N.J. Admin. Code § 10:66-1.1

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

Section 10:66-1.1 - Scope of service

(a) This chapter describes the policies and procedures of the New Jersey Medicaid and NJ FamilyCare fee-for-service programs pertaining to the provision of, and reimbursement for, medically necessary services in an independent clinic setting. The term independent clinic includes, but is not limited to, clinic types, such as: ambulatory care facilities, ambulatory surgical centers, ambulatory care/family planning clinics, substance use disorder treatment facilities, mental health independent clinics, and Federally qualified health centers (FQHCs).

(b) Medically necessary services provided in an independent clinic setting shall be in compliance with all applicable State and Federal Medicaid and NJ FamilyCare fee-for-service laws, and all applicable policies, rules and regulations as specified in the appropriate provider services manual of the New Jersey Medicaid and NJ FamilyCare fee-for-service programs. Services provided in an out-of-State independent clinic setting shall be in compliance with all applicable laws, rules and regulations of the state in which the facility is located.

(c) Independent clinic services are preventive, diagnostic, therapeutic, rehabilitative, or palliative services that are provided by a facility (freestanding) that is not part of a hospital but is organized and operated to provide medical care to outpatients, including such services provided outside the clinic by clinic personnel to any Medicaid or NJ FamilyCare fee-for-service beneficiary who does not reside in a permanent dwelling or does not have a fixed home or mailing address. Clinic services do not include services provided by hospitals to outpatients.

(d) The chapter is divided into six subchapters, as follows:

1.N.J.A.C. 10:66-1 contains scope of service, definitions, provisions for provider participation, prior authorization, basis for reimbursement, recordkeeping requirements, personal contribution to care requirements for NJ FamilyCare-Plan C and copayments for NJ FamilyCare-Plan D, and the medical exception process.

2.N.J.A.C. 10:66-2 contains policies and procedures pertaining to specific Medicaid-covered and NJ FamilyCare-covered services provided in an independent clinic. Where unique characteristics or requirements exist concerning a particular Medicaid-covered or NJ FamilyCare-covered service, the service is separately identified and discussed.

3.N.J.A.C. 10:66-3 contains information about HealthStart, a program for pregnant women and children.

4.N.J.A.C. 10:66-4 and its Appendices contain information about Federally qualified health centers, including rules governing the provision of services; the Medicaid cost report containing the forms used by Federally qualified health centers to determine Medicaid and NJ FamilyCare fee-for-service reimbursement amounts; and instructions for the proper completion of the forms. The Appendices are: Appendix A, Pre-2001 Cost Report; Appendix B, FQHC Annual Cost Reporting Requirements; Appendix C, New FQHC Medicaid Cost Reports for First and Second Years of Operation; Appendix D, Change in Scope of Service Application Requirements; and Appendix E, Medicaid Managed Care Wrap-around Reports.

5.N.J.A.C. 10:66-5 contains information about ambulatory surgical centers, including covered services, anesthesia services, facility services, and medical records.

6.N.J.A.C. 10:66-6 pertains to the Healthcare Common Procedure Coding System (HCPCS). The HCPCS contains procedure codes and maximum fee allowances corresponding to Medicaid-reimbursable services.

(e) N.J.A.C. 10:66-6 Appendix pertains to the Fiscal Agent Billing Supplement. The Fiscal Agent Billing Supplement contains billing instructions and samples of claim forms, prior authorization forms, and consent forms used in the billing process.

N.J. Admin. Code § 10:66-1.1

Amended by 49 N.J.R. 1405(a), effective 6/5/2017