N.J. Admin. Code § 10:56-1.5

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

Section 10:56-1.5 - Basis for reimbursement

(a) Reimbursement for covered services furnished under the New Jersey Medicaid/NJ FamilyCare fee-for-service programs shall be the customary and usual fee of the provider when it does not exceed Federal regulatory maximums and reasonable rates as determined by the Commissioner of Human Services. In no instance shall the charge to the program exceed the usual and customary fee of the provider for identical services to other governmental agencies or other groups or individuals in the community.

1. If a beneficiary receives care from more than one member of a partnership or corporation in the same discipline for the same service, the total maximum payment allowance would be the same as that of a single attending dentist. The allowance fee for a given service shall constitute full payment. No additional charge shall be made by the dentist to, or on behalf of, the covered Medicaid/NJ FamilyCare fee-for-service beneficiary.

2. The procedure codes which are used when submitting claims are listed in N.J.A.C. 10:56-3 --Health Care Financing Administration (HCFA) Common Procedure Coding System (HCPCS). The Fiscal Agent Billing Supplement that follows N.J.A.C. 10:56-3 in Appendix A provides information about the claim form and billing instructions. The provider, when submitting claims for services rendered, shall comply with the provisions of N.J.A.C. 10:56, Appendix A, which is incorporated herein by reference.

(b) A fee will be paid only for services rendered. If an eligible beneficiary does not return for completion of the treatment plan, only those services provided shall be billed.

(c) If circumstances involving an eligible beneficiary, over which the provider has no control, preclude completion of a service and/or authorized appliance, the New Jersey Medicaid/NJ FamilyCare fee-for-service programs will reimburse the provider of services an amount consistent with the stage of completion of the authorized service and/or appliance.

1. The stage of completion of the service shall be detailed on the Dental Claim Form (MC-10), or in the case of an appliance, denture or crown, the case (to the point of completion) shall be forwarded to a dental consultant for proration as determined by the Division dental consultant. The case will be returned to the provider and shall be retained for at least one year pending possible return of the beneficiary.

i. Requests for prorated reimbursement shall be submitted with all appropriate dental forms (either the dental claim for previously approved services or both the dental claim and the prior authorization form), a copy of the treatment plan and pertinent treatment records, any lab work to stage of completion and a written explanation of why the services were not completed. Payment will be delayed when requests for prorated reimbursement are incomplete.

ii. Should a patient return and completion of the prorated case occurs, the balance can be reimbursed. Prior authorization for the additional fee shall be submitted for review by a Division dental consultant. The provider shall include in the request documentation that the patient has returned and that the prorated work has been completed.

(d) Partial reimbursement for an appliance completed but not delivered to the beneficiary because of circumstances beyond the control of the provider will be authorized by the New Jersey Medicaid/NJ FamilyCare program. An amount equivalent to the professional component for inserting and adjusting the appliance will be deducted from the total reimbursement for such appliance. In the event the beneficiary returns and the service is completed, the provider may request reimbursement for the deducted amount. Procedures as outlined in (c) above will apply.

(e) Reimbursement is not made for, and beneficiaries shall not be asked to pay for, broken appointments.

(f) Reimbursement will be made only for dental treatment provided during the period of beneficiary eligibility, except that the treatment listed in paragraphs 1 through 5 below, if authorized and actually in the process of being rendered during such period, may be completed and payment allowed, provided the services are completed within 60 calendar days following the termination of eligibility, unless indicated below.

1. Prostheses (to include, for example, dentures, crowns, space maintainers, and appliances, but not comprehensive orthodontic appliances or services) actually in process of fabrication;

2. Extractions and such ancillary services as general anesthesia and radiographs, in conjunction with the insertion of an immediate denture when initial impressions have been taken during the period of eligibility;

3. Endodontic treatment if pulp has been extirpated and treatment authorized and those services necessary to complete the restoration of that tooth such as filling restoration(s) or, if authorized during a period of eligibility, post and core and crown.

4. Notwithstanding any rule in this chapter to the contrary, payment may be made for a denture(s) furnished after termination of eligibility of an individual where the last tooth in any specific arch is extracted during the period of eligibility.

i. A denture, complete or partial, may be furnished in the opposing arch as described at 10:56-2.13, Prosthodontic treatment, if it meets the guidelines of the program as specified in this chapter, and is authorized in conjunction with the above denture.

ii. In order to obtain reimbursement for this denture(s), the primary impression(s) shall be initiated within 120 days and the denture(s) inserted within 180 days after the extraction of the last tooth. Authorization procedures set forth in these rules are applicable.

5. For immediate dentures, similar to provisions for dentures inserted subsequent to the healing period, prior authorization shall have been obtained during the eligibility period and all preliminary extractions completed during that same period. Authorized immediate complete dentures shall be completed within 180 days of termination of eligibility.

ii. In order to receive reimbursement for this denture(s), primary impression(s) shall be initiated within 120 days and the denture inserted 180 days after the last preliminary extraction. Prior authorization procedures set forth in this chapter shall apply as described at 10:56-1.4.

(g) When other health or liability insurance is available, the Medicaid/NJ FamilyCare program requires that such benefits be utilized first and to the fullest extent. See 10:49-7.3, Third party liability (TPL) benefits, for further information. Supplemental payment shall be made by the Medicaid/NJ FamilyCare program up to the provider's customary and usual fee, if the combined total does not exceed the amount payable under the Medicaid/NJ FamilyCare program.

1. When other health insurance is involved, claims should not be filed with the Program unless accompanied by a statement of payment or denial from any other carriers.

2. Medicare coinsurance and deductible shall be payable by the New Jersey Medicaid/NJ FamilyCare program in combination Medicare/ Medicaid cases.

(h) Failure to comply with documentation requirements will result in denial of claims, delays in payment and recovery of any payments made prior to determinations of non-compliance.

(i) Authorization of dental treatment or services shall not guarantee payment by the Medicaid/NJ FamilyCare fee-for-service programs. The provider shall assure, at the time of each visit, that the beneficiary being treated is eligible for the Medicaid/NJ FamilyCare programs, and for the dental services to be rendered, by using the beneficiary's health benefits identification card with one of the eligibility verification systems available to the provider. See N.J.A.C. 10:49-2 for beneficiary eligibility information.

N.J. Admin. Code § 10:56-1.5

Amended by R.1985 d.7, effective 2/4/1985.
See: 16 N.J.R. 1933(a), 17 N.J.R. 309(a).
(g) text added: "and to the ... further information."
Amended by R.1986 d.385, effective 9/22/1986.
See: 18 N.J.R. 1337(a), 18 N.J.R. 1958(a).
Recodified from 10:56-1.11 and amended by R.1996 d.428, effective 9/16/1996.
See: 28 N.J.R. 3069(a), 28 N.J.R. 4243(a).
Former N.J.A.C. 10:56-1.5, "Standards of service", recodified to 10:56-2.2.
Amended by R.2000 d.426, effective 10/16/2000.
See: 32 N.J.R. 2411(a), 32 N.J.R. 3836(a).
In (f)1i, inserted ", but not comprehensive orthodontic appliances or services" following "appliances".
Amended by R.2001 d.268, effective 8/6/2001.
See: 33 N.J.R. 1554(a), 33 N.J.R. 2666(b).
Rewrote (a); in (b), (c) and (e), substituted references to beneficiaries for references to recipients; in (c), inserted a reference to NJ FamilyCare fee-for-service.
Amended by R.2004 d.25, effective 1/20/2004.
See: 35 N.J.R. 4032(a), 36 N.J.R. 568(a).
Inserted references to NJ FamilyCare throughout.
Amended by R.2007 d.36, effective 2/5/2007.
See: 38 N.J.R. 3419(a), 39 N.J.R. 479(a).
In (c)1, deleted "Services" preceding "Claim", and substituted "Division dental consultant" for "Chief, Bureau of Dental Services"; added new (c)1i and (c)1ii; in (d), substituted "beneficiary" for "recipient" two times; in (e), substituted "shall" for "may", rewrote (f); and added new (h) and (i).