N.J. Admin. Code § 10:62-1.16

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

Section 10:62-1.16 - Professional services requiring prior authorization

(a) Form FD-358 (Request for Prior Authorization for Vision Care Services) shall be used to request prior authorization for professional services. Instructions for completing the form are provided in the Fiscal Agent Billing Supplement. The completed form, clearly indicating the reasons for requesting the service requiring prior authorization, shall be submitted to the Vision Care Unit, Division of Medical Assistance and Health Services, Mail Code # 16, PO Box 712, Trenton, New Jersey 08625-0712. When a request for prior authorization is approved or denied, the provider shall receive a letter of notification from the fiscal agent.

(b) Items requiring prior authorization should not be provided to the New Jersey Medicaid/NJ FamilyCare fee-for-service beneficiary until the authorization is received by the provider from the fiscal agent.

(c) The following professional services require prior authorization:

1. Low vision work-up;

2. Vision training program;

3. Vision training work-up; and

4. All other services not specified as a covered service under 10:62-1.4.

(d) Vision care provider services rendered to New Jersey Medicaid/NJ FamilyCare fee-for-service beneficiaries who are enrolled in a managed care organization (MCO) that includes these services in its benefits package must be prior authorized by the MCO/primary care provider. The Fiscal Agent Billing Supplement contains details regarding obtaining prior authorization.

(e) Program reimbursement for intraocular lenses shall be limited to two implantation procedures per beneficiary per lifetime without prior authorization. Any request for an additional implantation procedure shall be prior authorized and shall include documentation regarding the medical necessity of the procedure.

N.J. Admin. Code § 10:62-1.16

Amended by 49 N.J.R. 2279(b), effective 7/17/2017