N.J. Admin. Code § 10:55-1.8

Current through Register Vol. 56, No. 12, June 17, 2024

Section 10:55-1.8 - Reimbursement for prosthetic and orthotic appliances

(a) This section outlines the Program's policy of reimbursement for prosthetic and orthotic services and specifies the procedure for submitting a claim to request payment.

(b) Providers of prosthetic and orthotic appliances shall be reimbursed on a fee-for-service basis not to exceed the maximum fee schedule allowance in N.J.A.C. 10:55-2. Generally, the reimbursement policy for the purchase or repair of any appliance or footwear is in accordance with the lower of the Medicaid and NJ FamilyCare maximum fee allowance or the provider's usual and customary charge. In certain instances, a maximum fee allowance cannot easily be established because of the variety of items that can be provided under the same HCPCS. In those instances, the notation "B.R.," by report, is listed in the fee schedule. In those cases, Medicaid and NJ FamilyCare fee-for-service reimbursement will be established by the Division after a review of the additional material submitted by the provider.

1. An additional labor charge shall only be paid for repair-related activities after warranty or prescription change. Such a charge shall not be reimbursed for a new item or appliance.

2. If it is necessary for the provider to visit the beneficiary at home or another setting to measure, fit or deliver an appliance, the following conditions shall apply:

i. The provider shall be reimbursed for travel time when the distance exceeds five miles one way. If more than one beneficiary is seen during the visit, travel time allowance shall only be billed for the initial beneficiary, in accordance with procedure code X3680, Travel time, N.J.A.C. 10:55-2;

ii. A maximum of three "home visits" shall be allowed, unless there is adequate documentation, including a prescription, justifying the need for additional visits; and

iii. No reimbursement for travel shall be provided if the provider is rendering a service that is not reimbursable by the NJ Medicaid/NJ FamilyCare programs.

(c) To request reimbursement for a service provided, the provider shall submit a CMS-1500 claim form using HCPCS procedure code(s) to identify the item or service provided. Instructions for submitting claims for payment are provided in the Fiscal Agent Billing Supplement following this chapter, N.J.A.C. 10:55.

1. HCPCS procedure codes are listed in N.J.A.C. 10:55-2, HCPCS, the CMS (Centers for Medicare and Medicaid Services).

2. Instructions for the completion of claim forms and other forms are provided in the Fiscal Agent Billing Supplement following N.J.A.C. 10:55-2.

i. Requirements for the timely submission of claims are listed in the Administration Chapter of this manual (10:49-7.2 ).

3. A provider shall submit a copy of the prescription along with the claim form to the fiscal agent, when the charge for repair and/or replacement of parts is less than $ 250.00.

(d) The provider shall verify beneficiary eligibility in accordance with N.J.A.C. 10:49-2. Payment shall not be made for services provided to an ineligible individual, even if the service was prior authorized, except under the following circumstances:

1. If fabrication of an appliance (including repair or replacement of parts on existing appliance) has commenced following authorization but has not been completed during the beneficiary's period of eligibility, reimbursement to the provider shall be allowed.

2. In circumstances involving the beneficiary over which no one may have control, such as moving out-of-State, or in case of death of the beneficiary, reimbursement will be made in an amount consistent with the stage of completion of the appliance consistent with the Program's Maximum Fee Allowance schedule.

i. The provider shall use the date fabrication of the appliance was begun as the date of service when the above situation(s) occur(s).

(e) For any Medicaid or NJ FamilyCare beneficiary who is covered under Medicare, responsibility for payments by the New Jersey Medicaid or NJ FamilyCare program for non-hospital based, Medicare Part B services shall be limited to the unsatisfied deductible and/or coinsurance amount to the extent that the combined total of these payments does not exceed the maximum fee allowance for the same or similar service provided by the Medicaid or NJ FamilyCare program in the absence of other coverage. This limitation shall apply for claims with dates of service on or after July 20, 1998.

N.J. Admin. Code § 10:55-1.8

Amended by R.2000 d.134, effective 4/3/2000.
See: 31 N.J.R. 3964(a), 32 N.J.R. 1206(a).
Rewrote the section.
Amended by R.2004 d.406, effective 11/1/2004.
See: 35 N.J.R. 4417(a), 36 N.J.R. 4963(a).
In (c), substituted "CMS" for "HCFA" in the introductory paragraph and substituted "CMS (Centers for Medicare and Medicaid Services)" for "HCFA (Health Care Financing Administration's) Common Procedure Coding System)" in 1.
Amended by R.2011 d.080, effective 3/7/2011.
See: 42 N.J.R. 2179(a), 43 N.J.R. 622(a).
In the introductory paragraph of (b), substituted "provider's" for the first occurrence of "provider"; in (b)2i, substituted a semicolon for a period at the end; in (b)2ii, substituted "; and" for a period at the end; and added (b)2iii.