1 of 46 documents new jersey administrative code


§ 10:56-1.7 Personal contribution to care requirements for NJ FamilyCare-Plan C and copayments for NJ FamilyCare-Plan D



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§ 10:56-1.7 Personal contribution to care requirements for NJ FamilyCare-Plan C and copayments for NJ FamilyCare-Plan D

(a) General policies regarding the collection of personal contribution to care for NJ FamilyCare-Plan C and copayments for NJ FamilyCare-Plan D are set forth at N.J.A.C. 10:49-9.

(b) Personal contribution to care for NJ FamilyCare-Plan C services shall be $ 5.00 per visit for dental services, except when the service is provided for preventive dental care.

1. A dental visit is defined as a face-to-face contact with a medical professional, including services provided under the supervision of the dentist, which meets the documentation requirements of this chapter and allows the dentist to request reimbursement for services.

2. Dental visits include dental services provided in the office, patient's home, or any other site, except the hospital, where the child may have been examined by the dentist or the dental staff.

3. Dental services which do not meet the requirements of an office visit, such as surgical services, laboratory or x-ray services, do not require a personal contribution to care.

(c) Dentists shall not charge a personal contribution to care for services provided to newborns, who are covered under fee-for-service for Plan C; or for preventive dental services, including screenings, fluoride treatments and routine dental evaluations.

(d) Dentists shall not charge a copayment for services provided to newborns, who are covered under fee-for-service Plan D; or for preventive dental services provided to children under 12 who are covered under NJ FamilyCare-Plan D including oral evaluations, oral prophylaxis and fluoride treatments.

9 of 46 DOCUMENTS

NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law

*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES

SUBCHAPTER 1. DENTAL SERVICES; GENERAL PROVISIONS
N.J.A.C. 10:56-1.8 (2014)
§ 10:56-1.8 Non-covered services
(a) A non-covered service is that procedure which is primarily for cosmetic purposes, for which dental necessity cannot be demonstrated, or which is determined to be beyond the scope of the program by a Medicaid/NJ FamilyCare dental consultant as specified in this chapter.

(b) Medical/dental supplies and equipment and other devices that are essential for the beneficiary's medical/dental condition shall be allowable unless such services are otherwise available at no charge from community services (such as the American Cancer Society or other service organizations).

(c) Standard tooth brushes, dental floss, and like items are considered personal hygiene items and shall not be covered by the Medicaid/NJ FamilyCare fee-for-service program.


10 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***

TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES

SUBCHAPTER 1. DENTAL SERVICES; GENERAL PROVISIONS
N.J.A.C. 10:56-1.9 (2014)
§ 10:56-1.9 Recordkeeping requirements
(a) Dentists shall maintain individual records which fully disclose the type and extent of services provided to the New Jersey Medicaid/NJ FamilyCare fee-for-service programs beneficiary, including detailing all services rendered for each encounter date. These records shall also fulfill the requirements of the New Jersey State Board of Dentistry as outlined in N.J.A.C. 13:30-8.7. The Medicaid/NJ FamilyCare Dental Claim Form (MC-10) shall not be an acceptable substitute. Such beneficiary records shall be maintained in the provider's office regardless of the actual place of service (dental office, long-term care facility, or hospital). These records shall be available for a minimum of seven years following the last date of service. The dentist shall also document services in facility records as required in (b) and (c) below. Such information shall be readily available to representatives of the New Jersey Medicaid/NJ FamilyCare fee-for-service programs or their agents as required.

1. The record shall include, but not be limited to, the following:

i. The name, address, and telephone number of the beneficiary, the beneficiary's date of birth and HSP (health services program) number, and, if a minor, name of parent(s) or guardian.

ii. Pertinent dental/medical history; and

iii. Detailed clinical evaluation data to include where applicable:

(1) Beneficiary's chief complaint;

(2) Diagnosis;

(3) Cavities;

(4) Missing teeth; and

(5) Abnormalities;

iv. Preoperative, progress, and postoperative radiographs, which shall be retained for a minimum of seven years following the last date of service. Professional liability insurance companies should be contacted for possible retention for longer periods. The number and type of radiographs shall be entered on the beneficiary's record. Postoperative radiographs shall be taken only when dentally necessary and only when such radiographs have diagnostic value.

v. Treatment plan with description of treatment rendered to include:

(1) Tooth number;

(2) Surfaces involved;

(3) Site and size of treatment area (lesion, laceration, fracture, and so forth);

(4) Materials used;

(5) Date(s) of service(s);

(6) Description of treatment or services rendered at each visit to include the name of the dentist or hygienist rendering it.

(7) All medications;

(8) Diagnostic laboratory and/or radiographic procedure(s) ordered, including the result(s);

(9) Copy of the dental prosthetic work authorization(s) (prescription(s)), and dental prosthetic laboratory receipt(s);

(10) Explanation for any duplication of services within one year (prosthetic services within seven and one-half years);

(11) Reasons for discontinuation of services (including attempts to complete treatment); and

(12) Referral and consultation reports.

(b) A complete description of treatment, as noted above, shall also be entered into a hospital's clinical records for any beneficiary treated at that facility. These entries shall also satisfy that specific hospital's regulations.

(c) A dentist who provides services for a nursing facility beneficiary (regardless of the place of service) shall, in addition to maintaining his or her own office records, provide the nursing facility with an entry for the beneficiary's clinical record that includes the following:

1. The results of an evaluation which will establish an admission record of the beneficiary's dental status.

i. If a current examination is required within six months of a previous examination performed by the same provider and billed to Medicaid/NJ FamilyCare, the results of the original examination shall be entered into the clinical record as the current dental status.

2. A time frame, established on an individual basis, for the next periodic evaluation of the beneficiary. The time frame shall be documented either at the time of evaluation or at the completion of treatment. For example, it may be entered on the clinical record for six months, one year, two years, three years, or any other time period that the attending dentist has established per his or her knowledge of the beneficiary and the beneficiary's dental status.

3. A record of dental treatment provided at each encounter.

i. A photocopy of the completed and signed Medicaid/NJ FamilyCare Dental Claim Form (MC-10) for evaluation and treatment will be accepted in lieu of a separate entry only if treatments (visits and description thereof) that preceded or followed the "dates of service" entered on the Medicaid/NJ FamilyCare Dental Claim Form (MC-10) are listed separately on the beneficiary's clinical record in addition to the recordkeeping requirements described in this section.


11 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES

SUBCHAPTER 1. DENTAL SERVICES; GENERAL PROVISIONS
N.J.A.C. 10:56-1.10 (2014)
§ 10:56-1.10 Utilization review, quality control, peer review, and TAMI review

(a) For the purposes of the New Jersey Medicaid/NJ FamilyCare fee-for-service program, utilization review, quality control and peer review are considered to be ongoing components in regard to the dental services provided to eligible beneficiaries.

(b) Utilization refers to that service, procedure or item provided to a beneficiary by a qualified provider, in a setting, at a time, and in an amount which is appropriate and acceptable to the standards of the profession, at a cost described at N.J.A.C. 10:56-3.

(c) Utilization review is the retrospective analysis of the performance of a dental provider with respect to the efficient provision for the use of services noted in (b) above, from the viewpoint of fiscal accountability.

(d) Quality is that standard of dental care or degree of excellence generally prevailing throughout the profession by those who provide similar service which is not related to any geographical area or population group as judged by competent practitioners who are qualified to perform those procedures.

(e) Dental review is the current ongoing review of the degree of quality in the delivery of continuing dental services and health care which is constantly monitored and maintained by the provision of direction, coordination and regulation through the cooperative efforts between representatives of the New Jersey Medicaid/NJ FamilyCare program and a qualified body of peers.

(f) Peer review is the evaluation by practicing dentists as to the quality and efficiency of services ordered and/or performed by other practicing dentists and is considered to be the all-inclusive term for dental review efforts including dental practice analysis, inpatient hospital and extended care utilization review and dental claims audit and review. In the accomplishment of the above, any or all reviews will include, but not be limited to, the following:

1. A clinical examination made on a sampling of cases. Such examination may be made prior to, during, or upon completion of treatment.

2. Additional diagnostic aids and data which may be requested to evaluate the case.

3. Adequate records, which shall be maintained by the dentist providing treatment and shall be available for inspection.

4. In the event a provider fails to respond to a request of the Division of Medical Assistance and Health Services for office records, radiographs, and/or other materials and correspondence within 30 days, the Division may recover any reimbursement related to the services involved, or if in reference to services not yet paid, reimbursement may be denied.

(g) TAMI review is that review done by the fiscal agent whereby, during the course of processing for payment, a claim is subjected to the Tooth Allocation Map Inquiry (TAMI). This system selects for further review and investigation any claim which shows a duplication of services or services presented in an illogical or impossible sequence. Claims and pertinent material are forwarded to the Bureau of Dental Services by the Fiscal Agent and the provider is informed of the problem and is likewise asked to forward specific and related material.


12 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES

SUBCHAPTER 2. PROVISIONS FOR SERVICES
N.J.A.C. 10:56-2.1 (2014)
§ 10:56-2.1 Dental treatment or services plan

(a) In accordance with good dental practice, a plan of treatment or services shall be developed and described for each Medicaid/NJ FamilyCare patient on the Dental Claim Form (MC-10) following a comprehensive evaluation. If no treatment is necessary, this fact shall be entered on the Dental Claim Form (MC-10) under Remarks (Item 20). (No Other Treatment Necessary or NOTN).

(b) Any dental treatment plan, including those not requiring prior authorization, may be reviewed by dental consultants of the New Jersey Medicaid/NJ FamilyCare program.

(c) In those instances where prior authorization is necessary, the two page prior authorization documents, that is, the Dental Prior Authorization Form MC-10(A) and the Dental Claim Form MC-10, shall be submitted along with the treatment plan and any additional documentation or radiographs appropriate to the request. A Division dental consultant may modify or deny the provider's treatment plan in accordance with the requirements of the New Jersey Medicaid/NJ FamilyCare fee-for-service programs, as specified in this chapter. Such modifications or denials are designed to provide dental treatment to the beneficiary that is adequate for the correction of the problem, that can be expected to last for the longest period of time, and represents, in the opinion of the dental consultant(s), the most judicious application of Medicaid/NJ FamilyCare fee-for-service reimbursement. If in the professional judgment of the provider such modification is not appropriate, the dentist may request another review by the Division dental consultant. A further review in the Bureau of Dental Services may be requested through the Division dental consultant.

(d) In any dental treatment or services plan, the dentist shall discuss the proposed treatment plan and receive approval from the beneficiary and/or family member/guardian before submission for authorization and again after authorization is received and prior to initiation of treatment. It is suggested that the provider have the beneficiary sign the office records or a separate statement that the treatment plan meets with their approval, since no alteration of the treatment plan will be reimbursed based on the subsequent rejection of all or part of that treatment plan by the beneficiary or family member/guardian.

(e) Consideration for development of a dental treatment plan shall be based upon the least costly treatment fulfilling the requirements of the specific situation. On the basis of post-utilization review, any dental treatment plan, including those not requiring prior authorization, may be reviewed by Division dental consultants to determine appropriateness of treatment. If the treatment is not appropriate, the payment shall be recovered.

(f) If, in the opinion of a dentist, the beneficiary requires the services of a specialist, the dentist shall note the name of the practitioner to whom the beneficiary is being referred on the Dental Claim Form (MC-10) under remarks (Item 20). The specialist shall note the name and Medicaid/NJ FamilyCare Provider Service Number of the referring dentist on the Dental Claim Form (MC-10) in section 14, which is designated as Referring Practitioner.


13 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES

SUBCHAPTER 2. PROVISIONS FOR SERVICES
N.J.A.C. 10:56-2.2 (2014)
§ 10:56-2.2 Standards of service
(a) The dental treatment plan provided shall be in accordance with the ethical and professional standards of the dental profession and meet the same high standard of quality normally provided to the community at large.

(b) All materials used and all therapeutic agents used or prescribed shall meet the specifications established by the American Dental Association.

(c) Experimental procedures, not approved by the New Jersey Board of Dental Examiners (N.J.A.C. 13:30), are not reimbursable by the New Jersey Medicaid/NJ FamilyCare program.

(d) When an emergency arises and consultation with the attending practitioner is impossible, due consideration shall be given to the preservation of those teeth that could be involved in the overall treatment plan of the attending practitioner



14 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law

*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***

TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES

SUBCHAPTER 2. PROVISIONS FOR SERVICES
N.J.A.C. 10:56-2.3 (2014)
§ 10:56-2.3 Special dental services
(a) Dental services for which no specific procedure code and description are noted, or which are limited or prohibited by this chapter, may be considered on a case-by-case basis, upon request. Such a request shall be submitted on the two part Dental Prior Authorization Form (MC-10A), and the Dental Claim Form (MC-10) and forwarded to the Bureau of Dental Services, Mail Code 21, PO Box 713, Trenton, New Jersey 08625-0713. An unspecified procedure code appropriate for the requested service shall be used when submitting the prior authorization request for these dental services. The request shall be accompanied by all supporting documentation.

1. If such unspecified services are associated with a temporomandibular joint dysfunction diagnosis or therapy, the requesting provider shall comply with the New Jersey Board of Dentistry protocol for diagnosis and treatment planning as set forth in N.J.A.C. 13:30-8.22.

(b) If reimbursement for the dental service is "By Report," the requesting provider shall forward, in addition to all documentation required for any prior authorization request, a detailed written report, treatment plan and other documentation, such as charting, records, or radiographs, relevant to the requested dental service.


15 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law

*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES

SUBCHAPTER 2. PROVISIONS FOR SERVICES
N.J.A.C. 10:56-2.4 (2014)
§ 10:56-2.4 Place of service
(a) In addition to the private office, dental services may be provided in the home, a hospital, ambulatory surgical center, approved independent clinic, nursing facility, residential treatment center and elsewhere.

(b) Services should be provided in any appropriate setting, governed by medical/dental necessity and not by the convenience or desires of the beneficiary or the providers of services.

1. Specific additional requirements for dental services rendered in the outpatient departments of approved licensed hospitals and services rendered in approved independent clinics are described in N.J.A.C. 10:52 and 10:66, respectively.

i. Hospital outpatient dental clinics are subject to the same New Jersey Medicaid/NJ FamilyCare program requirements and reimbursement schedule, as specified in this chapter, that apply to the dentist in "private" practice (see N.J.A.C. 10:52-2.3, 10:66 and 13:30.)

2. Dental services performed on an inpatient basis in approved licensed hospitals are reimbursable, provided that such services require a hospital level of care, which level of care requirement shall be documented on the hospital records.

i. Dental services are also reimbursable if the beneficiary is admitted for an eligible non-dental condition and the dental services are rendered as part of the prescribed treatment for such condition, or to alleviate the beneficiary's discomfort during the period of hospitalization.

(1) Admission may be by the dentist or by a physician, depending on the by-laws of the individual hospital.

(2) When inpatient services are performed by a dentist who is reimbursed by the hospital under contractual or other arrangements, the services are considered a hospital cost, and shall be billed by the hospital and not by the dentist.

(3) Authorization by a Division dental consultant shall be for services only and does not authorize the place of service; thus, such authorization does not guarantee payment.

(4) Whenever all or any portion of the hospital inpatient claim is denied for payment, the attending practitioner's claim for inpatient services rendered during the denial period will also be denied for payment.

(c) Dental services as performed by a licensed dentist in a nursing facility, or elsewhere outside the provider's office setting are reimbursable provided that:

1. The requirements of this chapter are followed.

2. In a nursing facility, the dentist rendering the dental services is not an owner, administrator, stockholder of the company or corporation or otherwise has a direct financial interest in the facility.

3. Reimbursement of a supplemental fee for an out-of-office visit in addition to a fee for service is limited to once per trip per facility, regardless of the number of recipients examined or treated during the visit.

4. The dentist who examines a nursing facility beneficiary shall provide the treatment necessary unless the examination indicates that a specialist is needed.


16 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES

SUBCHAPTER 2. PROVISIONS FOR SERVICES
N.J.A.C. 10:56-2.5 (2014)
§ 10:56-2.5 House calls and visits to beneficiary residences

(a) A provider may be reimbursed for a house call/visit (procedure code D9410) in addition to any other services provided on that day. Procedure code D9410 shall include house calls/visits to nursing homes, long-term care facilities, hospice sites, institutions, and other types of extended care facilities.

(b) The following apply to reimbursement for house calls/visits to the facilities identified in (a) above:

1. House calls/visits can be billed in addition to any other services provided to a specific patient on that day; and

2. Billing for house calls/visits using code D9410 shall be limited to once per trip to the facility, regardless of the number of patients examined or treated.

(c) Procedure code D9420, hospital calls, may be reported when providing treatment in the hospital or for operating room cases in the hospital or an ambulatory surgical center, and can be billed in addition to any dental services performed on that day; however, procedure code D9420 shall not be reimbursable if billed in conjunction with a consultation or other hospital calls on the same day. This use of code D9420 requires prior authorization. Prior authorization may be provided when the submitted evidence indicates a hospital, hospital operating room or ambulatory surgical center as the place of service or that the patient has special health needs that require the dental services to be provided in the hospital operating room or ambulatory surgical center. Requests for prior authorization of D9420 shall be submitted to the Division and shall include:

1. A complete pertinent medical history and medical diagnosis;

2. The chief dental complaint;

3. A description of the oral findings pertaining to the present condition, or, if not possible, an explanation as to why no such description is possible;

4. The history of the present dental condition, including all findings; and

5. A record of the working dental diagnosis and the treatment planned for the operating room visit.

(d) Any subsequent hospital calls also require prior authorization. A request for authorization of such subsequent hospital calls may be submitted after the fact, with dates of service noted. The prior authorization for subsequent hospital calls shall include the following information:

1. The diagnosis associated with the need for hospitalization;

2. Any subsequent dental care provided or needed, identified by procedure code;

3. Any changes in the dental diagnosis or treatment plan; and

4. The total number of visits.


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