N.J. Admin. Code § 10:76-2.6

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

Section 10:76-2.6 - Reimbursement methodology

(a) Providers will be reimbursed on a fee-for-service basis for PACT services provided to an eligible beneficiary, as described at 10:76-2.3(a), based on the lower of the provider's usual and customary charge or the established DMAHS contracted reimbursement rate for the service.

1. Reimbursement amounts for PACT services shall be determined by the Commissioner of the Department of Human Services.

2. The DMAHS contracted reimbursement rate shall be based on an average of PACT provider costs for billable beneficiaries, that is, those beneficiaries who meet the minimum service standards in PACT programs that are under contract with, and licensed by, the Department of Human Services.

(b) A unit of service shall be defined as one calendar month of services, with full reimbursement being provided for the month services are initiated and no reimbursement being provided for the month services are terminated, regardless of the quantity of services provided in either of those months.

(c) For months of service other than the first and last months, a minimum of two hours of face-to-face contact with, or on behalf of, the beneficiary shall be provided.

1. If the minimum face-to-face contact is not achieved and documented during any calendar month, the provider shall not seek reimbursement for the provision of PACT services to an eligible beneficiary during that month.

2. In calculating the monthly minimum service requirement, the PACT service provider shall not count any face to face contact provided during any time during which the beneficiary was a resident of an institution for mental disease (IMD), including State, county or private psychiatric hospitals, or incarcerated in any correctional facility, however;

i. If a beneficiary is in one of the settings described above for only a portion of the calendar month, and the minimum monthly service requirement is met during the remainder of the month, the provider may bill for PACT service for that month.

3. General acute care hospitals shall not be considered IMDs for the purposes of the PACT, and therefore face-to-face contact provided to, or on behalf of, an eligible beneficiary, while the beneficiary is in a general acute care hospital, can be counted towards the monthly minimum service requirement.

(d) Providers shall seek reimbursement by submitting a CMS-1500 claim form, in accordance with DMAHS rules at N.J.A.C. 10:49.

1. HCPCS code H0040 22 shall be billed monthly for PACT services. (See 10:76-3.2) .

N.J. Admin. Code § 10:76-2.6

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