N.J. Admin. Code § 10:52-1.2
The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise.
"Adult acute partial hospital" or "APH" means an intensive and time-limited acute psychiatric service for beneficiaries 18 years of age or older who are experiencing, or are at risk for, rapid decompensation. This mental health service is intended to minimize the need for hospitalization. See N.J.A.C. 10:52A.
"Advanced practice nurse (APN)" means a person currently licensed to practice as a registered professional nurse who is certified by the New Jersey State Board of Nursing in accordance with N.J.A.C. 13:37-7, and with 45:11-24 and 45 through 52, or similarly licensed and certified by a comparable agency of the state in which he or she practices.
"Base year" means the year from which historical cost data are utilized to establish prospective reimbursement in the rate year.
"Bundled drug service" means a drug that is marketed or distributed by the manufacturer or distributor as a combined package which includes in the cost of the drug, the drug product and ancillary services, such as, but not limited to, case management and laboratory services.
"Centers for Medicare & Medicaid Services (CMS)" means the agency of the Federal Department of Health and Human Services which is responsible for the administration of the Medicaid program.
"Clinically licensed mental health professional" means a mental health professional possessing a Master's or Doctoral degree from an accredited university in psychiatry, psychology, social work, psychiatric nursing or psychiatric rehabilitation counseling. In addition to the degree, the applicable training must be completed, including the appropriate residency (fellowship), internship or student placement required by the professional standards of the respective discipline, as well as the applicable State license.
"Current Cost Base" means the actual costs and revenue of the hospital as identified in the Financial Elements in the base reporting period for the purposes of rate setting.
"DoAS" means the Division of Aging Services in the New Jersey Department of Human Services.
"DOH" means the State Department of Health.
"Diagnosis Related Groups (DRGs)" means a patient classification system in which cases are grouped by shared characteristics of principal diagnosis, secondary diagnosis, age, surgical procedure, and other complications, and consumption of a similar amount of resources.
"Disproportionate share hospital" means a hospital designated as such by the Commissioner of the Department of Human Services, in accordance with N.J.A.C. 10:52-13.
"Division" means the New Jersey Division of Medical Assistance and Health Services within the New Jersey Department of Human Services.
"Division of Disability Services (DDS)" means the agency located within the Department which is designated as the agency responsible for information and referral for all individuals with disabilities.
"Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)" means a preventive and comprehensive health program for Medicaid/NJ FamilyCare-Children's Program-Plan A beneficiaries under 21 years of age for the purpose of assessing a beneficiary's health needs through initial and periodic examinations, health education and guidance, and identification, diagnosis, and treatment of health problems.
"Entity," as used in 10:52-1.3, means an outpatient department not contiguous to a main inpatient hospital for which that hospital is attempting to seek recognition and reimbursement as an outpatient hospital service.
"Equalization Factor" means the factor that is calculated based on defined Labor Market Areas and multiplied by hospital costs to permit comparability between differing regional salary costs in setting Statewide standard costs per case.
"Financial Elements" means the reasonable cost of items approved as reimbursable under Medicaid (see 10:52-5.9) .
"Group outpatient hospital psychiatric services" means an outpatient therapy for mental health disorders which involves a group of usually four to 12 beneficiaries who have similar problems and treatment needs. The group meets regularly with a therapist who uses the interaction of the group members to relieve distressful symptoms and modify beneficiaries' behavior.
"Group outpatient hospital psychiatric services for youth or young adults" means an outpatient therapeutic intervention for a youth or young adult with similar behaviors or functionality provided in a group of no more than eight individuals, in which interventions are provided directly by or under the direction of a clinically licensed mental health professional.
"Grouper" means the logic that assigns cases into the appropriate Diagnosis Related Groups in accordance with the clinical and statistical information supplied.
"Hospital (Approved Private Psychiatric)" facility that provides inpatient services to children under 21 years of age" means an institution that shall meet the requirements of paragraphs 1 through 5 above, listed in the definition of "Hospital (Approved Private Psychiatric)" or in addition to paragraphs 1 and 5 above, has facility accreditation by the Joint Commission.
"Hospital (Approved Special)" means an institution that is approved by the New Jersey State Department of Health as a special hospital (for definition of special hospital, see N.J.A.C. 8:43G-1.3(b)2) and which includes any hospital that assures the provision of comprehensive specialized diagnosis, care, treatment, and rehabilitation, where applicable, on an inpatient basis for one or more specific categories of patients; and is approved to participate as a provider in the Division if it meets the appropriate standards of participation for either a Special (Acute care or short-term) or a Comprehensive Rehabilitation Hospital and:
1. Is licensed as a special or comprehensive rehabilitation hospital by the New Jersey Department of Health;
2. Is accredited by the Joint Commission or the Commission on Accreditation as a hospital or rehabilitation facility; and/or
3. Has by-laws in effect with respect to its staff of physicians;
4. Requires every patient to be under the care of a physician;
5. Provides 24-hour nursing services rendered or supervised by a registered professional nurse, and has a registered professional nurse or licensed practical nurse on duty at all times;
6. Has in effect a hospital utilization review plan that meets the requirement of the law (Sec. 1861(K) of the Social Security Act); and has in place a discharge planning process that meets the requirements of the law (Sec. 1861(ee)) of the Social Security Act;
7. Is licensed as a hospital in the State of New Jersey, or licensed as a hospital by the appropriate agency under the laws of the respective state in which the hospital is located, or approved by the agency of the state or locality responsible for licensing hospitals meeting the standards established for such licensing;
8. Meets any other requirements that the U.S. Secretary of Health and Human Services finds necessary in the interest of health and safety of individuals who furnished services in the institution; and
9. For the purposes of 10:52-1.3 only, is where the main inpatient hospital services are located.
"Hospital (Approved General)" means an institution which is approved to participate as a provider in the Division if it:
1. Is licensed as a general hospital by the State of New Jersey, or licensed as a hospital by the appropriate agency under the laws of the respective state in which the hospital is located; (NOTE: When only a specific identifiable part of a multi-service institution is licensed, only the section licensed is considered a Medicaid/NJ FamilyCare provider);
2. Meets the requirements for participation and certification under Medicare (Title XVIII of the Social Security Act);
3. Has in effect a hospital utilization review plan applicable to all patients who received medical assistance under Medicaid (Title XIX) and NJ FamilyCare-Children's Program (Title XXI); and
4. Has signed a provider agreement to participate in and abide by Federal and State laws and regulations.
"Hospital (Approved Private Psychiatric)" means an institution which is approved to participate as a provider in the Division and:
1. Is licensed by the State of New Jersey as a psychiatric (mental-non-governmental) hospital or licensed as a private psychiatric hospital (non-governmental) by the appropriate agency under the laws of the respective state in which the hospital is located;
2. Meets the requirements for participation and certification under Medicare (Title XVIII of the Social Security Act) as a psychiatric hospital;
3. Has in effect a hospital utilization review plan applicable to all patients who receive medical assistance under Medicaid (Title XIX);
4. Meets the special Medicare standards relative to staffing requirements and clinical medical records; and,
5. Has signed a provider agreement to participate in and abide by Federal and State laws and regulations.
"Hospital (Approved Private Psychiatric) facility that provides inpatient services to children under 21 years of age" means an institution that shall meet the requirements of 1., 2., 3., 4. and 5. above, listed in the definition of "Hospital (Approved Private Psychiatric): or in addition to 1. and 5. above, has facility accreditation by the Joint Commission on the Accreditation of Health Care Organizations (JCAHO).
"Hospital (Approved Special)" means an institution which is approved by the New Jersey State Department of Health and Senior Services as a special hospital (for definition of special hospital, see 8:43G-1.3(b)2 ) and which includes any hospital which assures the provision of comprehensive specialized diagnosis, care, treatment and rehabilitation, where applicable, on an inpatient basis for one or more specific categories of patients; and is approved to participate as a provider in the Division if it meets the appropriate standards of participation for either a Special (Acute care or short term) or a Comprehensive Rehabilitation Hospital and:
1. Licensed as a special or comprehensive rehabilitation hospital by the New Jersey Department of Health and Senior Services;
2. Accredited by the Joint Commission on Accreditation of Health Care Organizations (JCAHO) or the Commission on Accreditation as a hospital or rehabilitation facility; and/or
3. Meets the requirements for participation and certification under Medicare (Title XVIII of the Social Security Act) as a hospital;
4. Has in effect a hospital utilization review plan applicable to all patients who receive medical assistance under Medicaid (Title XIX); and,
5. Has signed a provider agreement to participate in and abide by Federal and State laws and regulations.
"Individual outpatient hospital psychiatric services" means an outpatient therapy for mental health disorders that is tailored for a beneficiary and is administered one on one, in sessions which last between 30 minutes and one hour and which are provided on a regular basis for a defined period of time.
"Individual outpatient hospital psychiatric services for youth or young adults" means an outpatient therapeutic intervention that is provided directly to or on behalf of an individual youth or young adult, which may last between 30 minutes to one and a half hours and is provided on a regular basis as part of an integrated plan of service that may be supported by other strategies, interventions, and supports in the community. Such interventions may include family conferencing or family counseling with the purpose of the intervention to support a plan of treatment for the youth or young adult.
"Inliers" means inpatient cases which display common or typical patterns of resource use that are assigned to DRGs and have a length of stay within the high and low trim points.
"Inpatient" means a patient who has been admitted to an approved hospital as an inpatient on the recommendation of a physician, dentist or nurse midwife and receives room, board, and professional services in the hospital for a 24 hour period or longer, even though it later develops that the patient dies, is discharged or is transferred to another facility and does not actually stay in the hospital for 24 hours.
"Inpatient Hospital Services" means services that:
1. Are ordinarily furnished in a hospital for the care and treatment of inpatients;
2. Are furnished under the direction of a physician or dentist, except, as specified in 42 CFR 440.165 of the Social Security Act, for services provided by a certified nurse midwife;
3. Are furnished in an institution that:
i. Is maintained primarily for the care and treatment of patients with disorders including obstetrical services and services to the normal newborn;
ii. Is licensed or formally approved as a hospital by an officially designated authority for State standard-setting;
iii. Except in the case of medical supervision of nurse-midwife services, as specified in 42 CFR 440.165 of the Social Security Act, or private inpatient psychiatric facilities for children under 21 years of age, meets the requirements for participation in Medicare as a hospital; and,
iv. Has in effect a utilization review plan, applicable to all Medicaid patients, that meets the requirements of 42 CFR 482.30 of the Social Security Act, unless a waiver has been granted by the U.S. Secretary of Health and Human Services.
"Labor Market Area" means counties and municipalities in the State that are grouped in accordance with similar labor costs.
"Managed Long-Term Services and Supports (MLTSS)" means services that are provided under the Comprehensive Waiver through Medicaid/NJ FamilyCare managed care organization plans, the purpose of which is to support clients who meet nursing home level of care in the most appropriate setting to meet their specific needs.
"Medical social worker" means an individual who is licensed or certified in accordance with N.J.S.A. 45:15BB-1 et seq. and N.J.A.C. 13:44G and meets the Medicare certification requirements for education (See 42 U.S.C. § 1395x) .
"Medication management" means medication services to evaluate, prescribe or administer and monitor a beneficiary's use of psychotropic medications provided by, or under the supervision of, a licensed physician or APN.
"Medication management for youth or young adults" means therapeutic services provided by a qualified medical/mental health professional who, within the scope of their practice, evaluates, prescribes, administers, or monitors the use of therapeutic medications to assist in improving the ability of a youth or young adult to function in the community with, primarily, such therapeutic medications addressing the mental/behavioral health challenges of the youth or young adult. This service also includes providing education to the youth or young adult and their family/caregiver, as appropriate, about the benefits, side effects, and potential impact of the medications on the physical/mental health of the youth or young adult.
"Medication monitoring" means medication services provided to monitor a beneficiary's use of psychotropic medications under the supervision of a licensed physician or APN.
"Neonate" means a newborn less than 29 days of age.
"Nontherapeutic sterilization" means any procedure or operation, the purpose of which is to render an individual permanently incapable of reproducing and which is not either a necessary part of the treatment of an existing illness or injury, or medically indicated as an accompaniment of an operation on the female genitourinary tract. For the purpose of this definition, mental incapacity is not considered an illness or injury.
"Nursing facility (NF)" means an institution (or distinct part of an institution) certified by the New Jersey State Department of Health for participation in Title XIX Medicaid and Title XXI Children's Health Insurance Program, which is known in New Jersey as NJ FamilyCare, and primarily engaged in providing health-related care and services on a 24-hour basis to Medicaid/NJ FamilyCare beneficiaries, (children and adults) who, due to medical disorders, developmental disabilities, and/or related cognitive impairments, exhibit the need for medical, nursing, rehabilitative, and psychosocial management above the level of room and board. However, the nursing facility is not primarily for care and treatment of mental diseases that require continuous 24-hour supervision by qualified mental health professionals or the provision of parenting needs related to growth and development.
"Outliers" means patients who display atypical characteristics relative to other patients in a DRG and have lengths of stay either above or below the established trim points.
"Outpatient" means a patient registered in the outpatient department of a hospital or in a distinct part of that hospital who is expected to receive and who does receive professional services for less than a 24 hour period, regardless of the hour of admission; or whether or not a bed is used; or whether or not the patient remains in the hospital past midnight.
"Outpatient hospital services" means medically necessary items or services (preventive, diagnostic, rehabilitative, therapeutic, or palliative) provided to an outpatient, by or under the direction of a physician or dentist, except for the medical supervision of nurse midwife services; and/or by a psychiatric hospital or an excluded unit of a general hospital. The institution shall be licensed or formally approved as a hospital by the New Jersey State Department of Health, or certified by the officially designated authority in the state in which the hospital is located; shall meet the requirements for participation in Medicare (Title XVIII) as a hospital; and shall meet the criteria for participation as stated in N.J.A.C. 10:52-1.3.
"Partial hospital" or "PH" means an individualized, outcome-oriented psychiatric service which provides a comprehensive, structured, non-residential, interdisciplinary treatment and psychiatric rehabilitation program to assist beneficiaries who have a serious mental illness in increasing or maximizing independence and community living skills and enhancing the quality of their lives.
"Patient" means an individual who is receiving needed professional services that are directed by a licensed practitioner of the healing arts toward the maintenance, improvement, or protection of health, or lessening of illness, disability, or pain.
"Physician" means a doctor of medicine (M.D.) or osteopathy (D.O.) licensed to practice medicine and surgery by the New Jersey State Board of Medical Examiners, or similarly licensed by comparable agencies of the state in which he or she practices.
"Physician services" means those services provided within the scope of practice of a doctor of medicine (M.D.) or osteopathy (D.O.) as defined by the laws of New Jersey, or if in practice in another state by the laws of that state, and which services are performed by or under the direction and/or personal supervision of the physician. (See also 10:54-1.2.)
"Preliminary Cost Base (PCB)" means the estimated revenue a hospital may collect based on an approved schedule of rates which includes DRG rate amounts and indirect costs not included in the all-inclusive rate. Those indirect costs will either be the dollar amount specified or the estimated amount determined by a specific percentage adjustment to the rate.
"Rate year" means the year in which current reimbursement takes place.
"State fiscal year" means the State of New Jersey's fiscal year, which begins July 1 and ends the following June 30.
"Trim points" means the high and low length of stay cutoff points assigned to each DRG.
"Uniform Bill--Patient Summary (UB-92)" means the common billing and reporting form used by the hospital for each Medicaid inpatient.
"Young adult" means, for purposes of outpatient mental health/psychiatric services, an individual who is at least 18 years old and under 21 years old.
"Youth" means, for purposes of outpatient mental health/psychiatric services, an individual under 18 years old.
"Youth and young adult partial hospital" means an intensive, highly structured outpatient treatment program, provided in a hospital-based setting as approved by the Division of Medical Assistance and Health Services, that provides services designed primarily for youth and young adults under age 21 and intended to minimize the need for hospitalization that meets the requirements of this chapter and all other State rules and laws regarding youth and young adult partial hospital services.
N.J. Admin. Code § 10:52-1.2