N.J. Admin. Code § 10:60-3.4

Current through Register Vol. 56, No. 11, June 3, 2024

Section 10:60-3.4 - Certification of need for personal care assistant services

(a) To qualify for payment of personal care assistant services by the New Jersey Medicaid/NJ FamilyCare fee-for-service program, the beneficiary's need for services shall be certified in writing to the health care services firm by a physician/practitioner as medically necessary, at the time of initial application for services and annually thereafter for recertification. The nurse shall immediately record and sign verbal orders and obtain the physician's/practitioner's counter signature within 30 days.

(b) The certification of need for services must be on file in the beneficiary record at the service provider agency before the home health aide begins providing services for the beneficiary. For those cases that originate while a beneficiary is enrolled in a New Jersey Medicaid/ NJ FamilyCare managed care plan, the managed care plan authorization is based on medical necessity and shall serve as the certification of medical necessity for personal care assistant services. Services provided during a period where a beneficiary temporarily loses managed care eligibility, but is expected to reenroll the following month, shall be provided fee-for-service until the beneficiary is reenrolled in his or her managed care plan as a continuation of services without the need to obtain any additional certification.

(c) The physician's/practitioner's certification as described at (a) above must confirm that the home care assistance for the beneficiary is medically necessary. Such certification may be contained in a physician/practitioner's order, a prior authorization by a Medical Director in a managed care plan, a prescription, or documentation in the beneficiary Plan of Care (POC).

(d) A recertification of the beneficiary's need for services may be required more frequently in the event of a change in the disability status of the beneficiary enrolled in the PCA program.

(e) For fee-for-service beneficiaries, a recertification of the beneficiary's need for services shall be required in situations in which a certification was obtained from the beneficiary's attending physician/practitioner, and the beneficiary changes his or her physician/practitioner. Managed care plans can recertify the continued need for PCA services through continued prior authorization of services.

(f) For fee-for-service beneficiaries, if a beneficiary is approved to transfer his or her PCA services to another provider agency pursuant to N.J.A.C. 10:60-3.10, the new agency is responsible to obtain a new physician/practitioner's certification.

N.J. Admin. Code § 10:60-3.4

Amended by 50 N.J.R. 1992(b), effective 9/17/2018

Amended by 54 N.J.R. 1721(a), effective 9/6/2022