New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 54 - PHYSICIAN SERVICES
Subchapter 7 - PHYSICIAN SERVICES PROVIDED IN HOSPITALS AND NURSING FACILITIES
Section 10:54-7.9 - Psychiatric services; inpatient services
Universal Citation: NJ Admin Code 10:54-7.9
Current through Register Vol. 56, No. 18, September 16, 2024
(a) The New Jersey Medicaid/NJ FamilyCare program recognizes as a covered service, a medically necessary inpatient service that is provided to a Medicaid/NJ FamilyCare program beneficiary in an approved private psychiatric hospital or the psychiatric section of an approved general hospital with the following limitation. (See 10:49-2.3(b) for the Medically Needy program and the Hospital Services Chapter, 10:52-1.15, 2.9 and 4.2 for policies and procedures for hospital outpatient psychiatric services).
1. Reimbursement for either a psychiatric consultation, individual psychotherapy, family or group psychotherapy, or shock therapy shall be considered as inclusive for all psychiatric services performed on that day.
(b) When hospitalization is out-of-State, prior authorization is required for elective psychiatric hospitalizations but not for emergency hospitalizations.
1. When prior authorization is required, the request shall be submitted from the referring physician to the Office of Utilization Management, Mental Health Services, Division of Medical Assistance and Health Services, Mail Code #18, PO Box 712, Trenton, New Jersey 08625-9712, attached to the claim form.
2. The request shall include the following:
i. The diagnosis, as set forth in the Diagnostic and Statistical Manual of the American Psychiatric Association (Latest edition);
ii. A brief history and present clinical status;
iii. A treatment proposal;
iv. A summary of previous treatment and hospitalizations;
v. The anticipated length of hospitalization; and
vi. Evidence that suitable placement within New Jersey and/or within a reasonable distance of the patient's home is not available.
3. A request for retroactive authorization will be considered only when the request has been delayed by circumstances beyond the control of the hospital.
4. When the request for authorization is approved, both the request letter and the provider's claim form will be returned to the provider. When a claim is submitted for reimbursement, the provider must attach the request for approval and the approval to the UB-92 (CMS-1450), the hospital claim form.
5. If request for prior authorization is denied, the physician and/or hospital shall be notified of the reason, in writing, by the Central Office, Mental Health Services Unit, Office of Utilization Management, Division of Medical Assistance and Health Services, PO Box 712, Trenton, New Jersey 08625-0712.
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