N.J. Admin. Code § 10:66-4.1

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

Section 10:66-4.1 - Federally qualified health center (FQHC) services

(a) Federally qualified health center (FQHC) services are services provided by physicians, physician assistants, advanced practice nurses, nurse midwives, psychologists, dentists, clinical social workers, and services and supplies incident to such services as would otherwise be covered if furnished by a physician or as incident to a physician's services.

1. FQHCs shall accommodate an outstationed county board of social services (CBOSS) employee(s) for the purpose of determining Medicaid and NJ FamilyCare eligibility, pursuant to 42 U.S.C. § 1396a(a)(55).

2. A medical encounter is a face-to-face contact between a beneficiary and a physician or other licensed practitioner acting within his or her respective scope of practice, including a podiatrist, optometrist, chiropractor, advanced practice nurse, or nurse midwife.

i. Normally, only one medical encounter is covered per beneficiary, per day. More than one medical encounter is covered, however, when the beneficiary is seen by more than one licensed practitioner for the prevention, treatment or diagnosis of different injuries or illnesses, and practitioners of appropriate different specialties are involved.

ii. More than one medical encounter is also allowed if a beneficiary leaves the center after having been seen by a practitioner, then returns to the center and is seen by another practitioner on the same day.

iii. More than two medical encounters during a week for a beneficiary require clear documentation in the beneficiary's medical record demonstrating the medical necessity of the encounter(s).

iv. Interpretation of results of tests or procedures not requiring face-to-face contact between a beneficiary and a practitioner, and referrals to specialists, do not constitute a medical encounter.

3. A psychiatric encounter is a face-to-face contact between a beneficiary and a licensed mental health professional in which a covered mental health clinic service is provided.

4. A dental encounter is a face-to-face contact between a beneficiary and a dentist or a licensed dental professional in which a covered dental procedure is provided. All procedures shall be administered by or under the direct supervision of a dentist.

i. Normally, only one dental encounter is covered per beneficiary, per day. Only one dental encounter is covered when the beneficiary is seen by a licensed general practitioner and a dental hygienist or when the beneficiary is seen by two general practitioners on the same date of service.

ii. More than one dental encounter is covered, however, when the beneficiary is seen by a licensed general practitioner and a licensed specialist, such as an oral surgeon or an endodontist.

iii. More than two dental encounters during a week for a beneficiary require clear documentation in the beneficiary's dental record demonstrating the medical necessity for the multiple encounters.

iv. Interpretation of results of tests or procedure results not requiring face-to-face contact between the beneficiary and practitioner and referrals to specialists do not constitute a dental encounter.

5. An Early and Periodic Screening, Diagnosis and Treatment (EPSDT) medical encounter is a face-to-face contact between a beneficiary and a physician or other licensed practitioner acting within his or her respective scope of practice, including a podiatrist, optometrist, chiropractor, nurse, practitioner, or nurse midwife in which a covered EPSDT service is provided.

6. An OB/GYN encounter is a face-to-face contact between a beneficiary and a physician or other licensed practitioner acting within his or her respective scope of practice, including, but not limited to, a certified nurse midwife, in which a delivery or approved OB/GYN surgical procedure listed on Table A or Table B on the Molina website is performed.

Delivery codes are listed on Table A. OB/GYN surgical codes are listed on Table B. Tables A and B and annual updates are posted on the Molina website: www.njmmis.com.

N.J. Admin. Code § 10:66-4.1

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