N.J. Admin. Code § 10:56-2.7
Current through Register Vol. 56, No. 12, June 17, 2024
Section 10:56-2.7 - Diagnostic services: radiography(a) Radiological procedures shall be limited to those normally required to make a diagnosis and shall show all areas where treatment is anticipated with the exception of soft tissue lesions.(b) All radiographs should be examined carefully by the provider to assure quality care and to make certain that all necessary treatment has been diagnosed, planned for and/or completed.(c) Radiographs may be reviewed by dental consultants of the Medicaid/NJ Family Care fee-for-service programs and/or a dentist in private practice not employed by New Jersey Medicaid/NJ Family Care fee-for-service programs, if appropriate. It is recommended that the two film packet be used or a copy may be made by those dentists who wish to retain a set of radiographs in their office at all times.(d) The originals of all radiographic films shall be available to authorized representatives of the New Jersey Medicaid/NJ Family Care fee-for-service programs. Radiographs shall be forwarded to the Division of Medical Assistance and Health Services in the following situations: 1. When prior authorization is requested; or2. Upon request by the Medicaid/NJ Family Care fee-for-service programs for utilization review or adjudication purposes.(e) All radiographic films shall be suitable for interpretation and when submitted to the New Jersey Medicaid/NJ Family Care fee-for-service programs or their agents shall be properly mounted, marked "Right" and "Left" and identified with the beneficiary's name, the date, and the name of the dentist. Films that are technically unacceptable for proper interpretation will be returned to the provider for replacement at no additional cost to the Medicaid/NJ Family Care fee-for-service programs. No reimbursement shall be made for the new set of radiographs that the dentist is required to provide. When already reimbursed, recoupment will be made, unless a replacement set of radiographs is sent to the Division for review.(f) Reimbursement for dental radiographs shall be limited according to the following standards: 1. A complete series radiographic study is defined and limited by age. The maximum number of diagnostic radiographs that may be reimbursed as a single radiographic study every three years without prior authorization shall be as follows:i. Up to and including age six: eight films (six periapical plus two bitewing films);ii. Age seven, up to and including age 14: 12 films (10 periapical films, plus two bitewing films) or a panorex and two posterior bite wing films;iii. For those beneficiaries 15 years of age or older: 16 radiographs (at least 14 periapical plus two posterior bitewing films) or a panorex plus four posterior bite wing films;iv. A complete series radiographic study, which may include two or more bitewing radiographs with a panorex radiograph. Any additional films over and above that number, as limited by age, are considered to be part of that complete series and no additional reimbursement can be made. If, however, extenuating circumstances exist, the need for additional films in (f)1i through iii above must be substantiated and a specific authorization obtained from the Division dental consultant;v. The three year limitation in (b)4i(1), (2), and (4) above will continue to apply even though an age change transfers the beneficiary from one age category to another. For example, a beneficiary who has eight radiographs at age six is not eligible for the 12 film series until he or she has reached age nine and three years have passed;vi. The maximum amount reimbursable for radiographs billed individually or in groups in conjunction with an initial evaluation, and/or one treatment plan and/or within a six month period is that amount paid for a complete series as outlined in (b)4 above. During any 12 month period subsequent to a complete radiography series study within the three year period, the maximum number of radiographs permitted shall be as follows: (1) Up to and including age six -- four films;(2) Age seven and up to and including age 14 -- four films; and(3) Age 15 years of age or older -- six films;vii. If the provider requires additional films, he or she shall first secure prior authorization from the Division dental consultant;viii. If a beneficiary patient transfers to a new dental provider's office, that new dental provider's office shall request a copy of the beneficiary's radiographs from the previous dental provider, in accordance with 13:30-8.7. The previous dental provider may request approval through the prior authorization process for duplication of the films. That prior authorization request shall be directed to the Division dental consultant and shall indicate the type and number of films to be duplicated; orix. If the films or their copies cannot be provided by the previous dental provider, the new dental provider shall document this fact in the beneficiary's patient record and proceed to take the needed films that are required to diagnose, develop a treatment plan and provide treatment. It is not the intention of the Medicaid/NJ FamilyCare program to impede timely treatment while waiting for the previous dentist to provide the requested radiographs and records.(g) In an emergency situation, in order to establish a diagnosis which must be recorded under Remarks (Item 20) of the Dental Claim Form (MC-10) a radiograph may be taken at any time, as dentally necessary.(h) Postoperative radiographs normally taken at the conclusion of dental treatment by a dental provider shall be maintained as part of the beneficiary's dental records (for example, final radiographs at completion of endodontic treatment, or certain surgical procedures).(i) Radiological services other than those ordinarily provided by a practitioner in his or her own office may be referred to a dental specialist who will provide radiological services limited to his or her own special field. Radiological services may also be requested from a physician who is a specialist in radiology or a qualified hospital facility. 1. Services provided by another dentist, physician, or hospital facility shall be billed directly to the Medicaid/NJ Family Care fee-for-service programs by that provider and not by the referring dentist.N.J. Admin. Code § 10:56-2.7
New Rule, R.1996 d.428, effective 9/16/1996.
See: 28 N.J.R. 3069(a), 28 N.J.R. 4243(a).
Amended by R.2001 d.268, effective 8/6/2001.
See: 33 N.J.R. 1554(a), 33 N.J.R. 2666(b).
In (e), substituted "their" for "its"; in (f)1, rewrote ii and iii; inserted references to NJ Family Care fee-for-service and 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 (f)1iv, inserted reference to NJ FamilyCare.
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), substituted "shall" for "must"; in (f)1, substituted "The" for "It represents the" and "that may be reimbursed" for "reimbursable", and inserted "shall be"; in (f)1iv, inserted ", which" and "with a panorex radiograph", substituted "or more bitewing" for "bitewing or more", "Division" for "Medicaid/NJ FamilyCare" and a semicolon for a period at the end; in (f)1vi, substituted "evaluation" for "examination"; in (f)1vi(2), inserted "and" at the end; in (f)1vi(3), substituted a semicolon for a period at the end; rewrote (f)1vii; added new (f)1viii and (f)1ix; and in (g), deleted "Services" following "Dental".