N.J. Admin. Code § 10:60-3.9

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

Section 10:60-3.9 - Prior authorization for personal care assistant (PCA) services

(a) All personal care assistant (PCA) services shall be prior authorized, regardless of the number of hours requested per week.

(b) Prior approval for PCA services shall be obtained in accordance with the following procedures:

1. For fee-for-service cases, a registered nurse employed by the PCA provider agency shall complete a face-to-face evaluation of the beneficiary, at the beneficiary's home, and shall complete the State- approved PCA Assessment form, including information regarding the beneficiary's:

i. Supportive service/living environment needs;

ii. Cognitive/mental status;

iii. Ambulation/mobility;

iv. Ability to transfer (for example, from wheelchair to bed);

v. Ability to feed himself or herself;

vi. Ability to bathe himself or herself;

vii. Ability to toilet himself or herself;

viii. Ability to perform grooming and dressing tasks;

ix. Ability to perform housekeeping and shopping tasks; and

x. Ability to perform laundry tasks.

2. The provider agency shall total the numerical elements related to the need areas in (b)1 above;

3. The provider agency shall submit the State-approved PCA Assessment form, in electronic or paper format, and the prior authorization request form (FD-365) to the Division of Disability Services; and

4. Upon completion of the review of a prior authorization request, Division of Disability Services staff shall make a determination regarding the hours of PCA services to be authorized.

(c) Failure to comply with the prior authorization requirements shall result in denial of Medicaid/ NJ FamilyCare reimbursement and recoupment of funds for any services provided without documented prior authorization.

N.J. Admin. Code § 10:60-3.9

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