N.J. Admin. Code § 10:62-1.22

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

Section 10:62-1.22 - Reimbursement policies

(a) Instructions for submitting claims for payment of vision care services are provided in the Fiscal Agent Billing Supplement.

(b) Vision care services shall be identified by means of procedure codes, utilizing the CMS Healthcare Common Procedure Coding System (HCPCS). The codes and maximum fee allowance schedule are listed in N.J.A.C. 10:62-3.

(c) The provider shall use the practitioner's usual and customary charge when submitting a claim for vision care services. Reimbursement for covered services furnished under the New Jersey Medicaid/NJ FamilyCare fee-for-service programs shall be made on the basis of the provider's customary charge, not to exceed an allowance determined to be reasonable by the Commissioner of the Department of Human Services, and further limited by Federal policy ( 42 CFR 447 Subpart B) relative to payment of practitioners and other individual providers.

1. In no event shall the charge to the New Jersey Medicaid/NJ FamilyCare fee-for-service programs exceed the charge by the provider for identical services to other governmental agencies, private nonprofit agencies, trade unions or other individuals in the community.

2. If a beneficiary receives care from more than one member of a partnership or corporation in the same discipline for the same service, the maximum payment allowance shall be the same as that of a single provider. For purposes of reimbursement, optometrist and or physician, optometrist and physician groups, shared health care facility, or optometrist and physician sharing a common record shall be considered a single provider.

3. Reimbursement shall not be made for, and beneficiaries may not be asked to pay for, broken appointments.

(d) For reimbursement purposes, when the practitioner submits a claim for services, the services shall have been performed personally by the practitioner submitting the claim.

N.J. Admin. Code § 10:62-1.22

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