N.J. Admin. Code § 10:76-1.3

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

Section 10:76-1.3 - Provider participation criteria

(a) To participate in the Medicaid/NJ FamilyCare program, all providers shall be under contract with the Division of Mental Health and Addiction Services (DMHAS) as a provider of PACT services and shall meet the requirements set forth by the DMHAS related to PACT services in accordance with N.J.A.C. 10:37J.

(b) In order to participate in the Medicaid/NJ FamilyCare program, all applicants shall complete and submit the "Medicaid Provider Application" (FD-20) and the "Medicaid Provider Agreement" (FD-62), as well as a copy of their license provided by DHS, in accordance with N.J.A.C. 10:190, to:

Division of Medical Assistance and Health Services

Office of Provider Enrollment, Mail Code #9

PO Box 712

Trenton, New Jersey 08625-0712

(c) The applicant will receive written notification of approval or disapproval of Medicaid/NJ FamilyCare provider status from DMAHS. If approved, the applicant will be assigned a Medicaid/NJ FamilyCare Provider Number, and will receive a copy of this chapter as part of the provider manual.

(d) Prior to billing for PACT services, those who have previously enrolled, and are currently approved, as Medicaid/NJ FamilyCare providers in other categories of service, shall be required to enroll as a PACT provider by completing and submitted a new provider application and shall receive an additional, unique, provider identification number for submitting claims for the provision of PACT services.

(e) Upon approval as a Medicaid/NJ FamilyCare provider of PACT services, the provider shall conform to the provisions of this chapter and the provisions of N.J.A.C. 10:49, the Administration Manual for DMAHS programs.

(f) If a PACT provider loses its license from DHS, and is unable to provide services, the provider shall notify the Provider Enrollment Unit, at the address in (b) above, within five business days of losing the license.

1. The PACT provider will be disenrolled as a Medicaid/NJ FamilyCare PACT provider until such time as the license is restored. Once the provider's PACT license is restored by the Department of Human Services, the provider will be reinstated as a Medicaid/NJ FamilyCare PACT provider as long as the requirements of N.J.A.C. 10:37J and this chapter are met and continue to be met.

2. A PACT provider shall be held liable for recoupment of any monies paid for services during the time that they did not possess a valid license.

(g) In order to participate in the New Jersey Medicaid/NJ FamilyCare Program, a PACT services provider shall:

1. Have a valid National Provider Identifier (NPI) number obtained from the National Plan and Provider Enumeration System (NPPES);

2. Have a valid taxonomy code obtained from the NPPES; and

3. Remain a provider in good standing by successfully completing provider revalidation, when requested by DMAHS.

N.J. Admin. Code § 10:76-1.3

Amended by 48 N.J.R. 79(b), effective 1/4/2016

Amended by 55 N.J.R. 1333(b), effective 7/3/2023