New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 54 - PHYSICIAN SERVICES
Subchapter 3 - PROVISION OF SERVICES
Section 10:54-3.2 - Prior authorization

Universal Citation: NJ Admin Code 10:54-3.2

Current through Register Vol. 56, No. 18, September 16, 2024

(a) Prior authorization, as used in this chapter, is the approval granted by the New Jersey Medicaid/NJ FamilyCare program before a service is rendered or an item provided. For additional information about prior and retroactive authorization, see also N.J.A.C. 10:49-6 and 10:54-5 and 7.

(b) Certain services require prior authorization, such as cosmetic surgery, certain psychiatric services and all out-of-State inpatient and outpatient hospital services, except in the conditions listed in (c) below. Services rendered to Medicaid/NJ FamilyCare program beneficiaries enrolled in a Health Maintenance Organization (HMO) may also require authorization by the Health Maintenance Organization (for details, see Managed Health Care Services in N.J.A.C. 10:74).

(c) Prior authorization shall not be required for the following:

1. Hospital covered services to any beneficiary who resides out-of-State at the discretion of the New Jersey Department of Human Services and who has a HSP (Medicaid) case number with either:
i. The first and second digits of 90; or

ii. The third and four digits of 60; or

2. Emergencies and interstate hospital transfers.

3. Any covered service that requires prior authorization as a prerequisite for payment to New Jersey Medicaid/NJ FamilyCare providers also requires prior authorization if it is to be provided and reimbursed by the New Jersey Medicaid/NJ FamilyCare program in any other state.

Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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