N.J. Admin. Code § 10:54-7.10

Current through Register Vol. 56, No. 24, December 18, 2024

Section 10:54-7.10 - Psychiatric services (including prior authorization); hospital outpatient and other settings

(a) The following policies and procedures were developed to help ensure the appropriate utilization of hospital outpatient psychiatric services. These include the role of the evaluation team in relation to the patient's treatment regimen, with emphasis placed on intake evaluation, development of a Plan of Care (PoC), performance of periodic review for evaluation purposes, and supportive documentation for services rendered. (See N.J.A.C. 10:52-2.3 Recordkeeping and N.J.A.C. 10:66-2.5 for more specific policies and procedures for psychiatric (mental health services).

(b) Psychiatric services that are medically necessary rendered in an approved hospital outpatient department or in other settings, to a registered patient who is a Medicaid/NJ FamilyCare program beneficiary, shall not require prior authorization, except in the following situations:

1. Authorization for partial hospitalization and/or acute partial hospitalization services shall be provided in accordance with N.J.A.C. 10:52A, Psychiatric Adult Acute Partial Hospital and Partial Hospital Services.

2. Prior authorization is required for mental health services exceeding $ 900.00 in reimbursement to the physician rendered to a Medicaid/NJ FamilyCare program beneficiary in any 12-month service year, commencing with the patient's initial visit, when provided in other than an inpatient hospital setting. Reimbursement shall not be paid by the program for physician psychiatric services rendered to a registered hospital outpatient.

3. Prior authorization shall be required for mental health services exceeding $ 400.00 in payments in any 12-month service year rendered to a Medicaid/NJ FamilyCare program beneficiary residing in either a nursing facility or a residential health care facility.

(c) The request for authorization shall include the diagnosis, as set forth in the ICD-9 for dates of service before October 1, 2015, or the ICD-10 for dates of service on or after October 1, 2015, and also must include the treatment plan and progress report in detail. No post facto authorization will be granted.

1. For those Medicaid/NJ FamilyCare program beneficiaries who do not reside in a nursing facility and live in a community setting, including a residential health care facility, or for those receiving mental health services in the outpatient department of a hospital, an independent clinic or a physician's office, the request for prior authorization shall be submitted directly to Office of Utilization Management, Mental Services Unit, Division of Medical Assistance and Health Services, PO Box 712, Mail Code #18, Trenton, New Jersey 08625-0712 on the "Authorization of Mental Health Services (FD-07)" form.

2. For a Medicaid/NJ FamilyCare program beneficiary residing in a nursing facility, the request for prior authorization shall be submitted directly to the appropriate Medical Assistance Customer Center that serves that nursing facility on the "Authorization of Mental Health Services and/or Mental Health Rehabilitation Services (FD-07)" and the "Request for Prior Authorization: Supplemental Information (FD-07A)" forms.

3. When approved by the New Jersey Medicaid/NJ FamilyCare program, each authorization may be granted for a maximum period of one year. Additional authorizations may be requested.

4. The Division shall not reimburse the physician and/or hospital for both mental health services provided in the office and/or hospital or any other setting and medical day care center services provided to the same beneficiary on the same day. The Division shall also not reimburse the physician and/or hospital for both mental health services and partial hospitalization services provided to the same patient on the same day.

N.J. Admin. Code § 10:54-7.10

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