N.J. Admin. Code § 10:60-5.2

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:60-5.2 - Basis for reimbursement for EPSDT/PDN

(a) To be considered for EPSDT/PDN services, the beneficiary shall be under 21 years of age, enrolled in the Medicaid/NJ FamilyCare program and referred by a parent, primary physician/practitioner, hospital discharge planner, Special Child Health Services case manager, Division of Disability Services (DDS), Child Protection and Permanency (CP&P), Division of Mental Health and Addiction Services (DMHAS), or current PDN provider. Requests for services shall be submitted to the Division of Medical Assistance and Health Services (DMAHS) using a "Request for EPSDT Private Duty Nursing Services (FD-389)" form, incorporated herein by reference (see N.J.A.C. 10:60 Appendix C). The Request shall be completed and signed by the referring physician/practitioner and agreed to and signed by a parent or guardian. All sections of the Request shall be completed and a current comprehensive medical history and current treatment plan, completed by the referring physician/practitioner, shall be attached. The comprehensive medical history, current treatment plan, and other documents submitted with the request shall reflect the current medical status of the beneficiary and shall document the need for ongoing (not intermittent) complex skilled nursing interventions by a licensed nurse. Incomplete requests shall be returned to the referral source for completion prior to further action by DMAHS.

(b) Upon receipt of the fully completed Request (FD-389), a DMAHS Regional Staff Nurse shall conduct an assessment of the need for PDN services, as well as the level (LPN or RN) and amount of service required. A letter notifying the family and the person who referred the individual of the decision following the assessment shall be issued by DMAHS. When the child is found to be eligible for EPSDT/PDN services, the number of hours approved, the level of services, and the length of time of the approval (up to a maximum of six months) shall be noted.

(c) The PDN provider agency, selected by the family, shall submit a request to DMAHS for the PDN services on the "Prior Authorization Request Form (FD-365)" which contains a pre-printed prior authorization (PA) number. Telephone requests for prior authorization (PA) can be accommodated in an emergency but shall be followed immediately by a written request.

(d) Requests for continuation, or modification of PDN services during the treatment period, shall be submitted by the PDN agency, in writing, to DMAHS on the "Prior Authorization Request Form (FD-365)" In an emergency, requests for modification of services may be made by telephone but shall be followed immediately by a written prior authorization (PA) request.

N.J. Admin. Code § 10:60-5.2

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

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