N.J. Admin. Code § 10:90-13.2

Current through Register Vol. 57, No. 1, January 6, 2025

Section 10:90-13.2 - Payment of medical service claims for WFNJ/GA recipients residing in a nursing facility

(a) Claims resulting from medical services provided to WFNJ/GA recipients residing in a nursing facility, on or after February 1, 1997, shall be processed and paid by the New Jersey Division of Medical Assistance and Health Services (DMAHS) through its fiscal agent, in accordance with the rules appropriate for the services rendered (see N.J.A.C. 10:49). Payment of claims submitted to the fiscal agent for medical services covered under the WFNJ/GA program shall be based upon the Medicaid reimbursement methodology for the respective services. Those medical services identified at (a)2 below shall not be considered eligible for payment by the fiscal agent for WFNJ/GA program purposes.

1. Medical service claims with service dates on or after February 1, 1997 shall be submitted directly to the fiscal agent by the medical provider/vendor for payment processing. The original claim must be received by the fiscal agent within the time frame of one year from the date the service was rendered or the product was provided. If the original claim is not received by the fiscal agent within the one year time frame the claim shall not be processed for payment.

i. The provider/vendor shall direct all concerns relating to the payment or processing of WFNJ/GA medical service claims to the fiscal agent.

(1) A provider/vendor may, however, contact the agency in which the WFNJ/GA recipient is receiving assistance to ascertain information concerning WFNJ/GA policies, coverage of services and/or eligibility.

ii. Medical service claims, except for prescription claims, with service dates prior to February 1, 1997 shall be processed by the county/municipality. Such claims, however, must be received by the county/municipality within a time frame of six months from the date the service was rendered in order for that claim to be considered eligible for payment processing.

2. The following services are not considered eligible medical services for WFNJ/GA program purposes and shall not be processed for payment by the fiscal agent:

i. Inpatient or outpatient hospital services/care provided in a hospital either in-State or out-of-State, including, but not limited to, psychiatric hospitals, acute care hospitals, special hospitals, rehabilitation hospitals, Christian Science sanatoria and county or State hospitals;

(1) Exception: Inpatient hospitalization at Mt. Carmel Guild in Newark is an eligible medical service for the WFNJ/GA program.

ii. Professional services rendered to residents in public/private medical institutions;

iii. Professional services to WFNJ/GA clients residing in residential treatment centers for drug or alcohol abuse;

iv. Nursing facility per diem payments for individuals residing in Medicaid approved nursing facilities;

(1) See N.J.A.C. 10:90-13.5 concerning per diem payments for WFNJ/GA clients residing in non-Medicaid nursing facilities on or prior to June 30, 1995;

v. Early and periodic screening, diagnosis and treatment (EPSDT) services;

vi. Services provided under a home and community based services waiver, in accordance with Section 1915(c) of the Social Security Act, 42 U.S.C. § 1396n;

vii. Managed care services;

viii. Transportation for medical services provided under contract with a vendor or through a contract with the county agency;

ix. Medical services payable through other health insurance coverage, no-fault insurance benefits, or any other type of insurance/benefit coverage;

(1) Medical service bills shall be submitted to the appropriate primary carrier prior to being submitted for payment consideration through the fiscal agent;

x. HealthStart maternity and pediatric care services including comprehensive medical and health support service packages;

xi. Hospice services provided in a nursing facility;

xii. Maternity services provided by any type of provider including, but not limited to physicians, certified nurse specialists/clinical nurse practitioners, certified nurse-midwives and clinics;

xiii. Medical day care services;

xiv. Medical bills, which have been paid by the client or on his or her behalf; and

xv. Antiretroviral prescription medications (except for a one time emergency supply pending application processing and acceptance into the AIDS Drug Distribution Program).

3. The director of the county/municipal agency may authorize payment of other medical insurance premiums.

4. Prior authorizations required under the Medicaid program shall also be applicable for WFNJ/GA program purposes.

N.J. Admin. Code § 10:90-13.2

Amended by R.1998 d.42, effective 1/20/1998.
See: 29 New Jersey Register 3971(b), 30 New Jersey Register 389(a).
In (a)2, deleted former iii and recodified former iv through xvi as iii through xv.
Amended by R.1998 d.517, effective 11/2/1998.
See: 30 New Jersey Register 2417(a), 30 New Jersey Register 3962(a).
In (a)2, added a new xvi.
Amended by R.1999 d.182, effective 6/7/1999.
See: 31 New Jersey Register 20(a), 31 New Jersey Register 1508(a).
In (a)5, changed N.J.A.C. reference.
Amended by R.2000 d.267, effective 7/3/2000.
See: 32 New Jersey Register 1142(a), 32 New Jersey Register 2502(a).
In (a)2, added xvii.
Specially recodified from N.J.A.C. 10:90-13.1 and specially amended by R.2000 d.392, effective 9/1/2000 (to expire March 1, 2001).
See: 32 New Jersey Register 3615(a).
In (a), inserted "residing in a nursing facility" in the first sentence of the introductory paragraph and changed N.J.A.C. reference in 2iv(1). Former N.J.A.C. 10:90-13.2, Obtaining medical services, specially recodified to N.J.A.C. 10:90-13.3.
Recodified from N.J.A.C. 10:90-13.1 and amended by R.2001 d.42, effective 12/27/2000.
See: 32 New Jersey Register 3615(a), 33 New Jersey Register 564(a).
Former N.J.A.C. 10:90-13.2, Obtaining medical services, specially recodified to N.J.A.C. 10:90-13.3.
Amended by R.2003 d.226, effective 6/16/2003.
See: 34 New Jersey Register 2713(a), 35 New Jersey Register 2670(a).
In (a), rewrote 2 and deleted 5.