N.J. Admin. Code § 10:66-1.2
The following words and terms, when used in this chapter, shall have the following meanings, unless the context indicates otherwise:
"Ambulatory care facility" means a health care facility or a distinct part of a health care facility, licensed by the New Jersey State Department of Health, or similarly licensed by a comparable agency of the state in which the facility is located, which provides preventive, diagnostic, and treatment services to persons who come to the facility to receive services and depart from the facility on the same day.
"Ambulatory care/family planning facility" means a health care facility or a distinct part of a health care facility, licensed by the New Jersey State Department of Health, or similarly licensed by a comparable agency of the state in which the facility is located, to provide specified surgical procedures.
"Ambulatory surgical center (ASC)" means any distinct entity that: operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization; has an agreement with the Centers for Medicare & Medicaid Services (CMS) as a Medicare participating provider for ambulatory surgical services; is licensed, if required, by the New Jersey State Department of Health, or is similarly licensed by a comparable agency of the state in which the facility is located; and meets the enrollment requirements of the New Jersey Medicaid/NJ FamilyCare programs as indicated in the Administration chapter at N.J.A.C. 10:49-3.2 and N.J.A.C. 10:66-1.3.
"American Society of Addiction Medicine (ASAM)" means the professional society representing physicians, clinicians, and associated professionals in the field of addiction medicine. Their main office is located at 4601 North Park Ave., Upper Arcade, Suite 101, Chevy Chase, MD 20815, or they can be contacted on their website at: www.asam.org.
"ASAM level of care" refers to the ASAM Patient Placement Criteria developed by the American Society of Addiction Medicine, contained in "Patient Placement Criteria for the Treatment of Substance Related Disorder," 2nd Edition revised (2001) (ASAM PPC-2R), incorporated herein by reference, as amended and supplemented, which can be obtained from the ASAM Publications Center, by calling 1-800-844-8948.
"Audited financial statements" are defined in requirements set forth in 10:66-4.3. This section provides a set of guidelines so that FQHC providers will know the criteria for a satisfactory audit.
"Behavioral health services" refers to the treatment and amelioration of behavioral/mental health conditions, as well as efforts to prevent and intervene in substance use disorder.
"Clinical practitioner" means a physician (including doctor of medicine, osteopathy, dentistry, podiatry, optometry, and chiropractic medicine), advanced practice nurse, certified nurse midwife, and clinical psychologist.
"Clinic services" means preventive, diagnostic, therapeutic, rehabilitative, or palliative services that are furnished by a facility that is not a part of a hospital but is organized and operated to provide medical care to outpatients. The term includes the following services furnished to outpatients:
1. Services furnished at the clinic by or under the direction of a physician or dentist; and
2. Services furnished outside the clinic, by clinic personnel under the direction of a physician, to an eligible individual who does not reside in a permanent dwelling or does not have a fixed home or mailing address.
"Compensated hours" means, in the case of a Federally qualified health center only, all hours for which an employee receives compensation, payment or any form of remuneration, including regular time, overtime, vacation time, sick time, personal time, educational time, and all other compensated time.
"Dental clinic" means an independent clinic, whether freestanding, or a distinct component of a multi-service ambulatory care facility, licensed by the New Jersey State Board of Dentistry, or similarly licensed by a comparable agency of the state in which the facility is located.
"Dentist" means an individual who is licensed to practice dentistry in the state in which treatment is provided, whose practice is limited solely to dentistry and its specialties, as recognized by the American Dental Association, and who meets the requirements of N.J.A.C. 10:56.
"DHS" means the New Jersey Department of Human Services.
"Division of Mental Health and Addiction Services" or "DMHAS" means the division of the New Jersey Department of Human Services that is responsible for the administration of the State's mental health and addiction programs.
"Drug treatment center" means an independent clinic, whether freestanding, or a distinct part of a facility which is licensed or approved by the New Jersey State Department of Health and Senior Services (DHSS), or is similarly licensed by a comparable agency of the state in which the facility is located, to provide health care for the prevention and treatment of drug addiction and drug abuse, in accordance with N.J.A.C. 8:43A-26, Drug Abuse Treatment Services.
"End Stage Renal Disease (ESRD) facility" means a freestanding facility approved by the Centers for Medicare & Medicaid Services (CMS) for participation in the Medicare program as an end stage renal disease facility.
"Federally qualified health center (FQHC)" means an entity that is receiving a grant under Section 330 of the Public Health Service Act; or is receiving funding from such a grant under a contract with the recipient of such a grant and meets the requirements to receive a grant under Section 330 of the Public Health Service Act; or based on the recommendation of the Health Resources and Services Administration within the Public Health Service, is determined by the Secretary to meet the requirements for receiving such a grant; or was treated by the Secretary, for purposes of Medicare Part B, as a Federally Funded Health Center as of January 1, 1990; and includes an outpatient health program or facility operated by a tribe or tribal organization under the Indian Self-Determination Act ( Public Law 93-638 ) or by an urban Indian organization receiving funds under Title V of the Indian Health Care Improvement Act for the provision of primary health services.
"Freestanding facility" means a facility which may not be part of a hospital. However, a clinic may be located in the same building as a hospital, as long as there is no administrative, organizational, financial or other connection between the clinic and the hospital.
"Independent clinic" means a facility that is not part of a hospital but is organized and operated to provide medical care to outpatients.
"Level of Care Index-Adult-3 (LOCI 3)" is a comprehensive program for guiding assessments and documenting treatment, placement, and planning information for the six dimensions of the ASAM criteria placement findings for adults. This program can be accessed on the ASAM website: http://www.asam.org/quality-practice/guidelines-and-consensus-documents/the-asam-criteria.
"Local health department clinic" means an independent clinic that is licensed or approved by the New Jersey State Department of Health (DOH) to provide medical care to outpatients in accordance with N.J.A.C. 8:52.
"Managed care wraparound payments" means DMAHS payments made to FQHCs for the difference between the Medicaid FQHC encounter rate and amounts paid to FQHCs by managed care organizations for encounters provided to Medicaid and FamilyCare beneficiaries.
"Medical director" means a physician, doctor of medicine (M.D.) or osteopathy (D.O.), who is responsible for the direction, provision and quality of medical services provided to patients and who is qualified in accordance with 8:43A-1.14.
"Medicare Economic Index (MEI)" means that factor that adjusts reimbursement rates for annual inflation, which is determined in accordance with section 1842(b)(3) of the Social Security Act, 42 U.S.C. § 1395u(b)(3) and regulation at 42 C.F.R. 405.504.
"Medicare limit" means the Medicare FQHC urban payment limit as provided for in section 1833(a)(3) of the Social Security Act, 42 U.S.C. § 1395l(a) and section 1861(v)(1)(A) of the Social Security Act, 42 U.S.C. § 1395x(v), and section 1886(d)(2)(D) of the Social Security Act, 42 U.S.C. § 1395ww(d). The Medicare limit is adjusted for inflation annually by the Medicare Economic Index (MEI) applicable to primary care services.
"Mental health clinic" means an independent clinic, whether freestanding, or a distinct component of a multi-service ambulatory care facility, that meets the minimum standards established by the Community Mental Health Services Act implementing rules, including, but not limited to, N.J.A.C. 10:37, and is approved by the Division of Mental Health and Addiction Services (DMHAS), in accordance with that Division's rules, or is similarly licensed by a comparable agency of the state in which the facility is located.
"Mental health services worker" means an individual who possesses a bachelor's degree or associate's degree in psychosocial rehabilitation or mental health services, or related life or work experience, such as assuming leadership roles during participation in mental health services or mental health consumer initiatives.
"New Jersey Substance Abuse Monitoring System (NJSAMS)" is the automated client data collection system required by DHS to be used by all DHS New Jersey substance use disorder treatment facilities and providers to record and report consumer data including, but not limited to, admission, status, treatment services, utilization management, and discharge information.
"Opioid" means both opiates and synthetic narcotics.
"Opioid treatment provider" is a program licensed by DHS where opioid agonist treatment medication, such as methadone or buprenorphine, is dispensed, along with a comprehensive range of medical and rehabilitative services to alleviate the adverse medical, psychological, or physical effects attributed to the use of opioids. The program must be certified as an Opioid Treatment Program by the Federal Substance Abuse and Mental Health Services Administration (SAMHSA) and comply with all regulations enforced by the Drug Enforcement Administration (DEA) as referenced in N.J.A.C. 10:161B-11.1.
"Outpatient" means a patient of an organized medical facility, or a distinct part of that facility who is expected by the facility to receive and who does receive professional services for less than a 24-hour period, regardless of the hour of admission, whether or not a bed is used, or whether or not the patient remains in the facility past midnight.
"PA" means prior authorization. See 10:66-1.4.
"Patient" means a beneficiary who is receiving needed professional services that are directed by a licensed practitioner of the healing arts towards the maintenance, improvement, or protection of health, or lessening of illness, disability, or pain.
"Personal care assistant" means a person who has successfully completed a training program in personal care services and is certified by the New Jersey State Department of Law and Public Safety, Board of Nursing, as a homemaker-home health aide; who successfully completes a minimum of 12 hours in-service education per year offered by the agency; and who is supervised by a registered professional nurse employed by a Division homemaker/personal care assistant provider agency.
"Physician" means a doctor of medicine (M.D.) or osteopathy (D.O.) licensed to practice medicine and surgery by the New Jersey State Board of Medical Examiners, or similarly licensed by comparable agencies of the state in which he or she practices.
"Podiatrist" means an individual licensed to practice podiatry in the state in which treatment is provided, and whose practice is limited to podiatry, within the scope of practice for that state.
"Prevocational services" means interventions, strategies and activities within the context of a partial care program that assist individuals to acquire general work behaviors, attitudes and skills needed to take on the role of worker and in other life domains, such as: responding to criticism, decision making, negotiating for needs, dealing with interpersonal issues, managing psychiatric symptoms and adherence to prescribed medication directions/schedules. Examples of interventions not considered prevocational or covered by Medicaid and NJ FamilyCare include: technical occupational skills training, college preparation, student education, including preparation of school assigned classwork or homework and individualized job development.
"Prospective Payment System (PPS)" means a payment rate per encounter which is determined in accordance with 42 U.S.C. § 1396a(a) and adjusted annually by the MEI applicable to primary care services.
"Psychologist" means an individual who is licensed to practice psychology in the state in which treatment is provided, and who is a Diplomate of the American Board of Professional Psychology (Diplomate Qualified) or has been notified of admissibility to the examination by the American Board of Professional Psychology (Diplomate Eligible).
"Satellite" means an affiliate of a separately enrolled independent clinic. A satellite is located at a site distinct from that of the separately enrolled independent clinic but shares the same governing authority.
"Special minimum wage certificate" means a certificate issued by the U.S. Department of Labor pursuant to 29 C.F.R. § 525, which permits a worker with a disability to be paid at a rate below the rate which would otherwise be required by statute.
"Specialist" means a fully licensed physician who:
1. Is a diplomate of a specialty board approved by the American Board of Medical Specialties or the Advisory Board of the American Osteopathic Association;
2. Is a fellow of the appropriate American specialty college or a member of an osteopathic specialty college;
3. Is currently admissible to take the examination administered by a specialty board approved by the American Board of Medical Specialties or the Advisory Board of the American Osteopathic Association, or has evidence of completion of an appropriate qualifying residency approved by the American Medical Association or American Osteopathic Association;
4. Holds an active staff appointment with specialty privileges in a voluntary or governmental hospital which is approved for training in the specialty in which the physician has privileges; or
5. Is recognized in the community as a specialist by his or her peers.
"Specialist in dentistry" means an individual who is licensed to practice dentistry in the state in which treatment is provided, and whose practice is limited solely to his or her specialty, which is recognized by the American Dental Association. Additional conditions regarding the qualifications for a dental specialist for the New Jersey Medicaid and NJ FamilyCare fee-for-service programs are located in the New Jersey Medicaid and NJ FamilyCare fee-for-service programs' Dental Services chapter, N.J.A.C. 10:56.
"Specialist in podiatry" means an individual who is licensed to practice podiatry in the state in which treatment is provided, and who is a Diplomate of the appropriate American Podiatry Association-recognized board or has been notified of admissibility to examination by the appropriate American Podiatry Association recognized board.
"Substance use disorder treatment facility" means an independent clinic, whether freestanding, or a distinct part of a facility, that is licensed or approved by the New Jersey State Department of Health (DOH), or is similarly licensed by DHS, Division of Mental Health and Addiction Services (DMHAS), to provide health care for the prevention and treatment of drug addiction and drug abuse, in accordance with N.J.A.C. 8:43A-26 and/or 10:161B, as applicable.
"Therapeutic subcontract work activity" means production, assembly and/or packing/collating tasks for which individuals with disabilities performing these tasks are paid less than minimum wage and, pursuant to 29 C.F.R. § 525, a special minimum wage certificate has been issued to the organization/program by the U.S. Department of Labor.
"Vocational services" means those interventions, strategies and activities that assist individuals to acquire skills to enter a specific occupation and take on the role of colleague (that is, a member of a profession) and/or assist the individual to directly enter the workforce and take on the role of an employee, working as a member of an occupational group for pay with a specific employer.
"Withdrawal management" or "detoxification" means the short-term provision of care, usually not in excess of 30 days, prescribed by a physician and conducted under medical supervision, for the purpose of withdrawing a person from a specific psychoactive substance in a safe and effective manner, according to established written medical protocols.
N.J. Admin. Code § 10:66-1.2