N.J. Admin. Code § 10:52-1.6

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

Section 10:52-1.6 - Covered services (inpatient and outpatient)

(a) The Division will cover those inpatient services ordinarily furnished by an approved hospital maintained for the treatment and care of patients, and provided to any Medicaid/NJ FamilyCare fee-for-service beneficiary, for whom professionally developed criteria and standards of care were used to determine that the beneficiary warranted an appropriate hospital level of care for a given diagnosis or problem.

1. Inpatient psychiatric services in approved beds in a general hospital for patients of any age shall be covered services.

2. Inpatient room and board service shall be provided in a semi-private accommodation. Accommodations other than semi-private require certification of medical necessity or lack of availability of semi-private accommodations.

3. Inpatient services in an acute general hospital rendered the day after acute care is no longer medically necessary shall be covered only under specified conditions. (See Social Necessity Days in 10:52-1.14 and Administrative Days in 10:52-1.9.)

4. Non-physician services, supplies, and equipment supplied by an outside vendor to Medicaid/NJ FamilyCare beneficiaries who are receiving inpatient acute care hospital services shall be covered directly under the hospital reimbursement system. Vendor claims for these services are the responsibility of the acute care hospital where the beneficiary is a patient and shall not be billed directly to the Medicaid/NJ FamilyCare fiscal agent.

5. For beneficiaries in the Medically Needy Program, inpatient hospital services shall be available only to pregnant women. For information on how to identify a Medicaid beneficiary in the Medically Needy Program, refer to 10:49-2.3(c), Administration.

(b) The Division shall pay for eligible ancillary services provided during a non-covered period in an acute care hospital for the following situations:

1. When the Utilization Review Organization (URO) denies the entire admission for acute level of care; or

2. When the URO certifies the admission as acute but "carves out" days from the approved continued stay. For eligible ancillary services that were provided during days that were "carved out" or "non-covered" and occurring in an inlier stay, no additional reimbursement by Medicaid/NJ FamilyCare fee-for-service shall be made, because the services are already included in the DRG reimbursement rate; or

3. When the URO certifies that only part of the stay is acute.

(c) Medically necessary inpatient psychiatric services provided in an approved private psychiatric hospital shall be covered by the Division for any Medicaid/NJ FamilyCare beneficiary age 65 or older; or for any other Medicaid/NJ FamilyCare-Children's Program beneficiary before reaching the age of 21, except that a Medicaid/NJ FamilyCare beneficiary receiving the services immediately before attaining age 21 may continue to receive the services until they are no longer needed or until the beneficiary reaches age 22, whichever occurs first.

(d) Outpatient services include those medically necessary items or services (preventive, diagnostic, therapeutic, rehabilitative, or palliative) provided to an outpatient, by or under the direction of a physician or dentist, except for the supervision of certified nurse midwife services, pursuant to the rules of the Division, State and applicable Federal regulations, including those services listed below:

1. Outpatient psychiatric services in general hospitals and private psychiatric hospitals for patients of all ages;

2. Same day surgery shall be:

i. Identified on the UB-92 claim form as a 131 or 136 bill type in accordance with 8:31B-3.11(a)1;

ii. The patient shall be discharged before midnight of the day of admission so the admission date and discharge date are the same;

iii. The patient shall have had surgery performed in a fully equipped operating room, for example, one routinely equipped and capable of providing general anesthesia, and identified by an operating room charge on the claim; and

iv. The patient shall have had a normal discharge, for example was not transferred, did not leave "against medical advice," and was not discharged dead. (See 8:31B-3.11 Same day surgery.)

3. Physician services in hospitals (that is, specifically unbundled physicians): A physician practicing in a hospital out-patient department whose reimbursement is not part of the hospital's cost may bill fee-for-service if the arrangement with the hospital permits it.

(e) Transfer from one outpatient facility to another outpatient facility, or a change from an outpatient facility to a private practitioner's care is allowable; however, effort shall be made to avoid duplication of diagnostic tests or services.

(f) For policies and procedures for Ambulatory Surgical Centers, see 10:52-2.1 and N.J.A.C. 10:66-5, Independent Clinic Services.

(g) For policies and procedures for hospital-affiliated home health agencies, see 10:52-2.6 and N.J.A.C. 10:60, Home Care Services.

(h) For policies and procedures for Medical Day Care Centers (Hospital Affiliated), see 10:52-2.7 and N.J.A.C. 8:86, Adult Day Health Services.

(i) For policies and procedures for HealthStart (Comprehensive Maternity and Pediatric Care Services), see N.J.A.C. 10:52-3. For policies and procedures for Early and Periodic Screening Diagnostic and Treatment, see 10:52-2.4.

(j) For other policies and procedures related to specific services, both inpatient and outpatient, see N.J.A.C. 10:52-2.

N.J. Admin. Code § 10:52-1.6

Amended by 50 N.J.R. 1261(a), effective 5/21/2018