N.J. Admin. Code § 10:54-5.34

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

Section 10:54-5.34 - Prosthetic and orthotic services (P & O)

(a) Custom-made prosthetic and orthotic appliances (required to replace, support or strengthen parts of the body) are allowable when prescribed by a licensed physician. For purpose of the New Jersey Medicaid/NJ FamilyCare program, "custom-made" means a device or appliance fabricated (constructed and/or assembled) in an approved facility under the specific direction of a prescribing physician and designed to fit and perform a useful function solely for that specific individual for whom it was ordered.

1. Custom-made appliances must be fabricated by a person certified as a prosthetist and/or orthotist by the American Board for Certification in Orthotics, Prosthetics and Pedorthics, incorporated and fabricated in a facility accredited by the same certification board. The facility must be approved by the New Jersey Medicaid/NJ FamilyCare program to provide either prosthetic or orthotic (P & O) services or both to Medicaid/NJ FamilyCare program beneficiaries. The physician may contact the Medical Assistance Customer Center to determine which P & O dealers are eligible under the program. The P & O provider must obtain prior authorization from the Medical Assistance Customer Center to provide these services. For a listing of Medical Assistance Customer Centers, see the end of N.J.A.C. 10:49, Administration Manual, or the list can be downloaded free of charge from the Division of Medical Assistance and Health Services' website: http://www.state.nj.us/humanservices/dmahs/home/index.html.

(b) Prosthetic and orthotic appliances shall require a personally signed and dated order (prescription) by the prescribing physician, which includes the following:

1. Patient's name, age, address, H.S.P. (Medicaid) Case and Person Number; and

2. Relevant diagnosis(es) (including the ICD-9-CM code(s) for dates of service before October 1, 2015, and the ICD-10-CM code(s) for dates of service on or after October 1, 2015) supporting need for custom-made prosthetic and orthotic appliances; and

3. Detailed (meaningful) description of the prosthetic and orthotic appliance order. Terminology such as "leg brace", "artificial limbs", "orthopedic shoes", and so forth, on a prescription is unacceptable.

(c) The approved prosthetic and orthotic provider, upon receipt of an acceptable prescription, shall request prior authorization from the appropriate Medical Assistance Customer Center or the Podiatric Consultant, as appropriate, on a "Prior Authorization Form for Prosthetic and Orthotic Services (FD-357)."

1. In the event that a physician's prescription does not contain the prosthetic and orthotic nomenclature accepted by this Division, the facility shall transform the original prescription to conform to the accepted nomenclature. This does not imply that the physician's prescription will in any way be altered.

N.J. Admin. Code § 10:54-5.34

Amended by 48 N.J.R. 962(b), effective 6/6/2016