N.J. Admin. Code § 10:58A-1.5

Current through Register Vol. 56, No. 8, April 15, 2024

Section 10:58A-1.5 - Basis of reimbursement

(a) A claim is a request for payment for a Medicaid-reimbursable or NJ FamilyCare-reimbursable service provided to a Medicaid-eligible or NJ FamilyCare fee-for-service eligible individual. The claim may be submitted via hard copy or by means of an approved method of automated data exchange.

(b) An approved New Jersey Medicaid or NJ FamilyCare APN provider (see 10:58A-1.3, Provisions for participation) shall be reimbursed on a fee-for-service basis in accordance with N.J.A.C. 10:58A-4. Reimbursement shall be limited to payment for medically necessary covered services provided within the appropriate scope of practice in accordance with the individual category of certification for advanced practice.

(c) APN services may be reimbursed (see N.J.A.C. 10:49-7 and 8) under either of two billing mechanisms provided by Medicaid or NJ FamilyCare. The two mechanisms are: a direct billing entity as stated in this chapter or an employee reimbursed by another Medicaid or NJ FamilyCare provider who bills Medicaid or NJ FamilyCare on behalf of the APN's services, that is, physician employer, group or clinic.

1. When an APN is employed by an APN/physician group, the Medicaid or NJ FamilyCare program does not routinely reimburse both an APN visit and, on the same day, a visit to an MD or DO within the same billing entity.

i. If specific circumstances should require the two same-day visits, however, the provider entity shall document the medical necessity for the second visit (see concurrent care in (a)2 below).

ii. If a beneficiary receives care from more than one member of a group practice, a partnership or corporation in the same specialty, the total maximum fee allowance shall be the same as that for a single practitioner.

2. Concurrent care will be reimbursed under the following circumstances:

i. If concurrent care is provided, it shall be clearly documented that significant medical necessity exists for more than one clinician's services, as defined at 10:58A-1.2; and

ii. At such time as the beneficiary's condition permits, the primary APN/physician shall either resume sole responsibility or transfer the beneficiary to the APN/physician supplying additional (concurrent) care.

3. An APN and the collaborating physician shall not bill for concurrent care except when the concurrent care is medically necessary for admitting a beneficiary for inpatient hospital care, treating a medical emergency or arranging for prescriptions for controlled drugs. Such concurrent care is normally limited to a single visit.

4. An APN-initiated consultation to another health care professional, excluding another APN, will be allowed under the following conditions:

i. Where a medical condition requires evaluation from more than one perspective, discipline or specialty;

ii. Where significant medical necessity exists; and

iii. Where, subsequent to the consultation, the primary APN will either resume sole responsibility or transfer the beneficiary to the consultant.

5. When Division review of the documentation of a consultation fails to demonstrate medical necessity, reimbursement will be denied to the physician rendering the consultation.

6. A collaborating physician shall not bill for a consultation for the beneficiary of the APN. When it becomes necessary to admit a beneficiary for inpatient hospital care, or to prescribe controlled drugs, the collaborating physician may bill for concurrent care. Such concurrent care is limited to a single visit for each episode.

(d) An APN shall not be reimbursed as an independent provider by the New Jersey Medicaid/NJ FamilyCare fee-for-service programs when the program is required to reimburse an approved provider through another mechanism for these same services, for example, a hospital or home health agency-salaried APN whose salary is included in the Medicaid/NJ FamilyCare fee-for-service rate.

1. If an APN is employed by a physician, a physician group, another APN or APN group, a hospital, an independent clinic or other similar health care entity who is a Medicaid/NJ FamilyCare fee-for-service provider, the APN is referred to Physician Services (N.J.A.C. 10:54) or Hospital Services (N.J.A.C. 10:52) or Independent Clinic Services (N.J.A.C. 10:66) for rules and billing instructions.

i. APNs rendering services in clinics cannot bill fee-for-service. The clinic must bill for all services rendered in the clinic setting.

(e) When billing, an APN shall use his or her assigned Medicaid/NJ FamilyCare Provider Servicing Number to identify each service performed as separate and distinct from services rendered by any other provider.

(f) APN providers shall certify that they have personally rendered any services for which they have billed.

(g) Payment for APN services covered under the New Jersey Medicaid and NJ FamilyCare fee-for-service programs is based upon the customary charge prevailing in the community for the same service but shall not exceed the "Maximum Fee Allowance Schedule" specified in N.J.A.C. 10:58A-4. In no event shall the charge to the New Jersey Medicaid/NJ FamilyCare fee-for-service program exceed the charge by the provider for identical services to other individuals, groups or governmental agencies.

1. An APN billing independently receives direct payment from Medicaid/NJ FamilyCare fee-for-service for services rendered under the provisions of this chapter. Reimbursement is on a fee-for-service basis.

2. The submittal and processing of claims requires the entry of two numbers on the claim form: the Provider Billing Number and the Provider Servicing Number.

i. The Provider Billing Number and Servicing Numbers are identical when the APN is a solo practitioner who bills Medicaid/NJ FamilyCare fee-for-service directly for his or her services. The single number is entered on the claim form as the provider billing number and the identifier of the practitioner who rendered the service.

ii. If the APN is a member of an APN practitioner group, the number assigned to the practitioner group will be the Provider Billing Number. The number assigned to the APN practitioner will be the Provider Servicing Number. (See Fiscal Agent Billing Supplement for instructions for filling out the claim form.)

iii. When an employer of the APN (such as a physician, independent clinic, or similar health care organization) bills on behalf of the services rendered by an APN, the Provider Billing Number is the number of the employer. The identifier of the APN rendering the service will be the Medicaid/NJ FamilyCare fee-for-service Provider Servicing Number.

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

N.J. Admin. Code § 10:58A-1.5

Amended by R.1998 d.154, effective 2/27/1998 (operative March 1, 1998; to expire August 31, 1998).
See: 30 N.J.R. 1060(a).
In (a) through (c), inserted references to NJ KidCare throughout.
Adopted concurrent proposal, R.1998 d.487, effective 8/28/1998.
See: 30 N.J.R. 1060(a), 30 N.J.R. 3519(a).
Readopted the provisions of R.1998 d.154 without change.
Amended by R.2000 d.265, effective 7/3/2000.
See: 32 N.J.R. 1127(a), 32 N.J.R. 2483(a).
Substituted references to beneficiaries for references to patients and inserted references to NJ KidCare fee-for-service throughout; in (a), substituted a reference to NJ KidCare fee-for-service-eligible individuals for a reference to NJ KidCare-eligible individuals; in (c), deleted "for reimbursement of his or her services" at the end of the first sentence, and deleted a reference to hospitals in the introductory paragraph, and substituted a reference to medically necessary for a reference to necessary in 3; in (e) and (g), substituted references to Provider Servicing Numbers for reference to Medicaid Provider Servicing Numbers throughout; and in (g), substituted references to Provider Billing Numbers for references to Medicaid Provider Billing Numbers throughout.
Amended by R.2004 d.334, effective 9/7/2004.
See: 36 N.J.R. 312(a), 36 N.J.R. 4136(a).
Amended by R.2004 d.409, effective 11/1/2004.
See: 35 N.J.R. 4977(a), 36 N.J.R. 4968(a).
In (h), substituted "beneficiaries" for "clients" preceding "may not be asked".
Amended by R.2005 d.406, effective 11/21/2005.
See: 37 N.J.R. 2329(a), 37 N.J.R. 4445(a).
Substituted "APN/physician" for "practitioner/physician" throughout (c); substituted "APN" for "practitioner" in (c)iii, (d)1 and (g)2iii; substituted "Advanced practice nurses" for "Practitioners" in (d)1i.
Amended by R.2011 d.119, effective 4/18/2011.
See: 42 N.J.R. 2890(a), 43 N.J.R. 1015(a).
In (b), deleted the last sentence; in the introductory paragraph of (c), deleted "10:49-" preceding "8", and deleted a comma following "chapter" and "group"; in (c)3, substituted "APN" for "advanced practice nurse" and the first occurrence of "the" for "her or his", and deleted a comma following "emergency"; in the introductory paragraph of (d)1, deleted a comma following "(N.J.A.C. 10:52)", and substituted "rules" for "regulations"; (d)1i, substituted "APNs" for "Advanced practice nurses"; in (e), inserted "assigned Medicaid/NJ FamilyCare", deleted "she or he has" preceding "performed", and substituted "rendered by" for "of"; and in (g)1, deleted "his or her" preceding "services" and inserted "rendered".