N.J. Admin. Code § 10:54-5.1

Current through Register Vol. 56, No. 11, June 3, 2024

Section 10:54-5.1 - Apnea monitors; home

(a) The New Jersey Medicaid/NJ FamilyCare program shall reimburse durable medical service providers for the use of home apnea monitors under the provisions of N.J.A.C. 10:59 and 10:54-5.2 and 5.3.

(b) When an order or prescription for a home apnea monitor is received by the durable medical equipment (DME) provider, the DME provider shall complete and the prescribing physician shall sign a "Home Apnea Monitor Certification" form (FD-287) and the DME provider shall forward it along with the CMS 1500 claim form to the appropriate Medical Assistance Customer Center (MACC) for the initial prior authorization.

1. Each request by a physician shall include written medical data for the medical necessity of the monitor based on the recent evaluation by the physician.

2. Durable medical equipment (DME) providers may use their own Medical Necessity forms in place of, or in conjunction with, the FD-287 as long as all information required on the FD-287 form appears on the Medical Necessity forms.

3. In an urgent situation requiring immediate action, the DME provider may supply the home apnea monitor. However, this action shall be documented in the written request for authorization, which shall be submitted to the MACC no later than 10 working days following the receipt of the physician's order or prescription.

4. Prior authorization shall be issued for up to three months. Failure to obtain prior authorization will result in administrative denial.

(c) When it is anticipated by the physician that the need for home apnea monitoring will exceed the period of current authorization, the prescribing physician caring for the infant's apnea problem must complete and sign the recertification portion of the FD-287 and the DME provider shall complete and submit a new CMS 1500 claim form with this recertification portion to the MACC. The physician should sign this recertification portion in the course of the follow-up and reassessment of the infant's need for continued apnea monitoring. It is the DME provider's responsibility to inform the infant's parent/guardian of the recertification requirement and to remind them, in the course of the follow-up of the need to take the infant to the physician for reassessment.

(d) The physician shall obtain the FD-287 from the DME provider.

(e) The required information for recertification shall include:

1. Progress of the patient's current status;

2. Number of real alarms and treatment;

3. Pneumogram results, if any; and

4. Any additional information as requested by the Division medical consultant, such as a copy of the daily logs.

(f) The durable medical equipment (DME) provider shall report to the (MACC) any monitored infant who has not had a physician's visit in three months.

(g) Durable medical equipment (DME) providers have certain responsibilities related to training pertinent to the use of the apnea monitor for the family, caregiver, and/or relief personnel of which the physician should be aware.

(h) Physicians who are responsible for the follow-up and treatment of the infant's apnea problem shall receive monitoring reports on at least a monthly basis from the DME provider.

N.J. Admin. Code § 10:54-5.1

Amended by R.2001 d.51, effective 2/5/2001.
See: 32 N.J.R. 3929(a), 33 N.J.R. 555(a).
In (b), (c) and (f), substituted references to MACC for references to MDO throughout.
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), inserted "/NJ FamilyCare" and deleted "N.J.A.C." preceding "10:54-5.2"; in the introductory paragraph of (b), substituted "DME" for the second occurrence of "durable medical equipment (DME)", and substituted "CMS" for "HCFA"; and in (c), substituted "CMS 1500 claim form" for "Health Insurance Claim form (HCFA 1500)".