New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 52 - HOSPITAL SERVICES MANUAL
Subchapter 1 - GENERAL PROVISIONS
Section 10:52-1.6 - Covered services (inpatient and outpatient)
Current through Register Vol. 56, No. 18, September 16, 2024
(a) The Division will cover those inpatient services ordinarily furnished by an approved hospital maintained for the treatment and care of patients, and provided to any Medicaid/NJ FamilyCare fee-for-service beneficiary, for whom professionally developed criteria and standards of care were used to determine that the beneficiary warranted an appropriate hospital level of care for a given diagnosis or problem.
(b) The Division shall pay for eligible ancillary services provided during a non-covered period in an acute care hospital for the following situations:
(c) Medically necessary inpatient psychiatric services provided in an approved private psychiatric hospital shall be covered by the Division for any Medicaid/NJ FamilyCare beneficiary age 65 or older; or for any other Medicaid/NJ FamilyCare-Children's Program beneficiary before reaching the age of 21, except that a Medicaid/NJ FamilyCare beneficiary receiving the services immediately before attaining age 21 may continue to receive the services until they are no longer needed or until the beneficiary reaches age 22, whichever occurs first.
(d) Outpatient services include those medically necessary items or services (preventive, diagnostic, therapeutic, rehabilitative, or palliative) provided to an outpatient, by or under the direction of a physician or dentist, except for the supervision of certified nurse midwife services, pursuant to the rules of the Division, State and applicable Federal regulations, including those services listed below:
(e) Transfer from one outpatient facility to another outpatient facility, or a change from an outpatient facility to a private practitioner's care is allowable; however, effort shall be made to avoid duplication of diagnostic tests or services.
(f) For policies and procedures for Ambulatory Surgical Centers, see 10:52-2.1 and N.J.A.C. 10:66-5, Independent Clinic Services.
(g) For policies and procedures for hospital-affiliated home health agencies, see 10:52-2.6 and N.J.A.C. 10:60, Home Care Services.
(h) For policies and procedures for Medical Day Care Centers (Hospital Affiliated), see 10:52-2.7 and N.J.A.C. 8:86, Adult Day Health Services.
(i) For policies and procedures for HealthStart (Comprehensive Maternity and Pediatric Care Services), see N.J.A.C. 10:52-3. For policies and procedures for Early and Periodic Screening Diagnostic and Treatment, see 10:52-2.4.
(j) For other policies and procedures related to specific services, both inpatient and outpatient, see N.J.A.C. 10:52-2.