New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 54 - PHYSICIAN SERVICES
Subchapter 1 - GENERAL PROVISIONS
Section 10:54-1.2 - Definitions
The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise.
"APN" means an advanced practice nurse, as that term is defined at 10:58A-1.2.
"Appropriate State agency" means an agency that has a letter of agreement with the New Jersey Medicaid program that includes permission to request medical consultations that are consistent with good medical practice.
"Bundled drug service" means a drug that is marketed or distributed by the manufacturer or distributor as a combined package which includes the cost of the drug product and ancillary services such as, but not limited to, case management services and laboratory testing.
"Certified Nurse Midwife (C.N.M.)" means a registered professional nurse who:
1. Is licensed by the New Jersey State Board of Nursing, in accordance with N.J.A.C. 13:37;
2. Certified by the American College of Nurse Midwives (ACNM) (American College of Nurse Midwives, 818 Connecticut Ave. NW, Washington, DC 20006, 202-728-9860) or the American College of Nurse Midwives Certification Council (ACC) (Certification Council, 8401 Corporate Drive, Landover, MD 20785, 301-459-1321) and evidence of continuing competency as required by the ACNM; and,
3. Maintains current registration as a Certified Nurse Midwife with the New Jersey State Board of Medical Examiners, in accordance with N.J.A.C. 13:35-2A.
"Concurrent care" means care rendered to a patient by more than one physician/practitioner where the dictates of medical necessity require that services of one or more clinicians in addition to the attending clinician, so that appropriate and needed care may be provided to the patient.
"Consultation" means the professional evaluation of a patient by a qualified specialist recognized as such by this Program, that is requested by the attending physician or an appropriate State agency.
"Critical portion" means that portion of a medical/surgical procedure or service that must be performed by a physician with appropriate credentials and skills in the specialty relating to the procedure or service in order to minimize potential patient risk for severe injury, permanent disability, or death.
"Early and periodic screening, diagnosis and treatment (EPSDT)" means a preventive and comprehensive health program for Medicaid/NJ FamilyCare program beneficiaries under 21 years of age, including the assessment of an individual's health care needs through initial and periodic examinations (screenings), the provision of health education and guidance and the assurance that any identified health problems are diagnosed and treated at the earliest possible time.
"Federal Funds Participation Upper Limit (FFPUL)" means the maximum allowable cost or "MAC price" as defined by the Centers for Medicare and Medicaid Services (CMS).
"HealthStart" means a program of health services provided to pregnant women, infants and small children, as defined in 10:49-1.4.
"HealthStart Maternity Care Services" means a comprehensive package of maternity care services which includes two components, Medical Maternity Care and Health Support Services, and is provided in accordance with N.J.A.C. 10:54-6.
"HealthStart Maternity (Comprehensive) Care Services Provider" means a physician, a certified nurse midwife, a group of physicians, a group of certified nurse midwives (or mixed group of physicians and CNMs), a hospital, an independent clinic approved by the New Jersey State Department of Health and Senior Services and the New Jersey Medicaid program which provides HealthStart Maternity (Comprehensive) Care services either directly, or indirectly through linkage with other practitioners, in independent clinics, in hospital outpatient departments, or in physicians' offices.
"HealthStart Pediatric Care Provider" means a physician/practitioner or group of physicians/practitioners, an outpatient hospital department, or an independent clinic (including a local health department), meeting the New Jersey State Department of Health and Senior Services Improved Program Outcomes and/or the Child Health Conference Criteria, and approved by the New Jersey State Department of Health and Senior Services and the New Jersey Medicaid program to provide a comprehensive package of pediatric care services.
"Immediately available" means that the supervising physician is in the facility and able to respond and proceed immediately to the procedure or service site.
"Key portion" means that portion of a medical/surgical procedure or service as determined by the participating physician that is critical to ensure an optimal result.
"Labeler code" means a five-digit numeric code assigned by the Food and Drug Administration, which identifies the firm that manufactures or distributes a specific drug. This code is the first segment of the National Drug Code.
"Medicaid/NJ FamilyCare participating physician (participating physician)" means a physician, other than a resident, who is a participating provider of the New Jersey Medicaid/NJ Family Care program in its fee-for-service system who also directs, supervises and/or involves residents in the care of his or her patients who are Medicaid/NJ FamilyCare beneficiaries.
"National Drug Code (NDC)" - means an 11-digit number that identifies a drug product. The first five digits represent the labeler code identifying the drug manufacturer, the next four digits identify the drug product and the last two digits identify the package size.
"Nurse midwifery services" means those services provided by certified nurse midwives (C.N.M.) within the scope of practice of certified nurse midwifery in the rules and regulations of the Board of Medical Examiners of the State of New Jersey in N.J.A.C. 10:35-2A which are:
1. To manage the care of essentially normal women during the maternity cycle;
2. To provide care to essentially normal newborns at the time of delivery; and
3. To provide well-woman health care (see definition in 10:54-1.2) .
"Other permitted and qualified health care professionals" means health care professionals licensed or certified to practice in the State of New Jersey who are not physicians.
"Personal direction" means the supervision by a physician of a service performed by another licensed physician or licensed practitioner. The use of this term does not apply to the supervision of other health care personnel unless otherwise specified.
"Physician" means a doctor of medicine (M.D.), osteopathy (D.O.) or podiatric medicine licensed to practice medicine and surgery by the New Jersey State Board of Medical Examiners, or similarly licensed by comparable agencies of the state in which he or she practices.
"Physician services" means those services provided within the scope of practice of a doctor of medicine (M.D.) or osteopathy (D.O.) as defined by the laws of the State of New Jersey, or if in practice in another state by the laws of that state, and the services which are performed by or under the personal direction of the physician. It includes physician services furnished in the office, the patient's home, a hospital, a nursing facility and/or other settings. (For rules regarding personal direction, see 10:54-2.2.)
"Practitioner" refers to a licensed advanced practice nurse (APN), a certified nurse midwife, a dentist, a chiropractor, a podiatrist, or a psychologist, as defined by this rule. Practitioners are responsible for examining, diagnosing, treating and counseling patients, and ordering medications, within the specific scope of their practice, as defined by their specific Board. On occasion, this chapter defines rules and procedures which are provided by physicians and other practitioners; in these instances, the term "physician/practitioner" is used. The term practitioner does not refer to and is not inclusive of physicians (who are defined only as M.D. and DOs).
"Prior authorization" means the approval by the New Jersey Medicaid program before a service is rendered or an item provided. Services which require prior authorization are specified in this chapter (also see N.J.A.C. 10:49-6).
"Product code" means a four-digit numeric code, assigned by a firm that manufactures and distributes a drug, which identifies a specific strength, dosage form and formulation of the drug. This code is the second segment of the National Drug Code.
"Resident (which includes "intern" and "fellow")" means:
1. An individual who participates in a State-approved residency training program in a teaching setting in medicine, osteopathy, dentistry, or podiatry; or
2. A physician who is not in an approved residency training program, but who is authorized to practice only in a hospital, for example, individuals with temporary or restricted licenses, or unlicensed graduates of foreign medical schools.
"Teaching setting" means any hospital department, skilled nursing facility, patient's home, physician's office or satellite clinic and other areas where medical procedures and health care services are performed.
"Transfer" means the relinquishing of responsibility for the continuing care of the patient by one physician or practitioner and the assumption of such responsibility by another physician or practitioner.
"Unit of measure" or "UOM" means a value of measurement used to define a drug product. Acceptable UOM codes are: F2 (international measure), GM (gram), ML (milliliter) or UN (unit/each).
"Well-woman health care" means those preventive and referral services which may include family planning, reproductive health care counseling, and reproductive system's health care screening.
