N.J. Admin. Code § 10:54-3.2

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

Section 10:54-3.2 - Prior authorization

(a) Prior authorization, as used in this chapter, is the approval granted by the New Jersey Medicaid/NJ FamilyCare program before a service is rendered or an item provided. For additional information about prior and retroactive authorization, see also N.J.A.C. 10:49-6 and 10:54-5 and 7.

(b) Certain services require prior authorization, such as cosmetic surgery, certain psychiatric services and all out-of-State inpatient and outpatient hospital services, except in the conditions listed in (c) below. Services rendered to Medicaid/NJ FamilyCare program beneficiaries enrolled in a Health Maintenance Organization (HMO) may also require authorization by the Health Maintenance Organization (for details, see Managed Health Care Services in N.J.A.C. 10:74).

(c) Prior authorization shall not be required for the following:

1. Hospital covered services to any beneficiary who resides out-of-State at the discretion of the New Jersey Department of Human Services and who has a HSP (Medicaid) case number with either:

i. The first and second digits of 90; or

ii. The third and four digits of 60; or

2. Emergencies and interstate hospital transfers.

3. Any covered service that requires prior authorization as a prerequisite for payment to New Jersey Medicaid/NJ FamilyCare providers also requires prior authorization if it is to be provided and reimbursed by the New Jersey Medicaid/NJ FamilyCare program in any other state.

N.J. Admin. Code § 10:54-3.2

Amended by R.2001 d.51, effective 2/5/2001.
See: 32 N.J.R. 3929(a), 33 N.J.R. 555(a).
In (c)1, substituted "beneficiary" for "recipient" preceding "who resides out-of-State".
Amended by R.2012 d.124, effective 7/2/2012.
See: 43 N.J.R. 1477(a), 44 N.J.R. 1884(a).
In (a) and (c)3, inserted "/NJ FamilyCare" throughout; in (a), substituted "chapter" for "Chapter" and deleted "N.J.A.C." preceding "10:54-5"; and in (b), deleted a comma following the second occurrence of "services", substituted "State" for "state", and inserted "/NJ FamilyCare program".