N.J. Admin. Code § 10:56-2.4

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

Section 10:56-2.4 - Place of service

(a) In addition to the private office, dental services may be provided in the home, a hospital, ambulatory surgical center, approved independent clinic, nursing facility, residential treatment center and elsewhere.

(b) Services should be provided in any appropriate setting, governed by medical/dental necessity and not by the convenience or desires of the beneficiary or the providers of services.

1. Specific additional requirements for dental services rendered in the outpatient departments of approved licensed hospitals and services rendered in approved independent clinics are described in N.J.A.C. 10:52 and 10:66, respectively.

i. Hospital outpatient dental clinics are subject to the same New Jersey Medicaid/NJ FamilyCare program requirements and reimbursement schedule, as specified in this chapter, that apply to the dentist in "private" practice (see 10:52-2.3, 10:66 and 13:30.)

2. Dental services performed on an inpatient basis in approved licensed hospitals are reimbursable, provided that such services require a hospital level of care, which level of care requirement shall be documented on the hospital records.

i. Dental services are also reimbursable if the beneficiary is admitted for an eligible non-dental condition and the dental services are rendered as part of the prescribed treatment for such condition, or to alleviate the beneficiary's discomfort during the period of hospitalization.

(1) Admission may be by the dentist or by a physician, depending on the by-laws of the individual hospital.

(2) When inpatient services are performed by a dentist who is reimbursed by the hospital under contractual or other arrangements, the services are considered a hospital cost, and shall be billed by the hospital and not by the dentist.

(3) Authorization by a Division dental consultant shall be for services only and does not authorize the place of service; thus, such authorization does not guarantee payment.

(4) Whenever all or any portion of the hospital inpatient claim is denied for payment, the attending practitioner's claim for inpatient services rendered during the denial period will also be denied for payment.

(c) Dental services as performed by a licensed dentist in a nursing facility, or elsewhere outside the provider's office setting are reimbursable provided that:

1. The requirements of this chapter are followed.

2. In a nursing facility, the dentist rendering the dental services is not an owner, administrator, stockholder of the company or corporation or otherwise has a direct financial interest in the facility.

3. Reimbursement of a supplemental fee for an out-of-office visit in addition to a fee for service is limited to once per trip per facility, regardless of the number of recipients examined or treated during the visit.

4. The dentist who examines a nursing facility beneficiary shall provide the treatment necessary unless the examination indicates that a specialist is needed.

N.J. Admin. Code § 10:56-2.4

As amended, R.1973 d.259, eff. 10/1/1973.
See: 5 N.J.R. 267(a), 5 N.J.R. 341(f).
As amended, R.1981 d.219, eff. 7/9/1981 (to become operative August 1, 1981).
See: 12 N.J.R. 700(a), 13 N.J.R. 430(b).
(c)3 added.
Amended by R.1986 d.236, effective 6/16/1986 (operative July 1, 1986).
See: 18 N.J.R. 803(a), 18 N.J.R. 1287(a).
Added text in (a) "However, for recipients ... to N.J.A.C. 10:49-1.2)."
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 10:56-1.12 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 section, "Patient eligibility", repealed.
Amended by R.2001 d.268, effective 8/6/2001.
See: 33 N.J.R. 1554(a), 33 N.J.R. 2666(b).
Substituted references to beneficiaries for references to recipients throughout.
Amended by R.2004 d.25, effective 1/20/2004.
See: 35 N.J.R. 4032(a), 36 N.J.R. 568(a).
In (b), 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 (a), inserted "ambulatory surgical center,"; in (b)1, substituted "Specific additional requirements" for "Policies specific"; in (b)1i, substituted "requirements" for "policies, procedures", "specified in this chapter" for "outlined in this manual" and ", 10:66 and 13:30" for "(a)"; in (b)2, inserted commas following "reimbursable" and the first occurrence of "care", substituted "such services require a hospital" for "they require that" and inserted "level of care requirement"; in (b)2i(1), inserted a comma following "physician"; in (b)2i(2), deleted "(s)" following "dentist"; in (b)2i(3), inserted "Division" and substituted "shall be" for "of the Medicaid/NJ FamilyCare program is"; and in (c)1, substituted "requirements of this chapter" for "policies and procedures as detailed in this manual".