notice of the hearing is given.

10:49-10.6 Impartiality of official conducting the hearing 

  The hearing shall be conducted by an Administrative Law Judge from the Office of Administrative Law or by other persons eligible to conduct hearings pursuant to the New Jersey Administrative Procedure Act, set forth in N.J.S.A. 52:14B-1 et seq. and 52:14F-1 et seq.

10:49-10.7 Beneficiary's right to different medical assessment

   When the hearing involves medical issues, such as those concerning a diagnosis or an examining physician's report or the medical review team's decision, and if the hearing officer considers it necessary to have a medical assessment other than that of the person or persons involved in making the original decision, such medical assessment shall be obtained at Departmental expense from a source satisfactory to the claimant and shall be made part of the record.

10:49-10.8 Hearing procedures 

  The hearing shall be conducted pursuant to the procedures set forth in the Administrative Procedure Act and the Uniform Administrative Procedure Rules (N.J.A.C. 1:1).  The Special Hearing Rules set forth in N.J.A.C. 1:10B apply to claimant (beneficiary) hearings.  (See 42 C.F.R. 431.200, Subpart E).

10:49-10.9 Prompt, definitive and final action 

  Prompt, definitive and final administrative action shall be taken within 90 days from the date of the request for a fair hearing, except where claimant requests an adjournment.

10:49-10.10 Notification to claimants 

  Claimants shall receive a written final decision, in the name of the Department and shall be notified of their right to judicial review.

10:49-10.11 Action upon favorable decision to claimants 

  When the final hearing decision is favorable to claimants or when the Department decides in favor of claimants prior to the hearing, the Department shall make corrective payments retroactively to the date the incorrect action was taken or such earlier date as may be provided under State policy.

10:49-10.12 Hearing decision

   (a) A final decision by the Medicaid Agent's or DMAHS' head shall specify the reasons for the decision and identify the supporting evidence or may incorporate by reference the findings, conclusions, and recommendations, contained in the initial decision. 

  (b) Final decisions shall be binding on the Medicaid Agent or DMAHS. 

  (c) Under this rule, no person who participated in the local decision being appealed shall participate in a final administrative decision on such a case;  the Medicaid Agent or DMAHS shall be responsible for seeing that the decision is carried out promptly. 

  (d) The final decision shall be promptly implemented.

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

  The Medicaid Agent or DMAHS shall establish and maintain a method for informing, at least in summary form, all local agencies of all fair hearing decisions by the hearing authority and the decisions shall be accessible to the public (subject to the provisions of safeguarding public assistance information).

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

10:49-11.1 Program participation 

  (a) The provisions of this section were adopted and issued pursuant to Executive Order No. 34, dated March 29, 1976, and the authority vested in the Division of Medical Assistance and Health Services to implement the New Jersey Medicaid and NJ FamilyCare programs by rules and regulations set forth in N.J.S.A. 30:4D-5, N.J.S.A. 30:4D-17.1 a and c, Reorganization Plan No. 001-1996 and P.L. 1997, c.272. 

  (b) Suspension, debarment, and disqualification are measures which shall be invoked by the Division of Medical Assistance and Health Services to exclude or render ineligible certain persons from participation in contracts and subcontracts with the New Jersey Medicaid or NJ FamilyCare program, or in projects or contracts performed with the assistance of and subject to the approval of the Medicaid Agent or DMAHS, on the basis of a lack of responsibility. These measures shall be used for the purpose of protecting the interests of the New Jersey Medicaid and/or NJ FamilyCare programs and not for punishment. To assure the New Jersey Medicaid and/or NJ FamilyCare programs, the benefits to be derived from the full and free competition between and among such persons and to maximize the opportunity for honest competition and performance, these measures shall not be invoked for any time longer than deemed necessary to protect the interests of the New Jersey Medicaid and/or NJ FamilyCare programs. 

  1. Any individuals, including but not limited to, owners, officers, administrators, assistant administrators, employees, accountants, attorneys, and management services, who have been suspended, debarred or disqualified from participation in the Medicaid and/or NJ FamilyCare programs for any reason shall not be involved in any activity relating to the New Jersey Medicaid and/or NJ FamilyCare programs. 

  2. Providers reimbursed on a cost-related basis may not claim as allowable costs any amounts paid or credited to such individuals, and such amounts shall not be reimbursed by the New Jersey Medicaid and/or NJ FamilyCare programs. 

  3. Providers may not submit claims and shall not be reimbursed for any goods supplied or services rendered by such individuals. 

  4. The requirement in (b)3 above shall apply only for the period during which such individuals are suspended, debarred or disqualified from Medicaid and/or NJ FamilyCare participation.

   5. Claims shall not be submitted and claims shall not be reimbursable for any item or service (other than an emergency item or service, not including items or services furnished in an emergency room of a hospital) furnished at the direction or on the prescription of a physician, an individual or entity, during the period when such individual, entity or physician is excluded from participation in the Medicaid and NJ FamilyCare programs, and when the individual or entity furnishing such item or service has received written notice from the Division that the entity, individual or physician has been excluded from participation in the Medicaid and NJ FamilyCare programs.

  (c) The following words and terms, as used in this section, shall have the following meanings: 

  "Affiliates" means persons having an overt or covert relationship such that any one of them directly or indirectly controls or has the power to control another. 

  "Debarment" means an exclusion from State contracting, on the basis of a lack of responsibility evidenced by an offense, failure or inadequacy of performance, for a reasonable period of time commensurate with the seriousness of the offense, failure or inadequacy of performance. 

  "Disqualification" means a debarment or a suspension which denies or revokes a qualification to bid or otherwise engage in State contracting which has been granted or applied for pursuant to statute, rules or regulations. 

  "Exclusion" means the suspension, debarment or disqualification of any individual or entity from participation in any capacity in any program administered in whole or in part by DMAHS. 

  "Person" means any natural person, company, firm, association, corporation or other entity. 

  "State" means the State of New Jersey or any of the departments or agencies in the executive branch of government with the lawful authority to engage in contracting. 

  "State contracting" means any arrangement giving rise to an obligation to supply anything to or perform any service for the State, other than by virtue of State employment, or to supply anything to or perform any service for a private person where the State provides substantial financial assistance and retains the right to approve or disapprove the nature or quality of the goods or service or the persons who may supply or perform the same. 

  "Suspension" means an exclusion from State contracting for a temporary period of time, pending the completion of an investigation or legal proceedings. 

  (d) Any of the following, among other things, shall constitute a good cause for exclusion of a person by the Medicaid Agent or DMAHS: 

  1. Commission of a criminal offense as an incident to obtaining or attempting to obtain a public or private contract, or subcontract thereunder, or in the performance of such contract or subcontract; 

  2. Violation of the Federal Organized Crime Control Act of 1970, or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, perjury, false swearing, receiving stolen property, obstruction of justice or any other offense indicating a lack of business integrity or honesty; 

  3. Violation of the Federal or State antitrust statutes, or of the anti-kickback provisions of the Social Security Act at 42 U.S.C. s 1320 a-7b (b), subject to the exceptions set forth in 42 C.F.R. 1001.952; 

  4. Violations of any of the laws governing the conduct or elections of the State of New Jersey or of its political subdivisions; 

  5. Violation of the "Law Against Discrimination" (N.J.S.A. 10:5-1 et seq.), or of the "Act Banning Discrimination in Public Works Employment" (N.J.S.A. 10:2-1 et seq.) or of the "Act Prohibiting Discrimination by Industries Engaged in Defense Work in the Employment of Persons Therein" (N.J.S.A. 10:1-10 et seq.); 

  6. Violations of any laws governing hours of labor, minimum wage standards, prevailing wage standards, discrimination in wages, or child labor; 

  7. Violations of any laws, regulations or code of ethics governing the conduct of occupations or professions or regulated industries; 

  8. Willful failure to perform in accordance with contract specifications or within contractual time limits; 

  9. A record of failure to perform or of unsatisfactory performance in accordance with the terms of one or more contracts, provided that such failure or unsatisfactory performance has occurred within a reasonable time preceding the determination to debar and was caused by acts within the control of the person debarred; 

  10. Violations of contractual or statutory provisions regulating contingent fees; 

  11. Presentment for allowance or payment of any false or fraudulent claim for services or merchandise; 

  12. Submitting false information for the purpose of obtaining greater compensation than that to which the person is legally entitled;

  13. Submitting false information for the purpose of obtaining authorization requirements; 

  14. Failure to disclose or make available to the Medicaid Agent or DMAHS or its authorized agent, records of services provided to or payments made on behalf of Medicaid or NJ FamilyCare beneficiaries; 

  15. Failure to provide and maintain quality services to Medicaid or NJ FamilyCare beneficiaries within accepted medical community standards as determined by a body of peers; 

  16. Engaging in a course of conduct or performing an act deemed improper or abusive of the New Jersey Medicaid or NJ FamilyCare program following notification that said conduct should cease; 

  17. Breach of the terms of the Medicaid or NJ FamilyCare provider agreement entered into with the Medicaid Agent or DMAHS for failure to comply with the terms of the provider certification on the Medicaid or NJ FamilyCare claim; 

  18. Overutilizing the New Jersey Medicaid or NJ FamilyCare program by inducing, furnishing or otherwise causing an individual to receive service(s) or merchandise not otherwise required or requested by the beneficiary; 

  19. Rebating or accepting a fee or portion of a fee or charge for a Medicaid or NJ FamilyCare beneficiary referral; 

  20. Violating any provision of N.J.S.A. 30:4D-1 et seq.  (New Jersey Medical Assistance and Health Services Act) as amended or supplemented, or any rule or regulation promulgated by the Commissioner of Human Services or the Commissioner of Health and Senior Services pursuant thereto; 

  21. Conviction of any crime involving moral turpitude; 

  22. Submission of a false or fraudulent application for provider status to the Program or to its Fiscal Agent; 

  23. Any other cause affecting responsibility as a State contractor of such serious and compelling nature as may be determined by the Medicaid Agent or DMAHS to warrant exclusion, including such conduct as may be proscribed by the laws or contracts enumerated in this subsection, even if such conduct has not been or may not be prosecuted as violations of such laws or contracts; 

  24. Suspension, debarment or disqualification by some other department or agency in the executive branch; 

  25. Exclusion from participation in any state-funded medical assistance and/or health services program of another state; 

  26. Exclusion from participation in the delivery of medical care or services under Title XVIII, XIX, XX or XXI of the Federal Social Security Act by the Secretary of the United States Department of Health and Human Services; or 

  27. Failure to comply with an administrative subpoena issued by the Division. 

  (e) Conditions for debarment shall be as follows: 

  1. Debarment shall be made only upon approval of the Director of the Division, except as otherwise provided by law. 

  2. The existence of any of the causes set forth in (d) above, shall not necessarily require that a person be debarred.  In each instance, the decision to debar shall be made within the discretion of the Director of the Division unless otherwise required by law, and shall be rendered in the best interests of the Program. 

  3. All mitigating factors shall be considered in determining the seriousness of the offense, failure or inadequacy of performance and in deciding whether debarment is warranted. 

  4. The existence of a cause set forth in (d)1 through 7 above shall be established upon the rendering of a final judgment or conviction by a court of competent jurisdiction or by an administrative agency empowered to render such judgment.  In the event an appeal taken from such judgment or conviction results in reversal thereof, the debarment shall be removed upon the request of the debarred person unless other cause for debarment exists. 

  5. The existence of a cause set forth in (d)8, 9, 10 and 23 above shall be established by evidence which the Medicaid Agent or DMAHS determines to be clear and convincing in nature. 

  6. The existence of a cause set forth in (d)1 through 7, 11 through 22, and 24 above shall be established by a preponderance of the believable evidence. 

  7. Debarment for the cause set forth in (d)24 above shall be proper, provided that one of the causes set forth in (d)1 through 23 above was the basis for debarment by the original debarring agency.  Such debarment may be based entirely on the record of facts obtained by the original debarring agency, or upon a combination of such facts and additional facts. 

  (f) If the Medicaid Agent or DMAHS seeks to debar a person or his or her affiliates, the Medicaid Agent or DMAHS shall furnish such party with a written notice stating that debarment is being considered, setting forth the reasons for the proposed debarment and indicating that such party will be afforded an opportunity for a hearing if he or she so requests within a stated period of time.  All such hearings shall be conducted in accordance with the provisions of the Administrative Procedure Act.  However, where one department or agency has imposed debarment upon a party, a second department or agency may also impose a similar debarment without affording an opportunity for a hearing, provided that the second agency furnishes notice of the proposed similar debarment to that party and affords that party an opportunity to present information in his or her behalf to explain why the proposed similar debarment should not be imposed in whole or in part. 

   (g) Debarment shall be a reasonable, definitely stated period of time which as a general rule shall not exceed five years.  Debarment for an additional period shall be permitted provided that notice thereof is furnished and the party is accorded an opportunity to present information in his or her behalf to explain why the additional period of debarment should not be imposed. 

  (h) The scope of debarment rules shall be as follows: 

  1. Except as otherwise provided by law, a debarment may be removed or the period thereof may be reduced at the discretion of the debarring agency upon the submission of a good faith application under oath, supported by documentary evidence, setting forth substantial and appropriate grounds for the granting of relief, such as newly discovered material evidence, reversal of a conviction or judgment, actual change of ownership, management or control, or the elimination of the causes for which the debarment was imposed. 

  2. A debarment may include all known affiliates of a person, provided that each decision to include an affiliate is made on a case-by-case basis after giving due regard to all relevant facts and circumstances.  The offense, failure or inadequacy of performance of an individual may be imputed to a person with whom he or she is affiliated, where such conduct was accomplished within the course of his or her official duty or was effected by him or her with the knowledge or approval of such person. 

  3. Debarment by the Director of any provider of service shall preclude such provider from submitting claims for payment, either personally or through claims submitted by any clinic, group, corporation or other association to the Program or its fiscal agent for any services or supplies he or she has provided under the New Jersey Medicaid or NJ FamilyCare programs, except for services or supplies provided prior to the debarment. No clinic, group, corporation or other association which is a provider of services shall submit claims for payment to the program or its fiscal agent for any services or supplies provided by a person within such organization who has been debarred by the program, except for services or supplies provided prior to the debarment. 

  4. When the provisions of this section are violated by a provider of service which is a clinic, group, corporation or other association, the Director may debar such organization and/or any individual person within said organization who is responsible for such violation. 

  (i) The Medicaid Agent or DMAHS may suspend a person in the public interest for any cause specified in (d) above, or upon a reasonable suspicion that such cause exists, or when, in the opinion of the Medicaid Agent or DMAHS, such action is necessary to protect the public welfare and the interests of the Medicaid or NJ FamilyCare program. 

    (j) Conditions for suspension shall be as follows: 

  1. Suspension shall be imposed only upon approval of the Director of the Division and upon approval of the Attorney General, except as otherwise provided by law. 

  2. The existence of any cause for suspension shall not require that a suspension be imposed, and a decision to suspend shall be made at the discretion of the Director of the Division and of the Attorney General, and shall be rendered in the best interests of the New Jersey Medicaid and NJ FamilyCare programs. 

  3. Suspension shall not be based upon unsupported accusation, but upon adequate evidence that cause exists or upon evidence adequate to create a reasonable suspicion that cause exists. 

  4. In assessing whether adequate evidence exists, consideration shall be given to the amount of credible evidence which is available, to the existence or absence of corroboration as to important allegations, and to inferences which may properly be drawn from the existence or absence of affirmative facts. 

  5. Reasonable suspicion of the existence of a cause described in (d) above may be established by a judgment or order of an administrative agency, or court of competent jurisdiction, or by a judgment of conviction, grand jury indictment, accusation, arrest, or by evidence that such violations of civil or criminal law did in fact occur. 

  6. A suspension invoked by the Medicaid Agent or DMAHS for any of the causes described in (d) above may be the basis for the imposition of a concurrent suspension by another agency, which may impose such suspension without the approval of the Attorney General. 

  (k) The Medicaid Agent or DMAHS may suspend a person or his affiliates provided that within 10 days after the effective date of the suspension, the Medicaid Agent or DMAHS provides such party with a written notice stating that a suspension has been imposed and its effective date, setting forth the reasons for the suspension to the extent that the Attorney General determines that such reasons may be properly disclosed, stating that the suspension is for a temporary period pending the completion of an investigation and such legal proceedings as may ensue, and indicating that, if such legal proceedings are not commenced or the suspension removed within 60 days of the date of such notice, the party shall be given either a statement of the reasons for the suspension and an opportunity for a hearing, if he so requests, or a statement declining to give such reasons and setting forth the agency's position regarding the continuation of the suspension.  Where a suspension by the Medicaid Agent or DMAHS has been the basis for suspension by another agency, the latter shall note that fact as a reason for its suspension. 

  (l) A suspension shall not continue beyond 18 months from its effective date unless civil or criminal action regarding the alleged violation shall have been initiated within that period, or unless debarment action has been commenced. Whenever prosecution or debarment action has been initiated, the suspension may continue until the legal proceedings are completed. 

  (m) Scope of suspension rules shall be as follows: 

  1. A suspension may include all known affiliates of a person, provided that each decision to include an affiliate is made on a case-by-case basis after giving due regard to all relevant facts and circumstances.  The offense, failure or inadequacy of performance of an individual may be imputed to a person with whom he or she is affiliated, where such conduct was accomplished within the course of his official duty or was effectuated by him or her with the knowledge or approval of such person. 

  2. Suspension, by the Medicaid Agent or DMAHS, of any provider of service shall preclude such provider from submitting claims for payment, either personally or through claims submitted by any clinic, group, corporation or other association to the Program or its Fiscal Agent or DMAHS for any services or supplies he or she has provided under the New Jersey Medicaid or NJ FamilyCare program, except for services or supplies provided prior to the suspension. No clinic, group, corporation or other association which is a provider of services shall submit claims for payment to the Program or its Fiscal Agent for any services or supplies provided by a person within such organization who has been suspended by the Medicaid Agent or DMAHS, except for services or supplies provided prior to the suspension. 

  3. When the provisions of this section are violated by a provider of service which is a clinic, group, corporation or other association, the Director may suspend such organization and/or any individual person within said organization who is responsible for such violation. 

  (n) Exclusion from State contracting by virtue of debarment, suspension or disqualification shall extend to all State contracting and subcontracting within the control or jurisdiction of the Medicaid Agent or DMAHS. However, when it is determined essential to the public interest by the Director of the Division, and upon filing of a finding thereof with the Attorney General, an exception from total exclusion may be made with respect to a particular State contract.

   (o) Insofar as practicable, prior notice shall be given to the Attorney General and the Treasurer of any proposed debarment or suspension. 

  (p) The Medicaid Agent or DMAHS shall provide the State Treasurer with the names of all persons suspended or debarred and the effective date and term thereof, if any. 

  (q) This section shall be applicable to all persons, providers, contractors, Fiscal Agent, and their affiliates who engage in State contracting with the Medicaid Agent or DMAHS as defined in this section.

SUBCHAPTER 12. PROVIDER REINSTATEMENT

10:49-12.1 Definitions

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

  "Committee" means the Provider Reinstatement Committee. 

  "Person" means any natural person, company, firm, corporation, professional association, partnership, or other entity, who has been excluded from participation in the New Jersey Medicaid or the NJ FamilyCare program.

10:49-12.2 Requests for reinstatement 

  Persons who have been debarred, disqualified or suspended from participating in the New Jersey Medicaid or the NJ FamilyCare program shall petition the Director for reinstatement in writing.

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

  (a) Persons debarred or disqualified for a definitely stated period of time may petition the Director for reinstatement 90 days prior to the expiration of the period of debarment or disqualification. 

  (b) Persons disqualified for an indefinitely stated period of time may petition the Director for reinstatement after a disqualification period of eight years. 

  (c) Persons who have been suspended, debarred or disqualified as the result of an indictment, conviction or license revocation may immediately petition the Director for reinstatement upon acquittal, reversal of the conviction upon appeal or restoration of the license, whichever is applicable.

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

  (a) Persons debarred or disqualified for a definitely stated period of time may petition the Director for reinstatement 90 days prior to the expiration of the period of debarment or disqualification. 

  (b) Persons disqualified for an indefinitely stated period of time may petition the Director for reinstatement after a disqualification period of eight years. 

  (c) Persons who have been suspended, debarred or disqualified as the result of an indictment, conviction or license revocation may immediately petition the Director for reinstatement upon acquittal, reversal of the conviction upon appeal or restoration of the license, whichever is applicable.

10:49-12.5 Provider Reinstatement Committee

   (a) The Provider Reinstatement Committee shall be a non-standing committee that is convened for the purpose of evaluating requests for reinstatement. 

  1. The Committee shall be composed of three impartial officials of the New Jersey Medicaid or the NJ FamilyCare program appointed by the Director. 

   i. The Committee members shall not have been directly involved in the debarment, disqualification or suspension of persons   requesting reinstatement. 

   ii. The Chairperson of the Committee shall be an attorney from the Office of Legal and Regulatory Liaison/Division of Medical Assistance and Health Services. 

   iii. Whenever possible, the associate members of the Committee shall be one member of the Medicaid Agent or the NJ FamilyCare staff from the same discipline as the debarred, disqualified or suspended persons and one member from the general administrative staff of the Division.

10:49-12.6 Criteria for reinstatement 

  (a) Reinstatement will not be granted unless it is reasonably certain that the causes which led to the debarment, disqualification or suspension shall not be repeated. In determining a person's fitness for reinstatement, the Committee and the Director may consider, among other factors: 

  1. Statements from debarred, disqualified or suspended persons setting forth the reasons why they should be reinstated; 

  2. Statements from private health insurers, indicating whether there have been any questionable claims submitted during the period of exclusion from Program participation; 

  3. Statements from peer review bodies, probation or parole officers or professional associates, attesting to their belief, supported by facts, that the causes which led to the debarment, disqualification or suspension shall not be repeated; 

  4. The absence of any pending criminal, licensing, or professional disciplinary proceedings; 

  5. Full restitution and the payment of any criminal fines imposed; 

  6. Full satisfaction of any civil penalties imposed; 

  7. Full satisfaction of interest payments; 

  8. Compliance with the terms and conditions of Consent Orders or Court Orders;  and 

  9. Satisfaction of any conditions or requirements previously imposed by the Medicaid or the NJ FamilyCare program.

10:49-12.7 Committee procedures 

  (a) The Committee shall meet at the Division's central offices. 

  (b) Persons requesting reinstatement and/or their representative shall be notified, in writing, as to the time, date and place of the meeting. 

  (c) All correspondence concerning the meeting shall be directed to the Chairperson of the Committee. 

  (d) Persons requesting reinstatement may appear on their own behalf or be represented by counsel. 

  (e) The Committee shall be governed by the New Jersey Administrative Procedure Act concerning admissibility of evidence at the meeting. 

  (f) The Chairperson of the Committee shall rule on all procedural questions and objections that may be raised at the meeting. 

  (g) Persons requesting reinstatement shall have the burden of providing their fitness for reinstatement by a preponderance of the evidence. 

  (h) Persons may present evidence of their fitness for reinstatement by the testimony of witnesses under oath or by documentary evidence, or both. 

  (i) After reviewing the testimony and documentation presented, the Committee shall prepare a written report which discusses the testimony, contains findings of facts and recommended disposition. 

  (j) At least two members of the Committee shall concur in the recommended disposition. 

  (k) Copies of the Committee's report shall be sent to all parties at the meeting.  Upon receipt of the Committee's report, the parties shall have the opportunity to submit written objections or exceptions to said report within the time period specified by the committee. 

  (l) After the expiration of the time period prescribed for the filing of the exceptions, the Committee's report, exceptions or objections thereto, evidence and any transcripts shall be forwarded to the Director. 

  (m) The Director in consultation with the Commissioner of Health and Senior Services, where appropriate, shall have final decisional authority and may adopt, reverse or modify the Committee's recommended determination.  The Director may also, for cause, remand the matter back to the Committee for further testimony.

SUBCHAPTER 13. PROGRAM CONTROLS

10:49-13.1 Medical review and evaluation

   Under the provisions of Federal and State law, the Medicaid Agent or DMAHS shall provide continuing review and evaluation of the care and services provided under the Medicaid and NJ FamilyCare programs. This includes review of utilization of services of practitioners and other providers.

10:49-13.2 Audits 

  (a) A field audit shall be subject to the following: 

  1. "Completion of the field audit" for nursing facility providers for purposes of N.J.S.A. 30:4D-17(f) shall be defined in the following manner: 

   i. For all such audits and audit recovery cases pending on March 1, 1983, it shall mean the date that field work is completed,  or the date information requested from the provider during the course of that field work is received, whichever is later.

   ii. For all such audits and audit recovery cases pending on March 1, 1983, which are, have been or will be referred either to the Legal Action Committee, or to the Division of Criminal Justice or other agency for criminal investigation, it means the date the Office of Program Integrity Administration (OPIA) receives authorization to take administrative action.

  iii. For all such audits initiated on or after March 1, 1983, it means the date the exit conference is completed or the date information requested from the provider during the course of the exit conference is received, whichever is later. 

  2. "Completion of the field audit" for all other providers for purposes of N.J.S.A. 30:4D-17(f) shall be defined in the following manner: 

   i. For all such audits and audit recovery cases pending on March 1, 1983, it means the date of final screening of the case file   by the Assistant Director, OPIA or, if the case is referred to the Legal Action Committee or the Division of Criminal Justice,   the date OPIA receives authorization to take administrative action; 

   ii. For all such audits initiated on or after March 1, 1983, it means the date of final screening of the case file by the Assistant Director, OPIA. 

  3. Notwithstanding any of the previous subsections, if after the screening of any provider audit initiated on or after March 1, 1983, the Assistant Director, OPIA, determines with reasonable justification that an act or omission on the part of the provider requires additional field work, the field audit shall be considered completed when the additional field work is completed. 

  4. Notwithstanding any of the previous subsections, if after the screening of any provider audit initiated on or after March 1, 1983, the Assistant Director, OPIA, determines with reasonable justification that an act or omission on the part of the provider requires that additional information or documentation be obtained from the provider, then a completed field audit shall be considered reopened and interest shall again accrue for the period beginning 20 days from the date the request for such information or documentation is received by the provider and ending on the date that all of the requested information or documentation is received by the agency making the request. 

  5. Notwithstanding any of the previous paragraphs, if all or part of any provider audit initiated on or after March 1, 1983, is referred to the Division of Criminal Justice or other agency for criminal investigation: 

   i. In the event no criminal action results from the referral the field audit shall be considered completed one year from the   date the decision was made to refer the matter for criminal investigation;  and 

   ii. In the event criminal action does result from the referral, the field audit shall be considered completed on the date OPIA receives authorization to take administrative action. 

  (b) "Final audit," for purposes of N.J.S.A. 30:4D-7m only, means that point in the audit process when the Division issues to the provider an audit report specifically designated as the "final audit" for a specified period audited.

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

   All of the relevant provisions pertaining to fraud and abuse, third party liability, and administrative and judicial remedies which are contained in the following sections of N.J.S.A. 30:4D-1 et seq. and this chapter are fully applicable to all of the programs administered in whole or in part by the Division, including, but not limited to, Plans B, C and D of the NJ FamilyCare program: N.J.S.A. 30:4D-6c, 6f, 7h, 7i, 7k, 7l, 7.1, 12, 17(e), 17(f), 17(g), 17(i), 17.1 and 17.2, as well as N.J.A.C. 10:49-3.2, 4.1 through 4.5, 5.5, 6.1(a)3, 7.3, 7.4, 7.5, 8.2(a)1ii, 9.6 through 9.12, 11.1, 12.1 through 12.7, 13.1, 13.4, 14.2 through 14.6 and 16.5.

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

   (a) The Division of Medical Assistance and Health Services may pay a monetary reward for information that leads to the recovery of at least $100.00 from individuals or entities that have engaged in health care-related fraud or abuse including ineligible receipt of benefits involving the programs administered by DMAHS (including, but not limited to, the New Jersey Medicaid and NJ FamilyCare programs), the Pharmaceutical Assistance to the Aged and Disabled (PAAD) program administered by Department of Health and Senior Services, and/or the Work First New Jersey General Assistance (GA) program administered by the Division of Family Development. The determination of whether an individual or entity meets the criteria for an award, and the amount of the award, is at the discretion of DMAHS. DMAHS shall pay a reward only if a reward is not otherwise provided for by law. When DMAHS applies the criteria specified in (b), (c) and (e) below to determine the eligibility and the amount of the reward, DMAHS shall notify the beneficiary of the reward as specified in (d) below. 

  (b) The following pertain to information eligible for reward. 

  1. In order for an individual or entity to be eligible to receive a reward, the information supplied shall relate to the activities of a specific individual or entity, and shall specify the time period of the alleged activities. 

  2. DMAHS shall not give a reward for information relating to an individual or entity that, at the time the information is provided, is already the subject of a review or investigation by DMAHS or its contractors; the New Jersey Department of Human Services (DHS); the New Jersey Department of Health and Senior Services; the New Jersey Department of Law and Public Safety; the Health Care Financing Administration and the Office of the Inspector General of the U.S. Department of Health and Human Services or their contractors; the U.S. Department of Justice; the Federal Bureau of Investigation; or any other Federal, State, county or municipal law enforcement agency.

 (c) Any individual or entity (other than one excluded under (c)1 below) is eligible to receive a reward under this section if the information is submitted in the manner set forth in (f) below. 

  1. The following are excluded from eligibility to receive a reward: 

   i. An individual who was or is an immediate family member of an officer or employee of any of the agencies or entities listed in   (b)2 above at the time he or she came into possession of, or divulged, information leading to a recovery shall not be eligible to   receive a reward under this section; 

   ii. Any other Federal, State, county or municipal employee, contractor or grantee shall not be eligible for a reward under this section if the information submitted came to their knowledge in the course of their official duties; 

   iii. An individual or entity that illegally obtained the information submitted shall be excluded from receiving a reward under this section; and 

   iv. An individual or entity that participated in the sanctionable offense with respect to which payment would be made shall be excluded from receiving a reward under this section. 

  (d) After all funds have been recovered and DMAHS has determined a participant eligible to receive a reward under the provisions of this section, it shall notify the informant of his or her eligibility, by mail, at the most recent address supplied by the individual or entity. It is the individual's or entity's responsibility to ensure that the reward program has been notified of any change in their address or other relevant information (for example, change of name, phone number). 

  1. If the individual or entity has relocated to an unknown address, the individual or entity or their legal representative may claim the reward by contacting DMAHS within one year from the date on which DMAHS first attempted to notify the individual or entity about a reward. DMAHS does not consider the individual or entity or their legal representative eligible for a reward more than one year after the date on which it first attempted to give notice. DMAHS does not pay interest on rewards that are not immediately claimed. 

  2. If an individual has become incapacitated or has died, an executor, administrator, or other legal representative may claim the reward on behalf of the individual or the individual's estate. The claimant shall submit certified copies of the letters testamentary, letters of administration, or other similar evidence to show his or her authority to claim the reward. The claim shall be filed within one year from the date, on which DMAHS first gave or attempted to give notice of the reward. 

  (e) The following pertain to the amount and payment of a reward: 

   1. In determining whether it shall pay a reward and, if so, the amount of the reward, DMAHS shall take into account all relevant factors, including the significance of the information furnished in relation to the ultimate resolution of the case and the recovery. 

  2. The amount of the reward represents what DMAHS considers to be adequate compensation in the particular case, not to exceed 10 percent of the overpayments recovered in the case, or $1,000, whichever is less. 

  3. If more than one individual or entity is eligible to receive a reward in a particular case, DMAHS shall allocate the total reward amount (not to exceed 10 percent of the overpayments recovered in that case, or $1,000, whichever is less) among the participants. 

  4. DMAHS bases rewards only on recovered overpayments, not on amounts collected as interest, penalties and/or fines, and not on estimates of cost savings or cost avoidance. 

  5. DMAHS shall make payments as promptly as the circumstances of the case permit, but not until it has collected all overpayments, interest, penalties and fines. 

  6. No Division employee may make any offer or promise or otherwise bind DMAHS or DHS with respect to the payment or any reward under this subsection or the amount of the reward. 

  (f) An individual or entity may submit information on persons or entities engaging in, or that have engaged in, health care-related fraud and/or abuse against the programs listed in (a) above to Bureau of Program Integrity, Division of Medical Assistance and Health Services, PO Box 712, Trenton, NJ 08625-0712, or by calling the DMAHS Fraud and Abuse Hotline at 1-888-9 FRAUD-5 (1-888-937-2835). 

  1. A participant interested in receiving a reward shall provide his or her name, address, telephone number, and any other requested identifying information so that he or she may be contacted, if necessary, for additional information and, when applicable, for the payment of a reward upon resolution of the case. 

  (g) DMAHS shall not reveal a participant's identity to any person, except as required by law. 

  (h) If, after a reward is accepted, DMAHS finds that the awardee was ineligible to receive the reward, neither DMAHS nor DHS shall be liable for the reward, and the awardee shall refund all monies received. 

  (i) Receipt of a reward under this section by any applicant for, or beneficiary of, benefits under any program administered in whole or in part by the Division of Medical Assistance and Health Services, including, but not limited to, Medically Needy (N.J.A.C. 10:70), Medicaid Only (N.J.A.C. 10:71), New Jersey Care ... Special Medicaid Programs (N.J.A.C. 10:72), NJ FamilyCare (N.J.A.C. 10:78) and NJ KidCare (N.J.A.C. 10:79), Pharmaceutical Assistance to the Aged and Disabled, Work First New Jersey/General Assistance or AFDC-Related Medicaid shall not affect that individual's eligibility or continued eligibility for those benefits.

SUBCHAPTER 14. RECOVERY OF PAYMENTS AND SANCTIONS

10:49-14.1 Recovery of payments correctly made

   (a) Correctly paid benefits shall only be recoverable from the estate of an individual who was 65 years of age or older when the individual received medical assistance if:

   1. The individual leaves no surviving spouse; 

  2. For estates of individuals who died between February 1, 1984 and October 20, 1992, the individual left no surviving child; 

  3. For estates of individuals who died on or after October 21, 1992, the individual leaves no surviving child who is under the age of 21 or any surviving blind or permanently and totally disabled children; 

  4. The amount to be recovered is in excess of $500.00;  and 

  5. The gross estate is in excess of $3,000. 

  (b) Paragraphs (a)4 and 5 above shall apply to recoveries from the estates of individuals who died on or after July 20, 1981, but prior to December 22, 1995. 

  (c) For estates of individuals who died on or after April 1, 1995, in addition to the recoveries authorized under (a) and (b) above, any Medicaid payments correctly made on or after October 1, 1993, on behalf of individuals who received services on or after age 55 but prior to age 65, are recoverable from the estates of those individuals, subject to the conditions set forth in (a)1, 3, 4 and 5 and (b) above. 

  (d) Effective for estates created on or after October 4, 1999, the Division shall file any claim or lien against an estate under this section within 90 days after receiving actual written notice from the personal representative of the estate or any other interested party of the death of the Medicaid beneficiary. 

  (e) For estates of individuals who died on or after December 22, 1995, Medicaid claims under this section shall be deemed preferred claims, with a priority equivalent to that under subsection c. of N.J.S.A. 3B:22-2, that is, debts and taxes with preference under Federal or State law. 

  (f) The personal representative of the estate of a deceased Medicaid beneficiary or any other interested party, upon request to the Division, may obtain a "payoff statement" on the amount due under the claim, if that information is available to the Division at the time the request is received. 

  (g) Effective for estates pending on or created after October 4, 1999, if a family member of a deceased Medicaid beneficiary has, prior to the beneficiary's death, continuously resided in a home owned by the beneficiary at the time of the beneficiary's death, and that home was the beneficiary's primary residence, and was and remains the family member's primary residence, the Division may record a lien against the property, but will not enforce the lien until the property is voluntarily sold, or the resident family member either dies or vacates the property. 

  (h) For estates of individuals who died on or after October 1, 1993, which are subject to a recovery claim under this section which was either pending on or initiated after March 1, 1995, the estate representative may apply to the Division for a waiver or compromise of the claim based upon grounds of undue hardship, subject to the following policies and procedures: 

  1. Undue hardship can be demonstrated only if the estate subject to recovery is or would become the sole income-producing asset of the survivors, and pursuit of recovery is likely to result in one or more of those survivors becoming eligible for public assistance and/or Medicaid benefits. 

  2. There shall be a rebuttable presumption that no undue hardship exists if the hardship resulted from estate planning methods under which assets were divested in order to avoid estate recovery. 

  3. Upon receipt of written notice that the estate is subject to a recovery claim by the Division, the estate representative shall have 20 days from the date of receipt of the notice to file a request for a waiver or compromise of the Division's claim based upon undue hardship, together with evidence in support of the request.  If that request is not received by the Division within the time limit specified, the Division shall not grant a waiver or compromise based upon undue hardship.  Upon receipt of a timely request, the Division shall evaluate the request and the evidence submitted, and shall notify the applicant in writing of its decision within 45 days from the date that the request was received.  If the estate representative wishes to contest the Division's decision, a written request for a hearing shall be submitted to the Division within 20 days from the date of receipt of that decision, in accordance with the provisions of N.J.A.C. 10:49-10.  This request shall be forwarded by the Division to the Office of Administrative Law (OAL), which shall notify the parties of the hearing date and venue, and shall provide a description of the hearing process.  Subsequent to the hearing, the formal decision of the OAL shall include a description of the process leading to the final agency decision and the appeal rights available to both parties. 

  (i) The Division may elect not to pursue a claim under this section against the estate of an individual who died on or after December 22, 1995, if it determines, in its sole discretion, that to do so would not be cost-effective. 

  (j) For all estate recoveries pending on or initiated after October 4, 1999, no lien of any kind, inchoate or otherwise, and no right of recovery can either exist or be pursued until all of the conditions set forth in N.J.S.A. 30:4D-7.2a are met, including the absence of any surviving spouse or of any minor, blind, or permanently and totally disabled children. 

  (k) For all estate recoveries pending on or initiated on or after October 4, 1999, even when the statutory conditions for lien filing and recovery are met, recovery shall not be pursued against property held by any bona fide purchaser who has paid fair market value for the property, but shall be sought from the estate. 

  (l) For purposes of this section, the term "estate" with respect to a deceased Medicaid beneficiary shall include: 

  1. All real and personal property and other assets included within the individual's estate, as defined in N.J.S.A. 3B:1-1;  and 

  2. For individuals who died on or after April 1, 1995, the term "estate" shall also include any other real and personal property and other assets in which the Medicaid beneficiary had any legal title or interest at the time of death, to the extent of that interest, including assets conveyed to a survivor, heir or assign of the beneficiary through joint tenancy, tenancy in common, survivorship, life estate, living trust or other arrangement, as well as any proceeds from the sale of any such property which remain in the estate of the survivor, heir or assign of the beneficiary, to the extent of the beneficiary's interest; 

   i. Effective for future estates or estate recoveries pending on or after October 4, 1999, for purposes of this subsection, the   term "life estate" shall mean a life estate created upon the death of a beneficiary; 

   ii. Effective for future estates or estate recoveries pending on or after October 4, 1999, for purposes of this subsection, the term "other arrangement" shall include, but not be limited to, any trust or annuity in which the beneficiary had an interest at the time of death, including a trust or annuity established by a third party, subject to the exclusions discussed in

 (n) below. 

  (m) Any lien filed on or after October 4, 1999 against an estate as described in (l)2 above shall describe the extent of the deceased Medicaid beneficiary's interest covered by the lien, if known to the Division at the time the lien is filed.  For example, if a deceased Medicaid beneficiary at the time of his death owned real property as a tenant-in-common with another individual, the lien should state that it encumbers only 50 percent of the equity in the real property.  If the deceased Medicaid beneficiary held a tenancy-by-the-entirety or joint tenancy with a right of survivorship, then the lien shall state that it encumbers all of the property.  If the Division is not aware of the extent of the beneficiary's interest at the time that the lien is filed, the full amount of the Division's claim shall be listed on the lien. 

   (n) For purposes of this section, for future estates or estates pending on or after October 4, 1999, the term "estate" shall not include: 

  1. A life estate in which the beneficiary held an interest during his or her lifetime, but which expired upon the Medicaid beneficiary's death; 

  2. An inter vivos trust established by a third party for the benefit of the now-deceased Medicaid beneficiary, provided that: 

   i. The trust is a discretionary trust, constructed in such a way that the Medicaid beneficiary could not compel distributions   from the trust;  and 

   ii. The trust contains no assets in which the Medicaid beneficiary held any interest within either five years prior to applying for Medicaid benefits, or five years prior to the Medicaid beneficiary's death;  or 

  3. A testamentary trust established by a third party (including the spouse of the now-deceased Medicaid beneficiary) for the benefit of the now-deceased Medicaid beneficiary, provided that: 

   i. The trust is a discretionary trust, constructed in such a way that the Medicaid beneficiary could not compel distributions   from the trust;  and 

   ii. The trust contains no assets in which the Medicaid beneficiary held any interest within either five years prior to applying for Medicaid benefits, or five years prior to the beneficiary's death.  Assets of the community spouse which formed a part of the community spouse resource allowance shall not be considered assets of the Medicaid beneficiary.  Any assets of the community spouse other than those that formed part of the community spouse resource allowance shall be considered assets of the Medicaid beneficiary if acquired from the Medicaid beneficiary within five years prior to the date of application for Medicaid benefits or five years prior to the date of death of the Medicaid beneficiary.

10:49-14.2 Sanctions--Special Status Program

   (a) The "Special Status Program" either restricts the Medicaid or NJ FamilyCare beneficiary(s) listed on the Eligibility Identification (EI) Card to a single provider, except in a medical emergency, or warns providers that the beneficiary's card has been used by an unauthorized person or persons, or for an unauthorized purpose. If a warning card is issued, a message will be printed on the card alerting the provider to ask the Medicaid or NJ FamilyCare beneficiary for additional identification or to take other appropriate action. 

  1. The restrictive card is issued to Medicaid or NJ FamilyCare beneficiaries determined to have misused, abused or overutilized their Medicaid or NJ FamilyCare benefits. Overutilization occurs when a beneficiary has utilized Medicaid or NJ FamilyCare services or items at a frequency or amount that is not medically necessary. Examples of misuse or abuse include, but are not limited to, medically harmful or inappropriate use of different drugs or provider services, obtaining or attempting to obtain early refills of prescriptions in violation of N.J.A.C. 10:51-1.19(a)5, at more than one pharmacy, and forgery or alteration of prescriptions. A determination that there has been misuse, abuse or overutilization of benefits obtained by use of an (EI) Card shall create a presumption that the beneficiaries listed on the (EI) Card were responsible for such actions. If this presumption is successfully rebutted by the Medicaid or NJ FamilyCare beneficiary, he or she shall not be enrolled in the Special Status Program. 

   i. A beneficiary shall be permitted to change the designated provider upon demonstration of good cause and the Division may   grant the request. 

   ii. The Division may change the provider to which the beneficiary is restricted if a pattern of continued misuse, abuse or overutilization by the beneficiary is evident, or if it is determined that the provider has engaged in fraud or abuse, or if the Division determines that such a change is in the best interest of the beneficiary and/or the programs it administers in whole or part. 

  iii. The beneficiary may request a contested case hearing in the following situations: 

    (1) If the beneficiary objects to being included in the special status program; 

    (2) If the beneficiary requests a change and the request is denied; 

    (3) If the agency causes undue delay in responding to the beneficiary's request for change. 

  2. The warning card is issued to Medicaid or NJ FamilyCare beneficiaries determined to have had their EI Card used by an unauthorized person or persons, or for an unauthorized purpose. The purpose of the warning card is to notify providers that the beneficiary's (EI) Card has been used by an unauthorized person or persons, or for an unauthorized purpose. A message will be printed on the card alerting the provider to ask the Medicaid or NJ FamilyCare beneficiary for additional identification or to take other appropriate action. A determination that an (EI) Card has been used by an unauthorized person or for an unauthorized purpose shall create a presumption that the beneficiaries listed on the (EI) Card were responsible for such actions. If this presumption is successfully rebutted by the beneficiary, the beneficiary shall not be issued a warning card.

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

  (a) The Commissioner, Department of Human Services;  Director, Division of Medical Assistance and Health Services;  Assistant Director, Office of Program Integrity Administration;  and the Commissioner or Deputy Commissioner, Department of Health and Senior Services, or anyone serving in an acting capacity in any of those positions shall have the authority to adjust, compromise, settle or waive any claim, lien or certificate of debt arising under this Act (N.J.S.A. 30:4D-1 et seq.), and to execute an appropriate release or document of discharge with respect to that claim, lien or certificate of debt. 

  (b) Such authority may be exercised by other officials only in the following limited circumstances: 

  1. The Administrator, Bureau of Administrative Control may compromise, settle or waive any claim or lien not arising under N.J.S.A. 30:4D-7(h) within the dollar limits specified by the Director, Division of Medical Assistance and Health Services;  and 

  2. The Fiscal Agent may compromise, settle or waive claims arising under N.J.S.A. 30:4D-7(h) within the dollar limits specified by the Director, Division of Medical Assistance and Health Services.

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

   (a) The purpose of this section is to define areas of responsibility and establish basic principles and procedures in those collection activities in which the Division of Medical Assistance and Health Services (DMAHS), the Division of Family Development (DFD) and/or a county board of social services (CBOSS) may be involved. It is intended that maximum conservation of public funds be effected without duplication of effort. It is recognized that certain situations may fall into more than one of the following categories. Any such matter will be processed in accordance with the provisions of the first occurring applicable category. 

  (b) The following pertain to incorrectly granted assistance (cash and/or medical assistance): 

  1. In instances involving incorrect eligibility for medical assistance, whether or not in combination with cash assistance, the county board of social services (CBOSS) shall determine the period(s) of ineligibility and ascertain from DMAHS the amount of medical assistance incorrectly granted. The county board of social services (CBOSS) shall then attempt recovery of medical assistance incorrectly granted either by administrative collection, or by way of restitution in a criminal or disorderly persons proceeding. 

   i. Recoveries or attempts at recoveries can be made from those persons specified in N.J.S.A. 30:4D-7i. 

  2. When recovery cannot be obtained by these methods in a case generated by the Internal Revenue Service (IRS) unearned income component of the Income and Eligibility Verification System (IEVS), the case shall be referred by the county board of social services (CBOSS) to DMAHS for possible initiation of recovery proceedings. 

  3. When in any other case not generated by IEVS, recovery cannot be obtained by these methods, the county board of social services (CBOSS) is authorized after securing DMAHS approval to initiate recovery proceedings as DMAHS' agent. If the county board of social services (CBOSS) does not initiate such recovery proceedings, it shall refer the case to DMAHS for possible initiation of recovery proceedings. 

  4. When collection occurs in a case involving both cash assistance and medical assistance, the county board of social services (CBOSS) shall, in the absence of court instruction to the contrary, apply the proceeds to the repayment of cash assistance and the reimbursement of DMAHS for medical assistance. The reimbursement shall be made payable to the Treasurer, State of New Jersey, which shall then reimburse the county board of social services (CBOSS) in the amount of 25 percent of the gross recovery on a periodic basis to be determined by DMAHS. 

  5. When a county board of social services (CBOSS) recovers only for medical assistance improperly granted, the county board of social services (CBOSS) shall remit the proceeds to DMAHS. The reimbursement shall be made payable to the Treasurer, State of New Jersey, who will then reimburse the county board of social services (CBOSS) in the amount of 25 percent of the gross recovery on a periodic basis to be determined by DMAHS.

   6. When any county board of social services (CBOSS) action, whether alone or in combination with DMAHS, results in a recovery of improperly granted medical assistance from a case generated by the Internal Revenue Service (IRS) unearned income component of the IEVS match, all funds recovered shall be remitted to DMAHS payable to the Treasurer, State of New Jersey, which shall then reimburse the county board of social services (CBOSS) in the amount of 25 percent of the gross recovery on a periodic basis to be determined by DMAHS.

   (c) The following pertain to third party liability claims in tort actions: 

  1. Whenever either a county board of social services (CBOSS) or DMAHS learns of a situation in any case in which the other may have a claim, it will notify the other. 

  2. Unless the individual case circumstances intervene, the first claim after settlement or judgment is for any payments by New Jersey Medicaid or NJ FamilyCare program arising from the occurrence notwithstanding any (CBOSS) claim for recovery of cash assistance. The next claim is that which the county board of social services (CBOSS) may assert in accordance with an agreement to repay or similar document. The DMAHS and the county board of social services (CBOSS) will, insofar as their controls allow, maintain priority of payment in the above order. 

  (d) The following pertain to liquidation of potential resources: 

  1. The county board of social services (CBOSS) will participate in the liquidation of potential resources according to the Program requirements under which eligibility has been established, regardless of whether cash assistance is being granted. Notification of the potential resource to be liquidated shall be forwarded to DHSS, enabling it to seek a voluntary contribution. Sale of real property to which title is held by a county board of social services (CBOSS) is subject to DFD approval in all instances regardless of the proposed distribution of the proceeds. 

 2. All funds arising from the liquidation of resources and which, by action of law, regulation, or agreement with the owner, fall under the jurisdiction of either a county board of social services (CBOSS) or DHSS for distribution will, insofar as possible, be allocated as follows: 

   i. Proceeds will be first applied to the cash costs of liquidation, such as advertising costs and filing fees but not including   costs such as county board of social services (CBOSS) staff time, supplies, counsel fees or overhead. 

   ii. Proceeds will be next applied to any claims superior to that of the county board of social services (CBOSS) (for example, taxes). 

   iii. Proceeds will be next applied to any funds owing to and collectible by the county board of social services (CBOSS). 

   iv. Any residue remaining after the above payments are allocated would, in the absence of circumstances to the contrary, be the property of the client and thereby subject to (d)3 below. 

  3. All funds properly belonging to a beneficiary free of any agency claim are to be remitted to the beneficiary as promptly as possible or otherwise disbursed at the beneficiary's instruction. The county board of social services (CBOSS) will promptly reevaluate eligibility following such distribution, taking into consideration any voluntary repayment to the New Jersey Medicaid or NJ FamilyCare program. 

  (e) The following pertains to recovery from estates of deceased beneficiaries: 

  1. The county board of social services (CBOSS) shall normally undertake recovery activity as agent for DMAHS in any case in which the county board of social services (CBOSS) is or will be undertaking activities on its own account. However, in those cases where the recovery of medical assistance is possible and where the entire county board of social services (CBOSS) claim is for burial expenses only, DMAHS shall initiate recovery activity inclusive of county board of social services (CBOSS) burial costs. DMAHS may, in certain cases, assume direct jurisdiction in recovery of its claim concurrent with county board of social services (CBOSS) activity. DMAHS shall make the county board of social services (CBOSS) aware of its activity in such cases. 

  2. County board of social services (CBOSS) recoveries and distribution shall be in accord with the following procedures: 

   i. From the proceeds of liquidation, the county board of social services (CBOSS) shall first recover the amount necessary to   satisfy its own claim, including costs of liquidation and the claims of other New Jersey county board of social services   (CBOSS)s. The county board of social services (CBOSS) shall recover funds from the clearing account in the order in which the   funds were received in the clearing account. If any part of any remaining surplus has been received from the proceeds of assigned   life insurance for which there was a named beneficiary other than the client's estate, that surplus or the policy benefit,  whichever is less, is the property of the beneficiary and should be so directed. 

  ii. All other surplus funds are part of (or the entire) the client's estate and are payable to the legally designated   representative of the estate. If the representative of the estate is unknown or if no representative has been appointed and there are no known next of kin, the county board of social services (CBOSS) shall forward to the DMAHS an amount not to exceed the amount of the proper medical assistance claim as determined by communication with the Administrator, Bureau of Administrative Control, DMAHS. Any remaining funds will escheat to the State of New Jersey. 

   iii. When there are known next of kin, the county board of social services (CBOSS) shall request the next of kin to take appropriate legal action to be appointed administrator if the amount to be disbursed is greater than the claim of the New Jersey Medicaid or NJ FamilyCare program. If the claim of the New Jersey Medicaid or NJ FamilyCare program will equal or exceed the estate, the county board of social services (CBOSS) shall request the next of kin to sign a consent to transfer his or her rights to the New Jersey Medicaid or NJ FamilyCare program and, upon receipt of such signed consent, the county board of social services (CBOSS) shall forward the funds to DMAHS. 

   iv. When the next of kin will not sign a consent to transfer his or her right to the Medicaid Agent and DMAHS and will not file to become the administrator, the county board of social services (CBOSS) may, at its option, arrange for someone to file to become administrator or the county board of social services (CBOSS) may refer the information to DMAHS for action. 

   v. In any questions or dispute among two or more claimants on surplus funds, the county board of social services (CBOSS) shall withhold payment pending resolution by mutual consent of all claimants or by court order. 

  3. The Medicaid Agent or DMAHS recoveries and distribution shall be in accordance with the following procedures: 

   i. DMAHS shall undertake recovery activity in medical assistance payment cases in which no county board of social services   (CBOSS) shall be submitting a claim. However, should information from the county board of social services (CBOSS) be necessary to   such DMAHS activity, the county board of social services (CBOSS) shall communicate with DMAHS, supplying such material as may be   required. 

   ii. In cases in which DMAHS is acting for a county board of social services (CBOSS) in collection of burial expenses, DMAHS shall accord payment of the burial claim priority over its own recovery. 

  (f) The county board of social services (CBOSS) may at any time accept an offer of voluntary repayment, either on its own behalf or on behalf of the New Jersey Medicaid or NJ FamilyCare program, up to but not in excess of the amount of assistance granted. To any inquiry as to amount granted, the county board of social services (CBOSS) shall supply the appropriate information, identifying the respective amounts granted by the county board of social services (CBOSS) and the Medicaid Agent or DMAHS. In the absence of instruction from the payer, the county board of social services (CBOSS) will reimburse cash assistance first and then remit any balance to DHSS. 

   1. Compromise settlements of medical assistance are subject to DHSS approval. 

  (g) Regarding compromise settlements: 

  1. Compromise settlements of cash assistance are subject to DFD approval. 

  2. Compromise settlements of medical assistance are subject to DMAHS approval. 

  (h) This section shall apply to all pending and future recovery cases, except that: 

  1. The 25 percent incentive payments provided for in (b)4 and 5 above shall apply to all non-IEVS incorrect payment recoveries received by the county board of social services (CBOSS) on or after July 1, 1993. 

  2. Paragraph (b)6 above applies to all IEVS-related recoveries received on or after July 1, 1989 by either DMAHS or the county board of social services (CBOSS), whichever agency is handling the recovery.

10:49-14.5 Administrative charges/service fees 

  (a) A provider shall not pay nor require payment of an administrative charge or service fee for the privilege of doing business with another provider or for services for which reimbursement is included as part of the Medicaid or NJ FamilyCare fee. 

  1. An example of a prohibited practice is that a nursing facility may not require a pharmacy to pay an administrative charge or service fee to the facility for handling of the nursing facility resident's medications, drugs and/or related pharmaceutical records.

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

   Payment shall be made by the Department of Human Services/Division of Medical Assistance and Health Services to the county boards of social services (CBOSS) for conducting investigations and for determining whether applicants qualify for benefits under the New Jersey Medicaid or NJ FamilyCare program.

SUBCHAPTER 15. AVAILABILITY AND MAINTENANCE OF PROGRAM POLICY ISSUANCES

10:49-15.1 Maintenance of public policy issuances

   Program manuals and other policy issuances which affect the public, including the Medicaid Agent's rules and regulations governing eligibility, need and amount of assistance, beneficiary's rights and responsibilities, and services offered by the Medicaid Agent, shall be maintained in the State or Division Central Office and in each Medical Assistance Customer Center for examination during regular workdays and regular office hours by individuals, and upon request, for study or reproduction by such individuals. These manuals and other policy issuances are also distributed to entities which serve as custodians such as the State Library, county boards of social services (CBOSS), and regional legal services offices.

10:49-15.2 Availability of material

   (a) In order to facilitate public access, a current copy of material described in N.J.A.C. 10:49-15.1 shall be made available without charge to custodians who request the material for this purpose. 

  (b) Custodians shall meet the following requirements: 

  1. They shall be centrally located and publicly accessible to a substantial number of the beneficiary population they serve;  and 

  2. They shall agree to accept responsibility for filing all amendments forwarded by the Medicaid Agent.

10:49-15.3 Reproduction of policy material

   (a) The specific policy materials necessary for an applicant or beneficiary (or his or her representative) to determine whether a fair hearing should be requested, or to prepare for a fair hearing, shall be reproduced without charge upon request. 

  (b) The Medicaid Agent may impose a charge for copying or reproducing materials.  If a charge is imposed, it shall be computed pursuant to N.J.S.A. 47:1A-1.

SUBCHAPTER 16. DEMONSTRATION PROJECTS

10:49-16.1 Purpose

   This subchapter sets forth the basic parameters for demonstration projects established pursuant to N.J.S.A. 30:4D-1 et seq., as amended, and Section 1115 of the Social Security Act.  Any time a demonstration project is implemented, New Jersey Medicaid providers will receive information and instructions if the project is relevant to the services they provide.

10:49-16.2 Definitions 

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

  "Principal" means all Division management personnel. 

  "Project" means any demonstration project authorized through a waiver by the Secretary of Health and Human Services of certain requirements under Title XIX of the Social Security Act as provided under Section 1115 of the Social Security Act. 

  "Provider" means providers of medical and health services under a project. 

  "Recipient" means any beneficiary who receives services from the project. 

  "Services" means medical or health services rendered as an integral part of the project.

10:49-16.3 Implementation of projects

   The Medicaid Agent may implement projects directly or through contractual arrangements with any legal entity, including, but not limited to, corporations organized pursuant to Title 14A, New Jersey statutes (N.J.S.A. 14A:1-1 et seq.) and Title 15 revised statutes (R.S. 15:1-1 et seq.), as well as boards, groups, agencies, persons and other public or private entities.

10:49-16.4 Necessary criteria for a demonstration project

   (a) The following shall apply to all projects implemented under this subchapter:

   1. All projects shall have approval from the United States Department of Health and Human Services;

   2. All projects entered into under this subchapter shall be subject to all relevant State and Federal statutes and regulations, except to the extent that appropriate waivers shall have been granted; 

  3. The Commissioner of Human Services or the Commissioner of Health and Senior Services shall have the authority to review and approve in writing arrangements and agreements, whether formal or otherwise, between all projects and third parties prior to the execution thereof; 

  4. All projects in their hiring policies shall not discriminate against any individual on the basis of race, sex, religion, ethnicity or age, and shall comply with all the requirements of Title VI of the Civil Rights Act of 1964, as amended, and other applicable Federal and State laws or regulations pertaining to the civil rights of individuals; 

  5. No project shall deny services to any eligible person on the basis of race, sex, religion, ethnicity or age, and all projects shall comply with all the requirements of Title VI of the Civil Rights Act of 1964, as amended, pertaining to the civil rights of individuals; 

  6. All projects shall institute procedures for safeguarding of information in compliance with applicable Federal and State regulations and shall strictly adhere to same; 

  7. All projects shall collect and report data relevant to the project on a periodic basis, in a manner and fashion prescribed by the Medicaid Agent, including but not limited to, the following: 

   i. Financial data, such as line item expenditure statements and audit reports; 

   ii. Data necessary to the project regarding the characteristics of the population involved in the project and the control population, if any;  and 

   iii. Program data, such as number and type of service rendered; 

  8. All projects shall furnish to the Medicaid Agent, in a manner and fashion prescribed by the Medicaid Agent, periodic progress reports;

  9. The Medicaid Agent at its option may require receipt of copies of all project reports; 

  10. Any project entered into under this subchapter may include components fundable from sources other than that authorized by Section 1115 of the Social Security Act.  These funds cannot be matched under the provisions of Section 1115 if they are Federal funds or if these funds are not otherwise matchable; 

  11. Nothing herein shall abridge the Commissioner's statutory authority to implement and administer demonstration programs under Section 1115 of Title XIX of the Social Security Act and N.J.S.A. 30:4D-7, as amended; 

  12. Each project shall have the organizational and administrative capabilities to carry out its duties and responsibilities under the contract.  This shall include as a minimum the following: 

   i. A full-time administrator to manage the day-to-day business activities of the project; 

   ii. Data reporting capabilities sufficient to provide necessary and timely reports to the Medicaid Agent; 

   iii. Financial reports and books of accounts maintained in accordance with generally accepted accounting principles, which are sufficient to fully disclose the disposition of all program funds received;  and

   iv. An annual independent audit arranged for by the project; 

  13. Each project director shall advise the Medicaid Agent of the project's administrative organization and changes thereto.  This includes the functions and responsibilities of each principal, an organizational chart and a list of all personnel and providers used either directly by the project or through contractual arrangements.  For each principal and each provider not previously reported, the following information shall be included: 

   i. Full name; 

   ii. Business address; 

   iii. Date and place of birth; 

   iv. Social Security Account Number; 

   v. IRS employer number; 

   vi. Professional license number (when applicable);  and 

   vii. Medical specialty (when applicable); 

  14. Each project director shall submit to the Commissioner of Human Services or the Commissioner of Health and Senior Services for written approval a manual of administrative procedures which shall include personnel, purchasing and internal fiscal procedures.  This manual shall be in conformance with approved management procedure;  and 

  15. In those instances where a project involves the delivery of services, the following shall apply where appropriate and necessary: 

   i. The project shall demonstrate, to the satisfaction of the Commissioner of Human Services or the Commissioner of Health and Senior Services, the capability to provide for and/or arrange for the provision of those services which are required as components of the project; 

   ii. All individuals receiving services funded under Title XIX of the Social Security Act shall be informed in a simple, brief statement of their rights to a fair hearing; 

   iii. The project shall develop and establish grievance procedures for beneficiaries in addition to fair hearing procedures established pursuant to this paragraph; 

   iv. The project shall take steps to insure that it is rendering services that are consistent with and utilizes existing related Federal and State programs such as the EPSDT; 

   v. The project shall insure that there will be periodic peer review and quality of care audits; 

   vi. The project shall utilize eligibility criteria for eligibles to receive services as defined by the Department, and the Department shall insure, by a review process, that the project is in conformance with these criteria; 

   vii. The project shall take appropriate action to insure that the eligibility criteria provided per (a)15vi above is faithfully executed; 

   viii. The project shall obtain written approval from the Commissioner of Human Services and the Commissioner of Health and Senior Services prior to implementing the following: 

    (1) The methods of enrollment and enrollment forms to be used to enroll beneficiaries; 

    (2) The form and content of informational and instructional materials to be distributed to beneficiaries outlining the nature and scope of covered services provided by the project; 

    (3) The form and content of informational and instructional materials to be distributed to inform enrollees of changes in program scope or administration;  and 

    (4) Provider claim forms and instructions for their use where such claim forms are unique to this contract; 

   ix. The project shall provide to the Medicaid Agent, for written approval prior to use, the form and content of all public information releases pertaining to the project;  and 

   x. The project shall insure that all marketing representatives have received instruction, as appropriate, from the Medicaid Agent, on acceptable enrollment practices.

10:49-16.5 Sanctions related to demonstration projects

   The Commissioner of Human Services and the Commissioner of Health and Senior Services, in addition to any and all other authority, shall have the authority to totally suspend or partially reduce payment in order to enforce compliance with this subchapter.

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

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

   (a) EPSDT is a federally mandated comprehensive child health program for Medicaid beneficiaries from birth through 20 years of age.  The Omnibus Budget Reconciliation Act of 1989 (OBRA '89) codified EPSDT. Accordingly, the term "EPSDT Services" means the following: 

  1. EPSDT Screening Services; 

  2. Vision Services; 

  3. Dental Services; 

  4. Hearing Services;  and 

  5. Such necessary health care diagnostic services, treatment and other measures to correct or ameliorate defects, and physical and mental illnesses and conditions discovered by the screening services. 

  (b) A physician, independent clinic, or hospital outpatient department may provide EPSDT screening services.

SUBCHAPTER 19. HEALTHSTART

10:49-19.1 HealthStart

   HealthStart is a program which provides comprehensive maternity care services for all pregnant women (including those determined to be presumptively eligible) and child health care services for children (through two years of age) who are eligible for Medicaid benefits.  Detailed information about this program is included in the Physician Services Manual or N.J.A.C. 10:54, Independent Clinic Services Manual or N.J.A.C. 10:66, Nurse-Midwifery Services Manual or N.J.A.C. 10:58, and the Hospital Services Manual or N.J.A.C. 10:52.

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

 10:49-21.1 Purpose and scope

   The Medicaid Managed Care Program--New Jersey Care 2000 is a program under which Health Maintenance Organizations (HMOs) contract with the Department of Human Services to provide health care services to Medicaid beneficiaries.  Requirements governing HMO providers and services are codified at N.J.A.C. 10:49-74.  For more information, providers may contact the Medicaid Managed Care Hotline at 1-800-356-1561.

10:49-21.2 Capitation payment system

   Under the Medicaid Managed Care Program--New Jersey Care 2000, HMOs are reimbursed through a capitation payment system whereby DMAHS pays an HMO a set amount for the services it provides to beneficiaries, as described in N.J.A.C. 10:74.

10:49-21.3 Medicaid beneficiaries 

  (a) The Medicaid Managed Care Program--New Jersey Care 2000 is a mandatory enrollment program for AFDC and AFDC related New Jersey Care pregnant women and children and is offered to the SSI Medicaid beneficiary as an alternative to the existing Medicaid fee-for-service program. 

  (b) Medicaid beneficiaries enrolled in HMOs receive two identification cards. 

  1. One card is issued by the HMO and appropriate toll-free telephone numbers are indicated on the card.  These telephone numbers allow the provider to inquire whether a service the provider intends to perform will be covered or if the provider needs a prior approval. 

  2. The second card issued is the same Medicaid Eligibility Identification card issued to all beneficiaries.  However, on the card, the words "ENROLLED IN HMO XYZ, 1-800-XXX-XXXX" is imprinted (see Appendix Form #7). This card also provides the toll-free telephone number of the HMO in which the beneficiary is enrolled so that the provider can verify HMO membership.  Questions about covered services should be referred to this number.

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

   (a) The following services are provided under the Medicaid Managed Care Program--New Jersey Care 2000: 

  1. Primary and specialist care (Preventive health care and counseling, EPSDT); 

  2. Inpatient and outpatient hospital services; 

  3. Emergency medical care; 

  4. Laboratory and radiology services; 

  5. Prescription drugs (Legend and non-legend drugs); 

  6. Family planning services 

  7. Podiatrist services; 

  8. Chiropractor services; 

  9. Optometrist services; 

  10. Optical and hearing appliances; 

  11. Home health agency services; 

  12. Medical supplies and durable medical equipment; 

  13. Dental services; 

  14. Ambulance, Mobile Intensive Care Unit (MICU) and invalid coach transportation services; 

  15. Prosthetic and orthotic services; 

  16. Rehabilitation services (Outpatient rehabilitation therapies--physical therapy, occupational therapy, speech/language, audiology, 60 days/therapy/year.); 

  17. Hospice services;  and 

  18. Private duty nursing agency services. 

  (b) The following services are not covered by an HMO, but are available to beneficiaries and are payable by the Medicaid program on a traditional fee-for-service basis. 

  1. Medical day care; 

  2. Elective/induced abortion services; 

  3. Lower mode transportation; 

  4. Psychiatric inpatient hospital services; 

  5. Residential treatment center care services; 

  6. Intermediate care facility/mental retardation services; 

  7. Rehabilitation services in excess of 60 days per year; 

  8. Services to beneficiaries participating in waiver or demonstration programs; 

  9. Personal care assistant services; 

  10. Nursing facility care; 

  11. Substance abuse services--diagnosis, treatment and detoxification costs for methadone and its administration;  and 

  12. Mental health services. 

  (c) Certain services provided to beneficiaries who are enrolled in an HMO will no longer be reimbursed on a fee-for-services basis.  If the beneficiary is enrolled in an HMO, and the HMO restricts payment to providers who have agreed to contract with it, a provider who is not a contractor with the HMO, or who fails to obtain authorization from the HMO, may not be reimbursed.  It is therefore incumbent upon the provider to check the identification card of the Medicaid beneficiary prior to the provision of any service, even if the provider has received prior authorization from a Medicaid District Office or Medicaid's Central Dental Services Unit.  Failure to do so could result in a claim being rejected by both the Division's fiscal agent, Unisys, and the member's HMO. 

 (d) Persons in Home or Community-based Waiver Programs, those who are in demonstration programs, those who are in long-term care facilities or residential placement facilities and those in the Medically Needy program, or presumptive eligibility program, are excluded from enrolling in an HMO. Other persons, including pregnant women past the first trimester who have an existing relationship with an obstetrician, those persons who have chronic debilitating illnesses who are under the care of a physician who will coordinate their health care needs;  and individuals who are terminally ill with an established relationship with a physician or enrolled under the Hospice program, may be exempted from mandatory managed care under certain circumstances.  See N.J.A.C. 10:74-8 for further information on excluded or exempted persons. 

  (e) A beneficiary may elect to obtain family planning services either through the HMO or through a Medicaid-participating family planning provider on a fee-for-service basis. 

  (f) Reimbursement for any and all drugs prescribed for the treatment of mental health and substance abuse are the responsibility of the HMO with the exception of methadone (see N.J.A.C. 10:49-21.4(b)9).  A pharmacist dispensing these drugs shall participate in the pharmacy network of the Medicaid beneficiary's HMO. In addition, any ambulance, MICU or invalid coach transportation provided for behavioral health services also remain the responsibility of the HMO. A transportation provider providing ambulance, MICU or invalid coach services shall participate in the transportation network of the Medicaid member's HMO.

SUBCHAPTER 22. HOME AND COMMUNITY-BASED SERVICES WAIVER PROGRAMS

 10:49-22.1 Introduction 

  (a) Home and Community-Based Services Waivers are five-year, renewable Federal waiver programs, prepared by the Division of Medical Assistance and Health Services in response to the Omnibus Budget Reconciliation Act of 1981 (Section 2176, Public Law 97-35 and amendments under P.L. 99-509). These Home and Community-Based Services Waivers are submitted to the CMS of the United States Department of Health and Human Services. The purpose of these programs is to help eligible individuals remain in the community, or return to the community, rather than be cared for in a nursing facility or hospital setting. 

  (b) Retroactive eligibility is not available to waiver program beneficiaries;  no waiver service received prior to the date of enrollment shall be considered for reimbursement. 

  (c) Total program costs are restricted by limits on the number of community care slots and on per-person costs.  The case manager is responsible for the development of the service plan with the client/family, with input from provider agencies, and for monitoring the cost of the service package.

10:49-22.2 Approved Waivers 

  (a) The New Jersey Medicaid program has received waivers for the following programs: 

  1. Community Care Program for the Elderly and Disabled (CCPED); 

  2. Home and Community-Based Services Waivers for Blind or Disabled Children and Adults (Medicaid's Model Waivers I, II, and III); 

  3. AIDS Community Care Alternatives Program (ACCAP); 

  4. Traumatic Brain Injury Program; 

  5. Home and Community-Based Services Waiver Program for Developmentally Disabled Individuals; 

  6. Home and Community-Based Services Waiver Program for Children (ABC);  and 

  7. Assisted Living/Alternative Family Care (AL/AFC) Waivers.

10:49-22.3 Administration of waivered programs 

  (a) The Division of Medical Assistance and Health Services administers the following Home and Community-Based Services Waivers:  Home and Community-Based Services Waivers for Blind or Disabled Children and Adults Medicaid Model Waivers I, II, and III;  AIDS Community Care Alternatives Program (ACCAP) and Traumatic Brain Injury Waiver.

   (b) The Division provides oversight to the Division of Developmental Disabilities in its administration of its Home and Community-Based Services Waiver for developmentally disabled individuals. 

  (c) The Division provides oversight to the Division of Youth and Family Services (DYFS) in its administration of Home and Community-Based Services Waiver for Children. 

  (d) The Department of Health and Senior Services administers the Community Care program for the Elderly and Disabled (CCPED) waiver, and the Assisted Living/Alternate Family Care (AL/AFC) waiver.

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

  (a) Any questions regarding Home and Community-Based Services Waiver programs described in N.J.A.C. 10:49-22.2(a)2, 3, 4, 5, or 6, may be directed to the Bureau of Home Care Services (BHCS), located in the Division of Medical Assistance and Health Services' Central Office, telephone number (609) 588-2620. 

  (b) Any questions regarding Home and Community-Based Services Waiver programs described in N.J.A.C. 10:49-22.2(a)1 or 7 may be directed to DHSS, Division of Consumer Support Services, telephone (609) 588-2611.

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

  (a) CCPED became effective October 1, 1983.  The program allows for community care slots, allocated on a county basis in accordance with the needs of the county. 

  (b) The seven services listed below are available under CCPED. Other Medicaid (Title XIX) services are not available to the waivered population.  There is a cost cap on each individual service package. 

  1. Case management; 

  2. Home Health;

   3. Homemaker; 

  4. Medical day care; 

  5. Medical transportation (non-emergency); 

  6. Respite care;  and 

  7. Social day care.

  (c) Eligibility requirements for CCPED are as follows: 

  1. All individuals must be assessed to be in need of nursing facility care. 

  2. Individuals age 65 or over must be eligible for Medicare or have other health insurance coverage which includes hospital and physician coverage. 

  3. Individuals under 65 must be determined disabled by the Federal Social Security Administration and be eligible for Medicare or be determined disabled by the Division of Medical Assistance and Health Services' Disability Review Section and have other health insurance, including hospital and physician coverage. 

  4. An individual's own income must exceed the SSI community standard up to the institutional cap or be ineligible in the community because of SSI Deeming Rules.  An individual's resources may not exceed those required in the institutional program.  A spouse's income also is not considered.  While the spouse's resources are considered in the determination of eligibility, up to one-half of the couple's total resources are protected for the use of the spouse. 

  5. In order to be enrolled in the program, a waiver slot must be available.

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

  (a) The Model Waivers are Home and Community-Based Services Waiver programs for Blind or Disabled Children and Adults.  Included are Model Waiver I (effective September 1, 1983), Model Waiver II (effective April 1, 1985) and Model Waiver III (effective April 1, 1986). 

  1. Model Waivers I and II serve a maximum of 50 individuals each.  Model Waiver III serves 150.  There are no geographic limitations nor limitations on the number of individuals who can be served within any one county. 

  (b) The Model Waiver programs offer, with the exception of nursing facility services, all New Jersey Medicaid (Title XIX) services, plus case management.  Model Waiver III also offers private-duty nursing. "Private duty nursing" means individual and continuous care, in contrast to part-time or intermittent care, provided by licensed nurses.  Private duty nursing is limited to a maximum of sixteen hours per day per person and will be provided only when there is a live-in primary caregiver (adult relative or significant other adult) who accepts 24-hour responsibility for the health and welfare of the beneficiary. 

  1. Each individual's service package must be no more than the cost of institutional care, determined at a projected weighted cost of hospital care or net average cost of nursing facility care. 

  (c) Eligibility requirements for the Model Waivers are as follows: 

  1. Individuals must be in need of institutional care and meet the minimum nursing facility (NF) level of care criteria in accordance with N.J.A.C. 10:63-2.1 and 2.2.  Model Waiver III also requires that individuals be in need private-duty nursing service, in accordance with N.J.A.C. 10:60-1.12(b). 

  2. For Model Waivers I and II, individuals must meet optional categorically needy standards, in accordance with N.J.A.C. 10:71 and 10:72.  Total income must exceed the SSI community standard up to the institutional CAP, or the individual must be ineligible in the community because of SSI Deeming Rules.  Parental income or resources are not considered in determining eligibility.  While a spouse's income is not considered towards eligibility, up to one-half of the couple's total resources are protected for the use of the spouse. 

  3. Model Waiver III applicants can either be optional categorically eligible or categorically eligible.  In other words, MW III also serves individuals who are eligible under SSI, DYFS or AFDC programs. 

  4. Individuals must be blind or disabled children and adults.  Individuals who have not been determined disabled under the Social Security Act must be determined disabled by the Division of Medical Assistance and Health Services' Disability Review Section, in accordance with N.J.A.C. 10:71-3.12. 

  5. In order for an individual to be enrolled in the program, a waiver slot must be available.

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

  (a) ACCAP became effective March 1, 1987.  The program allows for an allocation of a specific number of slots in accordance with the needs of each county in the State. 

  (b) Total program costs are restricted by the number of community care slots each year and on per-person costs.  Each individual's service package must be no more than the cost of institutional care, determined at a projected weighted cost of hospital care or net average cost of nursing facility care.  ACCAP offers, with the exception of nursing facility services, all New Jersey Medicaid services, plus those listed in (b)1 through 7 below. 

  1. Case management; 

  2. For children: 

   i. Intensive supervision to children who reside in Division of Youth and Family Services' foster homes;  and 

   ii. Specialized group foster home;

   3. Hospice care services at home; 

  4. Medical day care (specialized); 

  5. (Certain) Narcotic and drug abuse treatments at home; 

  6. Personal care assistant services (no limitation on the number of hours);  and 

  7. Private-duty nursing. 

  (c) Eligibility requirements for ACCAP are as follows 

  1. Individuals must be in need of institutional care and meet, at a minimum, the nursing facility level of care criteria. 

  2. Individuals must be diagnosed as having AIDS or ARC. Children under the age of 13 may also be diagnosed HIV positive. 

  3. Individuals who are categorically needy or optional categorically needy are served under the program. 

  4. There is no deeming of parental income or resources in the determination of eligibility.  A spouse's income also is not considered.  While the spouse's resources are considered in the determination of eligibility, up to one-half of the couple's total resources are protected for the use of the spouse. 

  5. Individuals under the age of 65 who are eligible for coverage as optional categorically needy must be determined disabled by the Social Security Administration (SSA) or by the Disability Review Section, Division of Medical Assistance and Health Services. 

  6. In order for an individual to be enrolled in the program, a waiver slot must be available.

10:49-22.8 Traumatic Brain Injury Program

   (a) The Traumatic Brain Injury (TBI) Program is a renewable Federal waiver program under Section 1915(c) of the Social Security Act, 42 U.S.C. s 1396n, which offers home and community-based services to a beneficiary with an acquired traumatic brain injury.  The purpose of the TBI program is to help eligible beneficiaries to remain in the community, or to return to the community rather than be cared for in a nursing facility. 

  (b) The waiver, prepared by the Division of Medical Assistance and Health Services (DMAHS), encourages the development of community-based services in lieu of institutionalization. 

  (c) The Program is Statewide, with slots allocated as individuals, ages 18 through 65, are admitted to the program. 

  (d) The Division administers the overall program, and has the responsibility for assessing an applicant's need for care and, for determining which applicants will be served by the program. 

  (e) Program oversight shall be provided by the Division of Medical Assistance and Health Services through the Bureau of Home Care Services (BHCS) and the Surveillance Utilization Review Subsystem (SURS).  The delivery of home care services to TBI Waiver beneficiaries will be subject to a post-payment utilization review by professional staff of the Medicaid District Offices in accordance with N.J.A.C. 10:63-1.15. 

  (f) Applicants for participation in the TBI waiver program shall meet the following medical and financial eligibility criteria: 

  1. Be not less than 18 nor more than 65 years of age at the time of enrollment; 

  2. Have a diagnosis of acquired brain injury which occurred after the age of 16; 

  3. Exhibit medical, emotional, behavioral and/or cognitive deficits; 

  4. Meet the Division's nursing facility standard care criteria for Pre-Admission Screening (PAS), at N.J.A.C. 10:60-1.2; 

  5. Have a rating of at least four on the Rancho Los Amigos Levels of Cognitive Functioning Scale (see N.J.A.C. 10:60, Appendix I); 

  6. Be blind, disabled, or a child under the supervision of the Division of Youth and Family Services (DYFS) and be eligible for Medicaid in the community or be eligible for Medicaid if institutionalized. Persons eligible for the Medically Needy segment of New Jersey Care ... Special Medicaid Programs, or private Health Maintenance Organizations serving Medicaid beneficiaries are not eligible for this program. 

   i. There is no deeming of spousal income in the determination of eligibility for this program.  While spousal resources are considered in the determination of eligibility, up to one-half of the total resources are protected for the use of the spouse;    and 

  7. Be determined disabled by the Social Security Administration (SSA) or by the Disability Review Unit of the Division, using the SSA disability criteria. 

  (g) If the individual is dually diagnosed, for example, with a head injury and psychiatric illness or developmental disability or substance abuse addiction, a determination will be made during the initial review as to the most appropriate service system to manage the beneficiary's care.  This decision will be made based on clinical evidence as of onset of injury, and professional evaluation. 

  (h) Retroactive eligibility shall not be available to waiver beneficiaries for those Medicaid services provided only by virtue of enrollment in the waiver program.  Those individuals who are not eligible for Medicaid services in the community prior to enrollment in the TBI Waiver are not eligible for retroactive Medicaid eligibility. 

  (i) All applicants determined eligible for the TBI Waiver shall be issued a Medicaid Eligibility identification (MEI) Card. 

  (j) In order for an applicant to be enrolled in the program, a waiver slot must be available. 

  (k) Prior to formal application for the TBI waiver, a referral shall be submitted to the Bureau of Home Care Services (BHCS) of the Division, which shall review the referral to determine if the individual meets the basic criteria for the program. If it is determined that the individual referred is a potential candidate for the TBI waiver, the following shall occur: 

  1. Supplemental Security Income (SSI) beneficiaries shall be referred to the appropriate Medical Assistance Customer Center (MACC) serving their county of residence; 

  2. Children under the supervision of the Division of Youth and Family Services (DYFS) shall be referred to DYFS for the initiation of the formal application, which includes the determination of disability, and shall then be referred to the appropriate Medical Assistance Customer Center (MACC) serving the beneficiary's county of residence; and 

  3. Individuals who are not currently Medicaid eligible shall be referred by (BHCS) to the county board of social services (CBOSS) located in the county where the individual resides, for a determination of financial eligibility, including the referral for determination of disability. 

  (l) After the applicant has been determined financially eligible, he or she shall be referred to the Medical Assistance Customer Center (MACC) of the applicant's residence for a determination of medical eligibility by the Regional Staff Nurse (RSN). 

  (m) When the applicant is judged financially and medically eligible for the TBI waiver program, the MACC shall assign the case to a case management site and notify the (BHCS) of the beneficiary's approval for participation in the program. 

  (n) The MACC shall review and approve the plan of care prepared by the case manager initially, and at six month intervals. 

  (o) If a waiver beneficiary is categorically eligible for Medicaid services under the State Plan and no waiver services are required as a part of the plan of care, the beneficiary shall be terminated from the TBI program. 

  (p) All approved services under the New Jersey Medicaid program, except for nursing facility services, are available under the TBI Waiver from approved Medicaid providers in accord with an individualized plan of care.  (See N.J.A.C. 10:60-5.5 for a description of services.)

  (q) An individual shall be terminated from the TBI Waiver Program for the following reasons: 

  1. He or she no longer meets the income and resource requirements for Medicaid; 

  2. He or she no longer exhibits medical, emotional, behavioral and/or cognitive deficits which would qualify the individual for nursing facility care; 

  3. He or she attains a Level 8 or above on the Rancho Los Amigos Levels of Cognitive Functioning Scale; 

  4. He or she refuses to accept case management services;  or 

  5. He or she is categorically eligible for Medicaid State Plan services and does not require waiver services as part of the plan of care. 

  (r) Where termination is sought pursuant to (q) above, an individual shall be afforded the opportunity to request a hearing pursuant to N.J.A.C. 10:49-9.10.

SUBCHAPTER 23. LIFELINE PROGRAMS

10:49-23.1 Purpose and scope 

  Lifeline Programs provide an annual benefit to eligible persons toward the cost of electricity and natural gas.  The Lifeline Credit Program (LCP) and the Tenants Lifeline Assistance Program (TLAP) are administered by the Department of Health and Senior Services.  The rules for these programs are promulgated by the Department of Health and Senior Services.  Although the Department of Health and Senior Services also administers the Lifeline benefit, because Supplemental Security Income (SSI) beneficiaries receive the benefit as a Special Utility Supplement (SUS) in their monthly SSI checks, DMAHS is responsible for establishing the policies and procedures for eligibility for this benefit as part of their SSI income eligibility for the Medicaid program.

 10:49-23.2 Applications 

  (a) Applications for the Lifeline Programs are sent automatically to persons benefiting from the following Medicaid programs: 

  1. Medical Assistance to the Aged (MAA); 

  2. Medical Assistance Only (MAO);  and 

  3. New Jersey Care ... Special Medicaid Programs.

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

10:49-24.1 Introduction 

  (a) Effective for services rendered on or after February 1, 1997, consistent with N.J.A.C. 10:90-13, the Division's fiscal agent shall process Work First New Jersey/General Assistance (WFNJ/GA) claims. N.J.A.C. 10:49-24.3 describes the covered services that shall be processed by the fiscal agent. N.J.A.C. 10:49-24.4 describes services that shall not be processed by the fiscal agent. N.J.A.C. 10:49-24.5 indicates that payment for services shall be made using existing Medicaid reimbursement methodology. 

  (b) The information in this subsection is provided to assist providers in identifying a WFNJ/GA beneficiary. Consistent with N.J.A.C. 10:90-13.2, each municipal welfare department (MWD) or county board of social services (CBOSS) provides a validation card or letter for each client which is used to obtain medical services. The validation card or letter is supplied to each WFNJ/GA beneficiary at the time of opening or reopening of the case and monthly thereafter to ensure validity through all periods of assistance and eligibility. Each card or letter shall contain, at a minimum: 

  1. The name, address, and telephone number of the MWD and the agency's four-digit municipality code; 

   i. The four-digit codes range from 5001 to 5099 and from 5200 to 5786; 

  2. The first and last name(s) of the WFNJ/GA client(s) to whom the card or letter applies; 

  3. A six-digit client case number;  

   i. If the case number assigned to a WFNJ/GA client is less than six digits, the MWD/CBOSS shall add zeros (example: 000411);

   4. A two digit person number; and 

  5. The effective date and expiration date of the card or letter. 

   i. Validation cards or letters shall not be valid for more than one month. 

  (c) Providers may contact the local MWD/CBOSS that assists the WFNJ/GA client if there are questions regarding eligibility. Questions regarding WFNJ/GA requirements or coverage of services should be directed to DMAHS. Only questions related to claim processing should be directed to the fiscal agent. 

  (d) Dispute resolution requirements related to a client's eligibility for WFNJ/GA are contained in N.J.A.C. 10:90-9. Individuals shall contact the county or municipal agency to resolve any questions, consistent with the requirements contained in N.J.A.C. 10:90-9.

10:49-24.2 Administrative provisions

   (a) Any provider of services shall meet Medicaid requirements and be enrolled as a Medicaid provider. Requirements regarding enrollment and provision of service are set forth in the appropriate chapters of the New Jersey Administrative Code. 

  (b) The administrative requirements of the Medicaid program shall apply to these claims. The requirements contained in this chapter include, but are not limited to, N.J.A.C. 10:49-1, General Provisions; N.J.A.C. 10:49-3, Provider Participation; N.J.A.C. 10:49-4, Providers' Role in a Shared Health Care Facility; N.J.A.C. 10:49-5.5, Services not covered by the Medicaid or NJ FamilyCare-Plan A program; N.J.A.C. 10:49-6, Authorizations Required by Medicaid and NJ FamilyCare Programs; N.J.A.C. 10:49-7, Submitting Claims for Payment (Policies and Regulations); N.J.A.C. 10:49-8, Payment for Services Provided; N.J.A.C. 10:49-11, Exclusion from Participation in the New Jersey Medicaid and NJ FamilyCare Programs (Suspension, Debarment, and Disqualification); N.J.A.C. 10:49-12, Provider Reinstatement; N.J.A.C. 10:49-13, Program Controls; N.J.A.C. 10:49-14.2, Sanctions--Special Status Program; N.J.A.C. 10:49-14.3, Authority to adjust, compromise, settle or waive claims, liens and certificates of debt; and N.J.A.C. 10:49-14.5, Administrative charges/service fees. 

  1. WFNJ/GA claims processed by the Division's fiscal agent are not subject to the fair hearing processes described at N.J.A.C. 10:49-9.14.

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

  (a) The Medicaid fiscal agent shall reimburse only those WFNJ/GA program covered services listed below in this subsection when provided in an ambulatory setting, except as specified in N.J.A.C. 10:49-24.4(a)14. These services include: 

  1. Abortion (elective/induced); 

  2. Acupuncture; 

  3. ADDP covered anti-retroviral drugs; 

  4. Ambulance; 

  5. Ambulatory surgery; 

  6. Blood and blood plasma; 

  7. Case management services for the chronically mentally ill (for specific information, see N.J.A.C. 10:73); 

  8. Certified nurse practitioner/clinical nurse specialist services (for specific information, see N.J.A.C. 10:58A); 

  9. Chiropractic services (for specific information, see N.J.A.C. 10:68); 

  10. Clinic services (services in an independent outpatient health care facility, ambulatory care facility, ambulatory surgical center, ambulatory care/family planning/surgical facility, drug treatment center, Federally qualified health center, free-standing end-stage renal dialysis facility), such as dental, family planning, laboratory, mental health, minor surgery, personal care assistance, podiatry, radiology, rehabilitation, or vision care (for specific information, see N.J.A.C. 10:66), except that: 

   i. Professional services provided by a residential alcohol or drug abuse treatment facility to an individual residing in the   facility shall not be processed; 

  11. Dental services, including dentures (for specific information, see N.J.A.C. 10:56); 

  12. Durable medical equipment; 

  13. 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, except that: 

   i. Services provided primarily for the diagnoses and treatment of infertility, including sterilization reversals, and   related office (medical and clinic) visits, drugs, laboratory services, radiological and diagnostic services and surgical   procedures shall not be processed. 

  14. Hearing aid services (for specific information, see N.J.A.C. 10:64); 

  15. Home care services, including home health care (for specific information, see N.J.A.C. 10:60); 

  16. Hospice services, except those provided in a nursing home facility (for specific information, see N.J.A.C. 10:53A); 

   i. The following hospice services, with corresponding HCPCS, shall be processed under the WFNJ/GA program: 

    (1) Y6333 Routine home care rate; 

    (2) Y6334 Continuous home care rate; and 

    (3) Y6343 Drugs and biologicals co-payment (rendered in places other than long term care facilities). 

   ii. The following hospice services, with corresponding HCPCS, shall not be processed under the WFNJ/GA program: 

    (1) Y6335 Inpatient respite care rate; 

    (2) Y6336 General inpatient care; 

    (3) Y6337 Therapeutic leave days; 

    (4) Y6338 Bed hold days; 

    (5) Y6339 Hospice Respite Care; and 

    (6) Z2015 Room and board; 

  17. Laboratory (clinical) services (for specific information, see N.J.A.C. 10:61); 

  18. Medical supplies and equipment (for specific information, see N.J.A.C. 10:59); 

  19. Mental health services (for specific information, see N.J.A.C. 10:66); 

  20. Non-maternity nurse-midwifery services, such as family planning (for specific information, see N.J.A.C. 10:58); 

  21. Optometric services (for specific information, see N.J.A.C. 10:62); 

  22. Optical appliances (for specific information, see N.J.A.C. 10:62); 

  23. Personal care assistant; 

  24. Thermograms; 

  25. Thermography; 

  26. Pharmaceutical services (for specific information, see N.J.A.C. 10:51); 

   i. Prior authorization shall be required where patterns of medically harmful or inappropriate use of specific drugs, therapeutic drug classes, enteral nutritional supplements, needles and syringes have been identified, or for claims originating in certain municipalities where such patterns have been identified; and 

   ii. Effective with claims for dates of service on or after August 7, 2000, the Division's processing of claims for certain antiretroviral drugs shall be accomplished under the AIDS Drug Distribution Program (ADDP), administered by the   Department of Health and Senior Services (DHSS), except for emergency supplies as authorized under WFNJ/GA to avert a lapse in  treatment. These drugs shall include, but may not be limited to: thymidine nucleosides, thymidine analogs, protease inhibitors,  nucleoside analog reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, carbocyclic nucleoside analogs, purine nucleoside analogs of deoxyadenosine, and primidine nucleoside analogs; 

  27. Physician services (for specific information, see N.J.A.C. 10:54); 

  28. Podiatric services (for specific information, see N.J.A.C. 10:57); 

  29. Prosthetic and orthotic devices (for specific information, see N.J.A.C. 10:55); 

  30. Psychological service (for specific information, see N.J.A.C. 10:67); 

  31. Radiological services (for specific information, see N.J.A.C. 10:54); 

  32. Rehabilitative services (for specific information, see N.J.A.C. 10:66). Payments shall be made to eligible Medicaid providers only. No payment shall be made to privately practicing therapists who are not Medicaid providers. Rehabilitative services include: 

   i. Physical therapy; 

   ii. Occupational therapy; 

   iii. Speech-language pathology services; and 

   iv. Audiology services; 

  33. Transportation services which include ambulance and mobility assistance vehicle (for specific information, see N.J.A.C. 10:50 and 10:66); 

  34. Medicare coinsurance and/or deductible for services specified in (a)1 through 23 above, if otherwise reimbursed by the New Jersey Medicaid program; and 

  35. Inpatient services provided by Mt. Carmel Guild Hospital located in Newark, New Jersey.

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

  (a) Consistent with N.J.A.C. 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 N.J.A.C. 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. s 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 board of social services. 

10:49-24.5 Basis for reimbursement

   Except as noted under N.J.A.C. 10:49-24.3(a)16ii, payment for services shall be based upon the Medicaid reimbursement methodology for the respective service. (See specific provider chapter(s) for reimbursement methodology and requirements.)

CHAPTER 49. ADMINISTRATION MANUAL

APPENDIX

Medicaid Eligibility Identification Card (FD-73/178)                Form #1

Medically Needy Claim Transmittal (FD-311)                          Form #2

Public Assistance Inquiry (PA-1C)                                   Form #3

Certification of Presumptive Eligibility (FD-334)                   Form #4

Application for Payment of Unpaid Medical Bills (FD-74)             Form #5

Department of Human Services Medicaid ID (FD-152)                   Form #6

Validation of Eligibility (FD-34)                                   Form #7

Provider Application (FD-20)                                        Form #8

Provider Agreement (FD-62)                                          Form #9

Disclosure of Ownership and Control Interest Statement (HCFA-1513)  Form #10

Patient Certification Form (FD-197)                                 Form #11

Notice to Providers                                                 Form #12

Medical Assistance Customer Centers Directory                       Form #14

New Jersey County Boards of Social Services                         Form #15

 Notice to All Applicants and Providers 

  Please note that the ownership and direction of a professional practice must

  be in compliance with all applicable State statutes and regulations governing

  licensure.

  Any individual or entity found by staff of the Division of Medical Assistance

  and Health Services to be in violation any State statute or regulation

  governing the ownership and direction of a professional practice will be

  subject to appropriate sanctions contained in the statutes and regulations

  governing the programs administered by the Division of Medical Assistance and

  Health Services, including exclusion from the New Jersey Medicaid and NJ

  KidCare programs. In addition, such violations will be referred to the

  appropriate professional board or other licensure authority. 

To be completed by owner, managing partner or chief executive officer: 

  I hereby certify that _______ (name of entity applying for program

*29438   participation) is in compliance with State statutes and regulations governing

  the ownership and direction of a professional practice. 

____________________                    _______________________________________

Date                                                    Print or type name and title

                                        _______________________________________

                                        Signature 

Form #12

MEDICAL ASSISTANCE CUSTOMER CENTER

(MACC)

MACC OFFICE       DIRECTOR & PHONE #               ADDRESS

------------------------------------------------------------------------------

(03)  BURLINGTON  Nancy Weber, Director   Mt. Laurel Corporate Park

(11)  MERCER      (856) 787-3855                   1000 Howard Blvd, Suite 303

FAX#(856) 787-3877               Mt. Laurel, NJ 08054-2355

------------------------------------------------------------------------------

(04)  CAMDEN      Eileen Calabro, Director         1 Port Center, Suite 401

(08)  GLOUCESTER  (856) 614-2870                   2 Riverside Dr. 

(17)  SALEM       FAX#(856) 614-2575               Camden, NJ 08103-1018

------------------------------------------------------------------------------

(06)  CUMBERLAND  , [Barbara Smith] Director       Giles Building

(01)  ATLANTIC    (856) 690-5208                   1676 East Landis Ave

(05)  CAPE MAY    FAX#(856) 690-5223               PO Box 1513

                                                   Vineland, NJ 08362-1513

------------------------------------------------------------------------------

(07)  ESSEX       Kate Buckley-Straussl, Director  153 Halsey St

                  (973) 648-3700                   4th Floor

                  FAX#(973) 642-6468               Newark, NJ 07101-8004

                John Russell, Northern Regional Administrator

------------------------------------------------------------------------------

(09)  HUDSON      Robert Dueben, Director          438 Summit Ave

                  (201) 217-7100                   6th Floor

                  FAX#(201) 217-7122               Jersey City, NJ 07306-3186

------------------------------------------------------------------------------

*29439 (12)  MIDDLESEX   , [Susan Simon] Director         301 Blair Road

(20)  UNION       (732) 499-5700                   2nd Floor

                  FAX#(732) 499-5803               Avenel, NJ 07001-2936

------------------------------------------------------------------------------

(13)  MONMOUTH    , [Carol Coyle] Director         Juniper Business Plaza

                  (732) 761-3600                   3499 Highway 9 North

                  FAX#(732) 761-3621 or 3623       Suite 1H-A

                                                   Freehold, NJ 07728-3287

               Thomas Rafferty, Southern Regional Administrator

------------------------------------------------------------------------------

(14)  MORRIS      Stewart Klaus, Director          10 Park Place

(10)  HUNTERDON   (973) 631-6440                   Suite 340

(18)  SOMERSET    FAX#(973) 631-6448               Morristown, NJ 07960-7101

(19)  SUSSEX

(21)  WARREN

------------------------------------------------------------------------------

(15)  OCEAN       Gail Dempsey, Director           1510 Hooper Ave

                  (732) 255-0731                   Suite 130

                  FAX#(732) 255-0743               Toms River, NJ 08753-2295

------------------------------------------------------------------------------

(16)  PASSAIC     Kathleen Lohrey, Director        66 Hamilton St

(02)  BERGEN      (973) 977-4077                   Paterson, NJ 07505-2021

                  FAX#(973) 684-8182

------------------------------------------------------------------------------

Form #14

                       COUNTY BOARDS OF SOCIAL SERVICES

-------------------------------------------------------------------------------

ATLANTIC       1  FORREST GILMORE,     ATLANTIC COUNTY DEPARTMENT OF FAMILY

                    ACT. DEPT. HEAD

                  KAREN B. ENOUS, DIRECTOR OF WELFARE & COMMUNITY DEVELOPMENT

                                       1333 ATLANTIC AVE.

8:30-4:30          FAX 609-343-2374    ATLANTIC CITY, NJ           609-348-3001

                                         08401-8297

-------------------------------------------------------------------------------

BERGEN         2  EDWARD TESTA,        BERGEN COUNTY BOARD OF SOCIAL SERVICES

*29440                     DIRECTOR

8:00-4:30                              216 ROUTE 17 NORTH

8:00-8:00         FAX 201-368-8710     ROCHELLE PARK, NJ           201-368-4200

  (Tuesday)                              07662-3300

-------------------------------------------------------------------------------

BURLINGTON     3  ANN SABOE, DIRECTOR  BURLINGTON COUNTY BOARD OF SOCIAL

                                         SERVICES

                                       HUMAN SERVICES FACILITY

8:00-5:00                              795 WOODLANE RD.

8:00-7:30         FAX 609-261-0463     MOUNT HOLLY, NJ             609-261-1000

  (Thursday)                             08060-3335

-------------------------------------------------------------------------------

CAMDEN         4  ROBERT ELLIS,        CAMDEN COUNTY BOARD OF SOCIAL SERVICES

                    DIRECTOR

                                       ALETHA R. WRIGHT ADMINISTRATION BLDG.

8:30-4:30         FAX 856-225-5145     600 MARKET ST.

                    (Director Only)

7:30-7:30         FAX 856-225-7797     CAMDEN, NJ 08102-8800       856-225-8800

  (Thursday)

-------------------------------------------------------------------------------

CAPE MAY       5  JOSEPH B. FAHY,      CAPE MAY COUNTY BOARD OF SOCIAL SERVICES

                    DIRECTOR

                                       SOCIAL SERVICES BLDG.

                                       4005 ROUTE 9 SOUTH

8:30-4:30         FAX 609-889-9332     RIO GRANDE, NJ              609-886-6200

                                         08242-1911

-------------------------------------------------------------------------------

CUMBERLAND     6  GREGORY CURLISS,     CUMBERLAND COUNTY BOARD OF SOCIAL

                    DIRECTOR             SERVICES

                                       13 NORTHEAST BLVD.

8:30-4:30         FAX 856-692-7635     VINELAND, NJ 08360          856-691-4600

-------------------------------------------------------------------------------

ESSEX          7  JAMES J. WILLIAMS,   ESSEX COUNTY DEPARTMENT OF CITIZEN

                    DIRECTOR             SERVICES

                                       DIVISION OF WELFARE

                                       18 RECTOR ST., 9TH FL.

*29441 8:00-5:30         FAX 973-643-3985     NEWARK, NJ 07102            973-733-3000

-------------------------------------------------------------------------------

GLOUCESTER     8  CAROL PIRROTTA,      GLOUCESTER COUNTY BOARD OF SOCIAL

                    DIRECTOR             SERVICES

                                       400 HOLLYDELL DR.

7:30-4:30         FAX 856-582-6587     SEWELL, NJ 08080            856-582-9200

-------------------------------------------------------------------------------

HUDSON         9  ANGELICA HARRISON,   HUDSON COUNTY DIVISION OF SOCIAL

                    DIRECTOR             SERVICES

                                       JOHN F. KENNEDY OFFICE BLDG.

                                       100 NEWKIRK ST.

8:00-5:00         FAX 201-420-0343     JERSEY CITY, NJ 07306       201-420-3000

-------------------------------------------------------------------------------

HUNTERDON     10  JOHN F. CAHALAN,     COUNTY OF HUNTERDON

                    DIRECTOR

                                       DIVISION OF SOCIAL SERVICES

                                       DEPARTMENT OF HUMAN SERVICES

                                       P.O. BOX 2900

8:30-4:30         FAX 908-806-4588     FLEMINGTON, NJ              908-788-1300

                                         08822-2900

-------------------------------------------------------------------------------

MERCER        11  DENNIS C. MICAI,     MERCER COUNTY BOARD OF SOCIAL SERVICES

                    DIRECTOR

8:30-4:30                              200 WOOLVERTON ST., P.O. BOX 1450

8:30-8:30         FAX 609-989-0405     TRENTON, NJ 08650-2099      609-989-4320

  (Tuesday)

-------------------------------------------------------------------------------

MIDDLESEX     12  ANGELA B.            MIDDLESEX COUNTY BOARD OF SOCIAL

                    MACKARONIS,          SERVICES

                    DIRECTOR

                  FAX 732-745-4558     181 HOW LANE, P.O. BOX 509

8:30-4:15         WFNJ FAX             NEW BRUNSWICK, NJ 08903     732-745-3500

                    732-745-4555

-------------------------------------------------------------------------------

MONMOUTH      13  KATHLEEN A. BRADY,   MONMOUTH COUNTY DIVISION OF SOCIAL

                    DIRECTOR             SERVICES

*29442 8:30-4:30         FAX 732-431-6017     KOZLOSKI RD., P.O. BOX 3000

8:30-8:00         WFNJ FAX             FREEHOLD, NJ 07728          732-431-6000

  (Thursday)        732-431-6267

-------------------------------------------------------------------------------

MORRIS        14  CAROL A. NOVRIT,&