N.J. Admin. Code § 10:54-5.31

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

Section 10:54-5.31 - Nursing facility services

(a) An attending physician shall prescribe, and certify in the medical record, the medical necessity for nursing facility services for a Medicaid/NJ FamilyCare program patient.

(b) When physician services are provided to a patient in a nursing facility (formerly known as a skilled nursing facility or an intermediate care facility), reimbursement will not be made to any physician or practitioner, or for therapy or services rendered by an owner, partner, administrator, officer, or stockholder of the company or corporation or anyone who otherwise has a direct or indirect financial interest in the institution; except that:

1. A medical director who is neither an owner, partner, official, stockholder of the company or corporation, but who is reimbursed a salary by the facility for administrative purposes, may bill on a fee-for-service basis for medical services rendered by him to patients in that facility.

(c) Annual Resident Reviews (ARR) for individuals identified as having mental illness, who reside in Medicaid certified nursing facilities shall be performed by the individual's attending physician and forwarded to the Office of Utilization Management, Mental Health Services, Division of Medical Assistance and Health Services, PO Box 712, Trenton, New Jersey 08635-0712, for final determination of the need for specialized services.

1. The MACC will send a nursing facility (NF) Reassessment List to the NF in the first week of every month. The reassessment date is based upon the month the individual was initially admitted to the NF. The attending physician completes the psychiatric form by the 15th of the following month on those individuals with mental illness.

2. The completed psychiatric evaluation form will be forwarded to the Division of Mental Health Services (DMHS) to be reviewed by the DMHS psychiatrists to determine the need for specialized services.

3. The results of the DMHS determination will be returned to the nursing facility to be incorporated in the patient's chart.

(d) A more detailed guideline of physician services performed in nursing facilities (NF) can be found in the Long Term Care Facility Services, N.J.A.C. 10:63 (which is usually located in the facility). Assistance is also available to the physician, on a peer basis, from the Medical consultant in the Medical Assistance Customer Center. A director of Medical Assistance Customer Centers is located at N.J.A.C. 10:49, Appendix.

N.J. Admin. Code § 10:54-5.31

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), substituted "Utilization Management" for "Health Services Administration" in the introductory paragraph; in (c)1 and (d), substituted references to MACCs for references to MDOs.
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 program".