N.J. Admin. Code § 10:66-1.4

Current through Register Vol. 56, No. 24, December 18, 2024

Section 10:66-1.4 - Prior authorization (PA)

(a) In addition to N.J.A.C. 10:49-6.1, this section outlines prior authorization (PA) requirements for dental, mental health, substance use disorder, and vision care services, as specified in (b), (c), and (d) below. Prior authorization as specified in N.J.A.C. 10:49-6.2 shall be required for out-of-State clinics for specified dental, mental health, substance use disorder, and vision care services in accordance with N.J.A.C. 10:49-6 and in accordance with specific provider chapters. Prior authorization requirements by the Primary Care Provider (PCP) for persons participating in managed health care programs are located at N.J.A.C. 10:49-21.4(c).

(b) Dental services shall be prior authorized as indicated in the New Jersey Medicaid and NJ FamilyCare fee-for-service programs' Dental Services chapter, N.J.A.C. 10:56-1.4.

(c) In addition to the other requirements of this section, mental health and substance use disorder outpatient rehabilitative services, including individual psychotherapy, group therapy, family consultation, and family therapy, provided to each Medicaid or NJ FamilyCare fee-for-service beneficiary require prior authorization when payment to an independent clinic exceeds $ 6,000 for that Medicaid or NJ FamilyCare fee-for-service beneficiary in any 12-month period, commencing with the beneficiary's initial visit.

1. The maximum period of authorization shall not exceed 12 months for all mental health services. Additional authorizations may be requested.

i. The maximum period of authorization for partial care shall not exceed six months.

2. When requesting prior authorization, Forms FD-07 and FD-07A, "Request for Authorization of Mental Health Services and/or Mental Health Rehabilitation Services" and "Request for Prior Authorization: Supplemental Information," shall be completed and forwarded to: the Medical Assistance Customer Center (MACC) that serves the county in which the services are rendered. See the Fiscal Agent Billing Supplement, N.J.A.C. 10:66--Appendix, for instructions on the completion of the prior authorization forms.

3. The "Brief Clinical History" and "Present Clinical Status" sections of the FD-07A "Request for Prior Authorization: Supplemental Information" form are particularly important and must provide sufficient medical information to justify and support the proposed treatment request. Failure to comply may result in a reduction or denial of requested services.

4. A departure from the plan of care requires a new request for prior authorization when a change in the beneficiary's clinical condition necessitates an increase in the frequency and intensity of services, or change in the type of services which exceeds the cost of the services authorized.

5. Similarly, a new request for authorization is required for a medical/remedial therapy session or encounter that departs from the plan of care in terms of increased need, scheduling, frequency, or duration of services furnished (for example, unscheduled emergency services furnished during an acute psychotic episode).

6. If the request for prior authorization is approved, the Division's fiscal agent shall notify the provider in writing regarding the Division's decision; authorized date or time frame; and activation of the prior authorization number. If the request is modified, denied, or if the Division requires additional information, the provider is so notified in writing by the fiscal agent.

(d) Vision care services require prior authorization as indicated in the New Jersey Medicaid and NJ FamilyCare fee-for-service programs' Vision Care Services chapter, N.J.A.C. 10:62-1.16 and 2.5.

(e) Transportation services to and from a substance use disorder treatment facility will be authorized and provided by the DMAHS transportation broker. Providers are responsible for arranging the transportation by contacting the DMAHS transportation broker. A link to the transportation broker can be found on the DMAHS website:

http://www.state.nj.us/humanservices/dmahs/home/index.html. If you do not have internet access call the Provider Services hotline at 1-800-776-6334.

(f) With the exception of an intake assessment, all other substance use disorder services provided by a substance use disorder treatment facility shall require prior authorization including, but not limited to, substance use disorder-partial care programs, substance use disorder-intensive outpatient services, non-hospital based detoxification, short-term residential services, and opioid treatment/maintenance services. Prior authorization shall be provided by the Division of Mental Health and Addiction Services (DMHAS) or any DHS State agency or contracted entity approved to authorize these services.

1. The maximum period of authorization shall not exceed 12 months for outpatient mental health or substance use disorder services. Additional authorizations may be requested.

2. The maximum period of authorization for partial care services for mental health or substance use disorders shall not exceed six months.

3. A departure from the American Society of Addiction Medicine (ASAM) level of care requires a new request for prior authorization when a change in the beneficiary's clinical condition necessitates an increase or decrease in the frequency and intensity of services, or change in the type of services that exceeds the cost of the services authorized.

N.J. Admin. Code § 10:66-1.4

Amended by 49 N.J.R. 1405(a), effective 6/5/2017