New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 56 - MANUAL FOR DENTAL SERVICES
Subchapter 1 - DENTAL SERVICES; GENERAL PROVISIONS
Section 10:56-1.2 - Definitions

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise.

"Ambulatory Surgical Center (ASC)" means any distinct entity that: operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization; has an agreement with the Centers for Medicare & Medicaid Services (CMS) as a Medicare participating provider for ambulatory surgical services; is licensed, if required, by the New Jersey State Department of Health and Senior Services, or is similarly licensed by a comparable agency of the state in which the facility is located; and meets the enrollment and participation requirements of the New Jersey Medicaid/NJ FamilyCare programs as indicated at 10:49-3.2, and 10:66-1.3.

"Attending dentist" means one who assumes the primary and continuing dental care of the beneficiary. The services of only one attending dentist will be recognized at a given time.

"Clinical laboratory services" means professional and technical laboratory services ordered by a dentist within the scope of practice as defined by the laws of the state in which the dentist practices and, which are provided by a laboratory.

"Concurrent care" means that type of service rendered to a beneficiary by practitioners where the dictates of dental necessity require the services of dentists of different specialties in addition to the attending dentist so that needed care can be provided.

"Consultation" means that service rendered by a qualified dentist upon request of another practitioner in order to evaluate through personal examination of the beneficiary, history, physical findings and other ancillary means, the nature and progress of a dental or related disease, illness, or condition and/or to establish or confirm a diagnosis, and/or to determine the prognosis, and/or to suggest treatment. A consultation should not be confused with "referral for treatment" when one practitioner refers a beneficiary to another practitioner for treatment, either specific or general, for example, "Endodontic treatment on teeth No.'s 3 and 5"; or "Extract teeth No.'s 7, 8, 9, and 10"; or "Extract tooth or teeth causing pain."

"Dental Services" means any diagnostic, preventive, or corrective procedures administered by or under the direct personal supervision of a dentist in the practice of the practitioner's profession. Such services include treatment of the teeth, associated structures of the oral cavity and contiguous tissues, and the treatment of disease, injury, or impairment which may affect the oral or general health of the individual. Such services shall maintain a high standard for quality and shall be within the reasonable limits of those services which are customarily available, accepted by, and provided to most persons in the community within the limitations, and exclusions hereinafter specified.

"Direct personal supervision" means the actual physical presence of the dentist on the premises.

"Division" means the Division of Medical Assistance and Health Services.

"Emergency" means a specific condition of the oral cavity and/or contiguous tissues which causes severe and/or intractable pain and/or could compromise the life, health, or safety of the beneficiary unless treated immediately. For example:

1. Pain or acute infection from a restorable or a non-restorable tooth;

2. Pain resulting from injuries to the oral cavity and related structures;

3. Extensive, abnormal bleeding;

4. Fractures of the maxilla or mandible or related structures or dislocation of the mandible.

"Non-routine dental service" means any dental service that requires prior authorization by a Medicaid/NJ FamilyCare dental consultant in order to be reimbursed by the New Jersey Medicaid/NJ FamilyCare program.

"Nursing facility" means a long-term care facility or an intermediate care facility for the mentally retarded (ICF/MR).

"Participating dentist" means any dentist licensed to and currently registered to practice dentistry by the licensing agency of the State where the dental services are rendered, who accepts the promulgated requirements of the New Jersey Division of Medical Assistance and Health Services, and signs a provider agreement with the Division.

"Program" means the New Jersey/NJ FamilyCare program.

"Prior authorization" means approval by a dental consultant to the New Jersey Medicaid/NJ FamilyCare program before a service is rendered.

"Referral" means the directing of the beneficiary from one practitioner to another for diagnosis and/or treatment.

"Routine dental service" means any dental service that is reimbursable by the New Jersey Medicaid/NJ FamilyCare program without authorization by a Medicaid/NJ FamilyCare dental consultant.

"Specialist" means one who is licensed to practice dentistry in the state where treatment is rendered, who limits his or her practice solely to his or her specialty, which is recognized by the American Dental Association and is registered as such with the licensing agency in the state where the treatment is rendered.

"Transfer" means the relinquishing of responsibility for the continuing care of the beneficiary by one dentist and the assumption of such responsibility by another dentist.