Current through Register Vol. 56, No. 18, September 16, 2024
(a) Under the
Programs, payment for certain services shall require prior authorization except
in an emergency. It is the responsibility of the provider to obtain prior
authorization before furnishing or rendering a service. Specific instructions
are detailed in the appropriate Provider Services chapter.
1. Prior authorization should not be
construed as a guarantee that a person is eligible for the New Jersey Medicaid
or NJ FamilyCare program. At the time the service is to be provided, it is the
provider's responsibility to verify eligibility.
2. "Medical emergency" means a critical
illness or injury status for which prompt medical care may be crucial to saving
life and limb or sparing the beneficiary significant or intractable pain.
Services provided for a medical emergency are exempt from prior authorization.
Any service classified as a medical emergency that would have been subject to
prior authorization had it not been so classified, must be supported by a
practitioner's statement which describes the nature of the emergency, including
relevant clinical information, and must state why the emergency services
rendered were considered to be immediately necessary. To simply state that an
emergency did exist is not sufficient.
3. In addition to services that must be prior
authorized under the previous subsections, a provider may be required to submit
some or all services for prior authorization if in the judgment of the Medicaid
Agent or DMAHS the provider has engaged in conduct which would constitute good
cause for suspension, debarment or disqualification under
10:49-11.1(d).
Prior authorization under this subsection may be imposed prior to a hearing
under the same conditions applicable to suspensions under
10:49-11.1(j),
except that the approval of the Attorney General shall not be
necessary.
(b)
Retroactive authorization may be granted under certain circumstances provided
that the service is a part of continuing beneficiary care and, on the basis of
medical judgment, would have been authorized at the time the service was
rendered. Each case is considered on its own merit. Retroactive authorization
is an exceptional measure granted only under the following unusual
circumstances:
1. "Other coverage" (Medicare,
Third-Party liability, other insurance, etc.) has denied or made only partial
payment of a claim for services or items requiring prior authorization and it
would have been unreasonable to expect the provider to have requested
authorization prior to rendering the service;
2. Retroactive determination of
eligibility;
3. An "administrative
emergency" existed because communication between the provider and the staff of
the New Jersey Medicaid program could not be established (for example, during a
weekend, holiday or evening) and provision of the service should not have been
delayed. This differs from a medical emergency in that the beneficiary's
condition would not be impaired if the service was not provided (see example
below). In such instances, the request for retroactive authorization, including
an explanation of the circumstances, as well as the medical documentation
supporting the services, shall be submitted to the Medical Assistance Customer
Center (MACC) or Central Office, as appropriate, within five calendar days
after the service was provided or initiated. If verbal authorization was
obtained, confirming written documentation shall follow.
Example: A physician orders a Medicaid beneficiary home from
the hospital on a Friday evening. The beneficiary requires an electrical
hospital bed, but the Medical Supplier is unable to contact the Medical
Assistance Customer Center (MACC) to obtain prior authorization. It is
advantageous to the Medicaid program, the hospital and the patient to discharge
the beneficiary and not wait until authorization for the bed is requested on
Monday; or
4. In situations
not covered by (b)1, 2, and 3 above, the New Jersey Medicaid program follows
the doctrine of reasonableness which asks, "Is it reasonable to conclude that
the situation presented warrants waiver of procedural rules?"
