N.J. Admin. Code § 10:60A-3.4

Current through Register Vol. 57, No. 1, January 6, 2025

Section 10:60A-3.4 - Procedure for referral to and authorization of PMDC

(a) Medicaid/NJ FamilyCare reimbursement for PMDC is contingent upon the Department's issuance of authorization of PMDC to a Medicaid/NJ FamilyCare beneficiary.

(b) To request initial authorization, a PMDC administrator shall submit the following to the Division by regular mail:

1. A completed prior authorization request form, which requires provision of information identifying the Medicaid/NJ FamilyCare beneficiary, the primary health care provider' s report on the Medicaid/NJ FamilyCare beneficiary, and a statement of the PMDC facility's reasons for requesting approval, which form may be obtained by telephoning the fiscal agent at (800) 776-6334; and

2. A completed report of the Medicaid/NJ FamilyCare beneficiary's primary health care provider in the form at chapter Appendix A, incorporated herein by reference.

(c) Upon receipt of the fully completed documentation required pursuant to (b) above, professional staff designated by the Department shall:

1. Review the submitted documentation;

2. Schedule a visit with the child's parent at the Medicaid/NJ FamilyCare beneficiary's home or at an alternate location at which the Medicaid/NJ FamilyCare beneficiary is present;

3. Conduct an initial functional assessment pursuant to N.J.A.C. 10:60A-3.1;

4. Prepare a written evaluation and make a determination, documented in writing, that the Medicaid/NJ FamilyCare beneficiary is either clinically eligible or clinically ineligible to receive PMDC based on the results of the functional assessment; and

5. If, as a result of the functional assessment, professional staff designated by the Department determine that the Medicaid/NJ FamilyCare beneficiary is:

i. Clinically eligible for PMDC, the Division shall issue a written notice of authorization to receive PMDC to the Administrator, with a notification to the Medicaid/NJ FamilyCare beneficiary's parent and the fiscal agent, which authorization shall be valid for a period not to exceed 180 days from the date of the initial authorization approval; or

ii. Clinically ineligible for PMDC, the Division shall mail, to the Administrator and the Medicaid/NJ FamilyCare beneficiary's parent, a written notice of denial of authorization for PMDC that contains a summary of the procedures at N.J.A.C. 10:60A-3.5 to which the Medicaid/NJ FamilyCare beneficiary's parent must adhere to appeal the determination.

(d) Continuation of Medicaid/NJ FamilyCare reimbursement for PMDC is contingent upon the Division's reauthorization of PMDC in accordance with the following procedures:

1. The administrator shall submit a prior authorization request form to the Division no fewer than 20 business days before the expiration of the authorization for PMDC in effect at the time of request for reauthorization.

2. Upon receipt of the request, the Division shall schedule a visit to the facility during which professional staff designated by the Department shall:

i. Review the PMDC beneficiary's medical record and current interdisciplinary plan of care;

ii. Observe the PMDC beneficiary;

iii. Interview, as appropriate, facility staff providing prescribed therapies to the PMDC beneficiary; and

iv. Based on information obtained pursuant to (d)2i through iii above, prepare a written determination as to whether the PMDC beneficiary continues to be medically complex and/or technology dependent.

3. If professional staff designated by the Department determine that the PMDC beneficiary is:

4. The reauthorization procedures of this subsection shall not apply to PMDC beneficiaries enrolled in a Medicaid/NJ FamilyCare managed care organization (MCO), for whom reauthorization shall be conducted according to the MCO's contract with the Department and the requirements of the Medicaid State Plan or applicable waiver.

N.J. Admin. Code § 10:60A-3.4

Amended and Recodified from 10:166-3.4 by 56 N.J.R. 262(a), effective 2/20/2024