N.J. Admin. Code § 10:49-3.2

Current through Register Vol. 56, No. 9, May 6, 2024

Section 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 CMS-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 statutes and rules governing their ownership and direction (see Appendix, Form #12). Out-of-State providers shall certify that they comply with the requirements of the state in which the facility is located. 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 CMS-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 ).

3. If the application is denied, the applicant cannot resubmit a provider enrollment application for a period of one year from the date of the denial.

(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 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.

(i) All entities (as defined in (k) below) that receive or make annual Medicaid/NJ FamilyCare payments, under Title XIX of the Social Security Act, of at least $ 5,000,000 must, as a condition of receiving those payments, fully conform to the provisions of Section 6032 of the Deficit Reduction Act of 2005, 42 U.S.C. § 1396a(a)(68), incorporated herein by reference. If an entity furnishes items or services at more than a single location or under more than one contractual or other payment arrangement, the provisions of 42 U.S.C. § 1396a(a)(68) and of this subsection and (j) and (k) below shall apply to the entity and to each of its components and locations if the aggregate payments to or from that entity meet the $ 5,000,000 annual threshold, regardless of whether the entity submits claims for payments using one or more provider identification or tax identification numbers. Such an entity shall:

1. Establish written policies for all employees of the entity (including management), and of any contractor or agent of the entity, that provide detailed information about the Federal False Claims Act established under sections 3729 through 3733 of Title 31, United States Code ( 31 U.S.C. §§ 3729 through 3733 ), administrative remedies for false claims and statements established under chapter 38 of Title 31, United States Code ( 31 U.S.C. §§ 3801 et seq.), any State laws pertaining to civil or criminal penalties for false claims and statements, and whistleblower protections under such laws, with respect to the role of such laws in preventing and detecting fraud, waste, and abuse in Federal health care programs as defined in 42 U.S.C. § 1320a- 7b(f);

2. Include as part of such written policies, detailed provisions regarding the entity's policies and procedures for detecting and preventing fraud, waste and abuse; and

3. Include in any employee handbook for the entity a specific discussion of the laws described in (i)1 above, the rights of employees to be protected as whistleblowers, and the entity's policies and procedures for detecting and preventing fraud, waste and abuse.

(j) The following provisions apply to entities regulated under (i) above:

1. The written policies established by the entity that are required under (i) above, including the entity's policies and procedures for detecting and preventing fraud, waste and abuse, may be on paper or in electronic form. There is no requirement that an employee handbook be created by the entity, if none already exists.

2. The entity's policies shall be disseminated and shall be readily available to all employees and managers of the entity and to the entity's contractors and agents. The entity also shall:

i. Require the entity's contractors and agents to comply with these policies; and

ii. Request that the entity's contractors and agents disseminate and make these policies readily available to the employees and managers of the contractors and agents.

3. The requirements of Section 6032 of the Deficit Reduction Act of 2005 are deemed to be incorporated into all current and future provider participation agreements by virtue of existing language in all such agreements that providers shall comply with all applicable Federal laws.

(k) In (i) and (j) above, the following definitions apply:

1. "Annual" or "annually," for purposes of determining whether an entity meets the $ 5,000,000 threshold, means during the previous full Federal fiscal year (FFY). As an example, an entity will have met the $ 5,000,000 threshold as of January 1, 2008, if it received or made Title XIX payments in that amount in FFY 2007, which runs from October 1, 2006 through September 30, 2007.

2. "Contractor" or "agent" includes any contractor, subcontractor, agent, or other person which or who, on behalf of the entity, furnishes, or otherwise authorizes the furnishing of, Medicaid health care items or services, performs billing or coding functions, or is involved in monitoring of health care provided by the entity.

3. "Employee" includes any officer or employee of the entity.

4. "Entity" includes, but shall not be limited to, a governmental agency or facility, or an organization, unit, corporation, partnership, or other business arrangement (including any Medicaid managed care organization irrespective of the form of business structure or arrangement by which it exists), whether for-profit or not-for-profit, which receives or makes payments, under a State Plan approved under Title XIX or under any waiver of such plan, totaling at least $ 5,000,000 annually. A governmental component providing Medicaid health care items or services for which Medicaid payments are made would qualify as an entity (for example, a state, county or municipal health care facility, or a school district providing school-based health services). A government agency which merely administers all or part of the Medicaid program (for example, managing the claims processing system or determining beneficiary eligibility), shall not be considered an entity.

N.J. Admin. Code § 10:49-3.2

Amended by R.1997 d.354, effective 9/2/1997.
See: 29 N.J.R. 2512(a), 29 N.J.R. 3856(a).
In (b)1i, inserted "reenrollment"; and in (f) and (g), substituted "New Jersey Medicaid program" for "Division".
Amended by R.1998 d.116, effective 1/30/1998 (operative February 1, 1998; to expire July 31, 1998).
See: 30 N.J.R. 713(a).
Inserted references to NJ KidCare and made corresponding language changes throughout; and in (b) and (f), substituted references to Title XIX and Title XXI for references to Medicaid.
Adopted concurrent proposal, R.1998 d.426, effective 7/24/1998.
See: 30 N.J.R. 713(a), 30 N.J.R. 3034(a).
Readopted provisions of R.1998 d.116 without change.
Amended by R.2003 d.82, effective 2/18/2003.
See: 34 N.J.R. 2650(a), 35 N.J.R. 1118(a).
Rewrote the section.
Amended by R.2006 d.25, effective 1/17/2006.
See: 37 N.J.R. 3176(a), 38 N.J.R. 802(a).
In (b), substituted "CMS-" for "HCFA" throughout, deleted "licensing" preceding "statutes," and added "Out-of-State providers shall certify that they comply with the requirements of the state in which the facility is located."
Amended by R.2008 d.230, effective 8/4/2008.
See: 40 N.J.R. 984(a), 40 N.J.R. 4531(a).
Added (d)3.
Amended by R.2009 d.92, effective 3/16/2009.
See: 40 N.J.R. 5930(a), 41 N.J.R. 1244(a).
Added (i) through (k).