N.J. Admin. Code § 10:54-7.8

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

Section 10:54-7.8 - Physician services to the hospital patients

(a) Physician services that are rendered to a patient registered in the hospital outpatient department that are reimbursed as part of hospital costs shall not be billed directly by the physician to the Medicaid/NJ FamilyCare program. Any arrangement, contractual, employment, grant or otherwise, for payment of the physician(s) providing a service(s) to such a registered clinic patient is between the hospital and the physician(s). Physician services provided in the hospital outpatient department to Medicaid/NJ FamilyCare program beneficiaries that are not included in hospital costs may be billed by the physician directly to the New Jersey Medicaid/NJ FamilyCare program.

(b) For the hospital based physician providing services to an ambulatory non-registered (private) patient, the following applies:

1. This type of patient shall be considered to be the private ambulatory patient of a physician who has referred the patient to the hospital for the services provided, in part or whole, by a hospital based physician (for example, radiologist, pathologist, electrocardiographer, and so forth);

2. Such specific services are considered hospital costs when provided by the physician who is customarily reimbursed directly by the hospital, contractually or otherwise, and are not reimbursable directly to the referring physician.

(c) Direct patient care physician services which are considered the professional component of hospital care, (that is, for some emergency room physicians, radiologists, pathologists, and electrocardiographers), may be reimbursed when the physician bills directly by the fiscal agent under the following circumstances:

1. The physician shall be under contract with the individual hospital for the performance of the specific services;

2. The services are not part of the hospital costs; and

3. The professional component of the services are not reimbursed to the physician in whole or in part by the hospital.

N.J. Admin. Code § 10:54-7.8

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".
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" following the first and third occurrences of "Medicaid", and inserted "/NJ FamilyCare program" following the second occurrence of "Medicaid".