N.J. Admin. Code § 10:49-24.4

Current through Register Vol. 56, No. 23, December 2, 2024

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

(a) Consistent with 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 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. § 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 welfare agency.

N.J. Admin. Code § 10:49-24.4

Amended by R.2008 d.230, effective 8/4/2008.
See: 40 N.J.R. 984(a), 40 N.J.R. 4531(a).
In (a)18, substituted "welfare agency" for "board of social services".