New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 55 - PROSTHETIC AND ORTHOTIC SERVICES
Subchapter 1 - GENERAL PROVISIONS
Section 10:55-1.8 - Reimbursement for prosthetic and orthotic appliances
Current through Register Vol. 56, No. 18, September 16, 2024
(a) This section outlines the Program's policy of reimbursement for prosthetic and orthotic services and specifies the procedure for submitting a claim to request payment.
(b) Providers of prosthetic and orthotic appliances shall be reimbursed on a fee-for-service basis not to exceed the maximum fee schedule allowance in N.J.A.C. 10:55-2. Generally, the reimbursement policy for the purchase or repair of any appliance or footwear is in accordance with the lower of the Medicaid and NJ FamilyCare maximum fee allowance or the provider's usual and customary charge. In certain instances, a maximum fee allowance cannot easily be established because of the variety of items that can be provided under the same HCPCS. In those instances, the notation "B.R.," by report, is listed in the fee schedule. In those cases, Medicaid and NJ FamilyCare fee-for-service reimbursement will be established by the Division after a review of the additional material submitted by the provider.
(c) To request reimbursement for a service provided, the provider shall submit a CMS-1500 claim form using HCPCS procedure code(s) to identify the item or service provided. Instructions for submitting claims for payment are provided in the Fiscal Agent Billing Supplement following this chapter, N.J.A.C. 10:55.
(d) The provider shall verify beneficiary eligibility in accordance with N.J.A.C. 10:49-2. Payment shall not be made for services provided to an ineligible individual, even if the service was prior authorized, except under the following circumstances:
(e) For any Medicaid or NJ FamilyCare beneficiary who is covered under Medicare, responsibility for payments by the New Jersey Medicaid or NJ FamilyCare program for non-hospital based, Medicare Part B services shall be limited to the unsatisfied deductible and/or coinsurance amount to the extent that the combined total of these payments does not exceed the maximum fee allowance for the same or similar service provided by the Medicaid or NJ FamilyCare program in the absence of other coverage. This limitation shall apply for claims with dates of service on or after July 20, 1998.