N.J. Admin. Code § 10:54-5.43

Current through Register Vol. 56, No. 23, December 2, 2024

Section 10:54-5.43 - Termination of pregnancy

(a) The Division shall reimburse for medically necessary termination of pregnancy procedures on Medicaid/NJ FamilyCare program beneficiaries when performed by a physician in accordance with 13:35-4.2, of the rules of the New Jersey State Department of Law and Safety, Division of Consumer Affairs, Board of Medical Examiners.

(b) A physician may take the following factors into consideration in determining whether a termination of pregnancy is medically necessary on a Medicaid/NJ FamilyCare program beneficiary:

1. To save the life of the mother;

2. That the pregnancy was the result of an act of rape;

3. That the pregnancy was the result of an act of incest; or

4. That in the physician's professional judgment, the termination was medically necessary and consistent with the Federal court ruling that a physician may take the following factors into consideration in determining whether a termination of pregnancy is medically necessary:

i. Physical, emotional and psychological factors;

ii. Family reasons; and

iii. Age.

(c) The determination of medical necessity shall be subject to review by the Medicaid/NJ FamilyCare program in accordance with existing rules and regulations of the Medicaid/NJ FamilyCare program and consistent with the New Jersey State Department of Law and Safety, Division of Consumer Affairs, Board of Medical Examiners, 13:35-4.2.

(d) A "Physician Certification" (Form FD-179) shall be attached to the hospital's Medicaid claim form, either for inpatient or outpatient services, if any of the procedures on the claim relate to a voluntary elective abortion.

1. A copy of the completed FD-179 shall also be attached to:

i. The physician's Medicaid/NJ FamilyCare claim form, as appropriate; and

ii. The anesthesiologist's Medicaid/NJ FamilyCare claim form.

(e) Any New Jersey physician with electronic billing capabilities must submit a "hard copy" of the CMS 1500 claim form (for inpatient or outpatient services) for all termination of pregnancy claims with the "Physician Certification" attached to the claim form and must not submit the claim through EMC claim processing.

N.J. Admin. Code § 10:54-5.43

Amended by R.2001 d.51, effective 2/5/2001.
See: 32 N.J.R. 3929(a), 33 N.J.R. 555(a).
In (a), substituted "beneficiaries" for "recipients" preceding "when performed by a physician"; in (b), substituted "beneficiary" for "recipient" at the end of the introductory paragraph.
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 the introductory paragraph of (b), inserted "/NJ FamilyCare program"; in (b)1 and (b)2, deleted "or" from the end"; in the introductory paragraph of (b)4, substituted "judgment" for "judgement"; in (b)4i, deleted a comma following "emotional"; in (b)4ii, deleted a comma from the end; in (c), inserted "the" preceding and inserted "/NJ FamilyCare program" following the first occurrence of "Medicaid" and "/NJ FamilyCare" following the second occurrence of "Medicaid"; in (d)1i and (d)1ii, inserted "/NJ FamilyCare"; in (d)1i, deleted a comma from the end; and in (e), substituted "CMS" for "HCFA".