N.J. Admin. Code § 10:53A-2.7

Current through Register Vol. 57, No. 1, January 6, 2025

Section 10:53A-2.7 - Monitoring

(a) On a random selection basis, the Division shall conduct post-payment quality assurance reviews based on Surveillance and Utilization Review System (SURS) reports and other sources to assure compliance with program, personnel, recordkeeping and service delivery requirements. Provisions shall be made to recover funds, when reviews by the Division reveal that overpayments to the hospice have been made. At the specific request of the Division, the hospice shall submit a plan of care and other documentation for those Medicaid/NJ FamilyCare FFS beneficiaries selected for a quality assurance review.

1. The review shall involve contact with the hospice and the beneficiary and will focus on the following areas:

i. Number of beneficiaries;

ii. Cost per beneficiary including the "cap" requirements;

iii. Number of days of service per beneficiary and the quality of services;

iv. Comparative analysis between claim payments and the plan of care; and

v. Completion of forms necessary for eligibility for hospice services.

(b) On-site monitoring visits shall be made by the Division staff for the purpose of determining compliance with the provisions of the Medicaid/NJ FamilyCare FFS hospice rules and for quality assurance purposes. The results of the on-site monitoring shall be reported to the hospice with a copy for the Division. When indicated, a plan of correction will be required. Continued non-compliance with requirements may result in such sanctions as: the curtailment of accepting new beneficiaries for services; termination of the hospice's provider contract; and/or the suspension, debarment or disqualification of the hospice or hospice-related parties from participation in the Medicaid/NJ FamilyCare FFS program.

N.J. Admin. Code § 10:53A-2.7

Amended by R.2003 d.320, effective 8/4/2003.
See: 34 New Jersey Register 2899(a), 35 New Jersey Register 3568(a).
In (a), in last sentence substituted "Medicaid/NJ FamilyCare FFS beneficiaries" for "Medicaid recipients"; in (b), in first and third sentence inserted "/NJ FamilyCare FFS" following "Medicaid"; substituted "beneficiary" for "recipient" and "beneficiaries" for "recipients" throughout.