N.J. Admin. Code § 10:52-2.3

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:52-2.3 - Dental services

(a) Dental services in the outpatient department shall be provided in accordance with the requirements contained in N.J.A.C. 10:56, Dental Services. The outpatient dental department shall be subject to the same policies and procedures that apply to the Medicaid/NJ FamilyCare fee-for-service provider of dental services in the community, with the following exceptions:

1. Emergency dental care provided under special circumstances in a hospital emergency room; or

2. Outpatient dental services provided to NJ Medicaid/NJ FamilyCare fee-for-service beneficiaries with chronic medical conditions and/or developmental disabilities resulting in special healthcare needs.

(b) A hospital with an outpatient dental department serving Medicaid/NJ FamilyCare fee-for-service beneficiaries is given a unique provider number for that department. A hospital that starts an outpatient dental department shall request a provider number for that department from the fiscal agent.

(c) Reimbursement for a dental service is determined by the Commissioner of the Department of Human Services in accordance with N.J.A.C. 10:56, and is based on the same fee, conditions, and definitions for the corresponding service, utilized for the payment of individual Medicaid/NJ FamilyCare fee-for-service dental practitioners and providers in the community, except in cases in which the beneficiary's special healthcare needs, as described in (a)1 or 2 above, require that dental services be performed in the outpatient operating room setting. Reimbursement for outpatient operating room charges for services provided to clients with special healthcare needs, as described in (a)1 or 2 above, shall be at the hospital's outpatient cost-to-charge ratio. In no event shall the charge to the Division exceed the charge by the provider for identical services to other groups or individuals in the community.

1. If a dental procedure code is assigned both a specialist and non-specialist "Maximum Fee Allowance Schedule", the amount of the payment will be based upon the status (specialist or non-specialist) of the individual practitioner who actually provided the billed service.

i. If the dentist providing the services is a resident, intern, or house staff member, the status of the supervising dentist, specialist or non-specialist, determines the amount of the payment.

2. Covered emergency dental care performed in the hospital emergency room shall not be reimbursed if the services were provided in the emergency room and the dental clinic was available at the same time.

N.J. Admin. Code § 10:52-2.3

Amended by 50 N.J.R. 1261(a), effective 5/21/2018