N.J. Admin. Code § 10:52-1.8

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

Section 10:52-1.8 - Non-covered services (inpatient and outpatient)

(a) The following non-covered services (inpatient and outpatient) shall not be eligible for payment by the Division:

1. Hospital admissions of the following description:

i. Admission for any condition for which hospitalization is not medically necessary;

ii. Admission primarily for rest cure, custodial care, convalescent care or diet therapy for exogenous obesity;

iii. Admission for illnesses which, according to generally accepted professional standards, are not amenable to favorable modification. However, psychiatric services in a general hospital shall be covered for the purpose of determining that such disorders or illness (such as senility) are not amenable to favorable modification;

iv. Admission for diagnostic procedures which may be done on an out-of-hospital basis including, but not limited to, laboratory tests, electrocardiograms and diagnostic radiological services;

v. Admission or extension of hospital stay solely for research or teaching studies;

vi. Admission for inpatient services provided in an approved private psychiatric hospital unless:

(1) The Medicaid beneficiary is age 65 or over;

(2) The Medicaid beneficiary has not attained age 21, except that a beneficiary who is receiving such services immediately preceding the date on which he or she attained age 21 will continue to be covered until the date the individual no longer requires such services or the date the individual reaches age 22, whichever occurs first;

(3) The NJ FamilyCare-Plan A beneficiary has not attained the age of 21; or

(4) The FamilyCare-Children's Program-Plan B, C or D beneficiary has not attained the age of 19; and

vii. Admission of beneficiaries in the Medically Needy Program, except for pregnant women. For information on how to identify a Medically Needy beneficiary, see 10:49-2.3(c), Administration.

2. Any service or item requiring prior authorization (see 10:52-1.10, Prior authorization) which has been performed without prior authorization.

3. Medically unnecessary items and services, as follows:

i. Any service or item which is not medically necessary for the prevention, diagnosis, palliation, rehabilitation or treatment of a disease, injury or condition;

ii. Inpatient hospital services rendered prior to the day it is medically necessary for the diagnostic services or surgical or medical treatment for which the patient is admitted.

iii. Inpatient hospital services rendered in a general hospital at any time following the day that such services are no longer medically necessary, except when special circumstances, that is, "social necessity," exist which prevent the discharge or transfer of the patient or when an inpatient is eligible for "administrative days" (see 10:52-1.14, Social Necessity and 10:52-1.9, Administrative Days).

iv. Inpatient hospital services denied for lack of medical necessity shall not be covered.

4. Private duty nursing services in the hospital inpatient setting;

5. Research or Teaching Studies;

6. Surgery (Elective), as follows:

i. Cosmetic Surgery, except that the Division shall consider authorization of a request from the patient's physician for elective cosmetic surgery, if a significant redeeming medical necessity can be demonstrated; and,

ii. Second Opinion Elective Procedures without meeting the Second Opinion requirement (see 10:52-1.13 Second Opinion Program);

7. Transportation, except as in 10:52-2.16 Transportation-Services (Hospital-based);

8. Fee-for-service billed by a hospital-based physician who is salaried and whose services are reimbursed as part of the hospital's cost;

9. Other services and items not directly related to the care of the patient, such as:

i. Inpatient items and services including guest meals and accommodations, television, telephone, and similar items and services. Personal items shall be billed to the patient directly, provided the patient is informed and agrees to accept responsibility for personal items; and,

ii. Outpatient items and services which are not usually part of the outpatient service; for example, eyeglasses, custom-made limbs and braces, or surgical supplies.

10. Services and items that are billed by, and payable to, another vendor;

11. Services and items furnished by the hospital, for which the hospital does not normally charge;

12. Services and items not medically required for the diagnosis or treatment of a disease, injury or condition; and,

13. Services provided to a patient during the same period for the same condition by both private practitioner and outpatient facility, or by two different facilities, shall not be covered. Payment shall be made for only one service, except in a medical emergency. (For definition of a medical emergency, see 10:49-6.1(a)2.)

N.J. Admin. Code § 10:52-1.8

Recodified from N.J.A.C. 10:52-1.6 by R.1998 d.564, effective 12/7/1998.
See: 30 N.J.R. 1257(a), 30 N.J.R. 4225(a).
Former N.J.A.C. 10:52-1.7, Administrative Days (Nursing Facility Level of Care)--General, Special (Classification A & B) and Private Psychiatric Hospitals, recodified to N.J.A.C. 10:52-1.8.
Recodified from N.J.A.C. 10:52-1.7 and amended by R.2000 d.29, effective 1/18/2000.
See: 31 N.J.R. 3151(a), 32 N.J.R. 276(a).
In (a), substituted references to beneficiaries for references to recipients and changed N.J.A.C. references throughout, inserted 1vi(3), deleted a former 9, and recodified former 10 through 14 as 9 through 13. Former N.J.A.C. 10:52-1.8, Administrative Days (Nursing Facility Level of Care)--General, Special (Classification A & B) and Private Psychiatric Hospitals, recodified to N.J.A.C. 10:52-1.9.
Amended by R.2005 d.214, effective 7/5/2005.
See: 37 N.J.R. 436(a), 37 N.J.R. 2506(a).
In (a), rewrote the introductory paragraph, substituted "a beneficiary who is" for "an individual" preceding "receiving such services" in 1iv(2), added a new 1iv(3), recodified former 1iv(3) as 1iv(4) and rewrote the paragraph, deleted "and/" following "diagnostic services" in 3ii, rewrote 3iii and amended the N.J.A.C. reference in 7.
Amended by R.2011 d.010, effective 1/3/2011.
See: 42 N.J.R. 1656(a), 43 N.J.R. 43(a).
In (a)13, substituted "a medical" for "an" twice, updated the N.J.A.C. reference, and deleted ", Administration" from the end.