Current through Register Vol. 56, No. 18, September 16, 2024
(a) Providers shall
complete a Provider Application and sign a Provider Agreement (see Appendix,
N.J.A.C. 10:49) or a specialized agreement, and submit such other information
or documentation, including, but not limited to, social security number and
date of birth, as the program may require, depending on the nature of the
services provided.
1. Policies and rules
pertaining to shared health care facilities are outlined in N.J.A.C.
10:49-4.
2. All practitioners
participating in a group practice shall personally sign both the group
application and the provider agreement if individual documents, or shall sign a
single signature sheet if both documents are contained in a single
packet.
(b) All
providers shall be required to complete Form CMS-1513, Ownership and Control
Interest Disclosure Statement (see Appendix, Form #10) at the time of
application or reapplication. In addition, at the time of application or
reapplication, all professional practices must certify that they comply with
all applicable State statutes and rules governing their ownership and direction
(see Appendix, Form #12). Out-of-State providers shall certify that they comply
with the requirements of the state in which the facility is located. Providers
prior to 1973 were not required to utilize provider agreement forms; however,
they shall comply with all applicable State and Federal Title XIX and Title XXI
laws, policies, rules and regulations.
1. As a
condition of continued participation in the New Jersey Medicaid and NJ
FamilyCare programs, a provider may, from time to time, be required to:
i. Complete a provider reenrollment
application form and sign a provider participation agreement; and/or
ii. Complete a Form CMS-1513, Ownership and
Control Interest Disclosure Statement.
2. The New Jersey Medicaid program or NJ
FamilyCare program shall terminate any existing agreement or contract if the
provider fails to disclose information required by (b)1ii above.
3. Enrollment documentation requested by the
New Jersey Medicaid or NJ FamilyCare program shall be furnished within 35
calendar days of the date of the written request.
(c) An out-of-State provider shall have a
current, approved provider agreement with the New Jersey Medicaid or NJ
FamilyCare program and hold a current, valid certification and/or license from
the appropriate agency under the laws of the respective state in which the
provider is located.
(d) A provider
application may be requested from the fiscal agent of the New Jersey Medicaid
and NJ FamilyCare program. An appropriate program enrollment package will be
mailed to the requesting provider. The enrollment application must be completed
in full and returned to the fiscal agent, along with all the necessary
attachments.
1. The applicant's eligibility to
participate in the New Jersey Medicaid and NJ FamilyCare program will be
confirmed in writing. A provider number will be assigned and returned to the
applicant along with the appropriate program Provider Manual.
2. If the application is denied, the
applicant will receive a notification which explains the decision to deny and
the applicant's right to appeal the decision (see N.J.A.C. 10:49-10
).
3. If the application is denied,
the applicant cannot resubmit a provider enrollment application for a period of
one year from the date of the denial.
(e) If a provider is found to be currently
enrolled, but has been inactive for at least two (2) years, the applicant will
be required to complete a new application. If the application is approved, the
provider's existing record on the Provider Master File will be
reactivated.
(f) The New Jersey
Medicaid program or NJ FamilyCare program may refuse to enter into or to renew
a provider participation agreement with any applicant or provider who has been
suspended, debarred, disqualified, or excluded by the Title XIX or Title XXI
program of another state. The program may terminate any existing agreement with
a provider, if good cause for exclusion of the provider from program
participation exists under any of the provisions of
10:49-11.1(d)1
through 27.
(g) The New Jersey
Medicaid program or NJ FamilyCare program shall not enter into a provider
participation agreement with an applicant who has been suspended or excluded
from participation in the delivery of medical care or services under Medicare
(Title XVIII), Medicaid (Title XIX), or the Social Services Block Grant Act
(Title XX) of the Federal Social Security Act, by the Secretary of the United
States Department of Health and Human Services.
(h) The Division may place a moratorium on
the enrollment of new providers for particular provider types and/or in
particular geographic areas if it determines that beneficiary access to
services would not be adversely affected, and:
1. That the number of providers already
enrolled is sufficient to adequately serve beneficiaries;
2. That a moratorium is necessary in order to
address fraud and/or abuse; or
3.
That other compelling reasons warrant a moratorium.
(i) All entities (as defined in (k) below)
that receive or make annual Medicaid/NJ FamilyCare payments, under Title XIX of
the Social Security Act, of at least $ 5,000,000 must, as a condition of
receiving those payments, fully conform to the provisions of Section 6032 of
the Deficit Reduction Act of 2005,
42 U.S.C. §
1396a(a)(68), incorporated
herein by reference. If an entity furnishes items or services at more than a
single location or under more than one contractual or other payment
arrangement, the provisions of
42 U.S.C. §
1396a(a)(68) and of this
subsection and (j) and (k) below shall apply to the entity and to each of its
components and locations if the aggregate payments to or from that entity meet
the $ 5,000,000 annual threshold, regardless of whether the entity submits
claims for payments using one or more provider identification or tax
identification numbers. Such an entity shall:
1. Establish written policies for all
employees of the entity (including management), and of any contractor or agent
of the entity, that provide detailed information about the Federal False Claims
Act established under sections 3729 through 3733 of Title 31, United States
Code (
31
U.S.C. §§
3729 through
3733
), administrative remedies for false claims and statements established under
chapter 38 of Title 31, United States Code (
31
U.S.C. §§
3801 et seq.), any State
laws pertaining to civil or criminal penalties for false claims and statements,
and whistleblower protections under such laws, with respect to the role of such
laws in preventing and detecting fraud, waste, and abuse in Federal health care
programs as defined in
42
U.S.C. §
1320a- 7b(f);
2. Include as part of such written policies,
detailed provisions regarding the entity's policies and procedures for
detecting and preventing fraud, waste and abuse; and
3. Include in any employee handbook for the
entity a specific discussion of the laws described in (i)1 above, the rights of
employees to be protected as whistleblowers, and the entity's policies and
procedures for detecting and preventing fraud, waste and abuse.
(j) The following provisions apply
to entities regulated under (i) above:
1. The
written policies established by the entity that are required under (i) above,
including the entity's policies and procedures for detecting and preventing
fraud, waste and abuse, may be on paper or in electronic form. There is no
requirement that an employee handbook be created by the entity, if none already
exists.
2. The entity's policies
shall be disseminated and shall be readily available to all employees and
managers of the entity and to the entity's contractors and agents. The entity
also shall:
i. Require the entity's
contractors and agents to comply with these policies; and
ii. Request that the entity's contractors and
agents disseminate and make these policies readily available to the employees
and managers of the contractors and agents.
3. The requirements of Section 6032 of the
Deficit Reduction Act of 2005 are deemed to be incorporated into all current
and future provider participation agreements by virtue of existing language in
all such agreements that providers shall comply with all applicable Federal
laws.
(k) In (i) and (j)
above, the following definitions apply:
1.
"Annual" or "annually," for purposes of determining whether an entity meets the
$ 5,000,000 threshold, means during the previous full Federal fiscal year
(FFY). As an example, an entity will have met the $ 5,000,000 threshold as of
January 1, 2008, if it received or made Title XIX payments in that amount in
FFY 2007, which runs from October 1, 2006 through September 30, 2007.
2. "Contractor" or "agent" includes any
contractor, subcontractor, agent, or other person which or who, on behalf of
the entity, furnishes, or otherwise authorizes the furnishing of, Medicaid
health care items or services, performs billing or coding functions, or is
involved in monitoring of health care provided by the entity.
3. "Employee" includes any officer or
employee of the entity.
4. "Entity"
includes, but shall not be limited to, a governmental agency or facility, or an
organization, unit, corporation, partnership, or other business arrangement
(including any Medicaid managed care organization irrespective of the form of
business structure or arrangement by which it exists), whether for-profit or
not-for-profit, which receives or makes payments, under a State Plan approved
under Title XIX or under any waiver of such plan, totaling at least $ 5,000,000
annually. A governmental component providing Medicaid health care items or
services for which Medicaid payments are made would qualify as an entity (for
example, a state, county or municipal health care facility, or a school
district providing school-based health services). A government agency which
merely administers all or part of the Medicaid program (for example, managing
the claims processing system or determining beneficiary eligibility), shall not
be considered an entity.
