Current through Register Vol. 56, No. 18, September 16, 2024
(a) Advanced practice nurses who are certified in the advanced practice category of "Psychiatric/Mental Health" (APN, Psychiatric/Mental Health) are qualified to perform and be reimbursed independently for psychiatric evaluations for the New Jersey Medicaid/NJ FamilyCare fee-for-service program.
1. For each psychiatric therapy patient contact, written documentation shall be developed and maintained to support each medical or remedial therapy, service, activity, or session for which billing is made. The documentation shall consist of the following:
i. The specific services rendered and modality used, such as individual, group, and/or family therapy;
ii. The date services were rendered;
iii. The duration of services provided (1 hour, 1/2 hour);
iv. The signature of the APN, Psychiatric/Mental Health, who rendered the service;
v. The setting in which services were rendered;
vi. A notation of impediments, unusual occurrences or significant deviations from the treatment described in the Plan of Care;
vii. Notations of progress, impediments, treatment, or complications; and
viii. Other relevant information.
(b) Prior authorization for mental health services shall be required when services are rendered in certain settings:
1. Prior authorization for inpatient hospital mental health services is not required.
2. For services provided in nursing facilities and all facilities covered under the Rooming and Boarding House Act of 1979 (RBHA '79) 55:13B-1 et seq., prior authorization shall be required for mental health services exceeding $ 400.00 in payments in any 12-month service year rendered to a Medicaid/NJ FamilyCare beneficiary residing in either a nursing facility of RBHA '79 facility. The request for prior authorization shall be submitted directly to the appropriate Medical Assistance Customer Center (MACC) that serves that nursing or RBHA '79 facility on the "Authorization of Mental Health Services and/or Mental Health Rehabilitation Services (FD-07)" and the "Request for Prior Authorization: Supplemental Information (FD-07A)" forms.
3. Services provided by an APN in an independent clinic, including a mental health clinic or an FQHC shall only be billed by the clinic after prior authorization in accordance with the Independent Clinic Services Manual, 10:66-1.4.
4. In all other settings: prior authorization shall be required for mental health services rendered to a Medicaid/NJ FamilyCare beneficiary (within a 12-month service year commencing with the patient's initial visit) when those services are provided in a setting other than an inpatient hospital, nursing facility or RBHA '79 facility, and when the reimbursement for those services exceeds $ 900.00 to the APN, Psychiatric/Mental Health. The request for prior authorization shall be submitted directly to the Medical Assistance Customer Center (MACC) that serves the county in which the services are rendered. Provider shall use the "Authorization of Mental Health Services and/or Mental Health Rehabilitation Services (FD-07)" form and the form "Request for Prior Authorization: Supplemental Information (FD-07A)" to request prior authorization for these services.
(c) Prior authorization for mental health services may be granted by the New Jersey Medicaid/NJ FamilyCare fee-for-service program for a maximum period of one year, and additional authorizations may be requested. The request for authorization shall include the diagnosis, as set forth, for dates of service before October 1, 2015, in the ICD-9-CM, or for dates of service on or after October 1, 2015, in the ICD-10-CM, the treatment plan and the progress report, in detail. When a request for prior authorization is denied or modified, the APN shall be notified of the reason, in writing, by the fiscal agent.
1. When a patient's authorized treatment plan is changed because of a change in the patient's treatment needs, which results in an increase in service or change in the kind of service, a new authorization or a modification of the existing authorization shall be requested by the APN.
2. Ordinarily only one mental health procedure shall be reimbursed per day for the same beneficiary by the same physician, group of physicians, shared health facility, psychologist or APN, Psychiatric/Mental Health sharing a common record. When circumstances require more than one mental health procedure, the medical necessity for the services shall be documented in the patient's chart, and a determination regarding reimbursement shall be made by the Division on a case-by-case basis.
(d) An APN, Psychiatric/Mental Health providing mental health services shall document those services as described above and at 10:58A-1.4, Recordkeeping.
(e) Advanced practice nurses who are certified in the advanced practice category of "Psychiatric/Mental Health" (APN, Psychiatric/Mental Health) are qualified to perform services and to be reimbursed independently for the treatment of postpartum mental health disorders in women.
1. These services are available to women during pregnancy and/or after a delivery, miscarriage or the termination of a pregnancy. The services shall be billed using the regular mental health service HCPCS located at 10:58A-4.2(n).
2. Treatment for postpartum-related mental health disorders for Medicaid and NJ FamilyCare beneficiaries enrolled in managed care organizations are considered "out-of-plan" and shall be reimbursed under a fee-for-service arrangement.
3. The HCPCS for the treatment for postpartum-related mental health disorders shall be exempt from prior authorization and, as such, shall be excluded from the $ 900.00 threshold contained in 10:58A-2.9(b)4.
(f) Mental health services provided to NJ FamilyCare-Plan D beneficiaries shall not require prior authorization. Mental health services shall be provided to NJ FamilyCare-Plan D beneficiaries under the following limitations:
1. Mental health services provided on an inpatient basis at a psychiatric or mental health services hospital shall be limited to 35 days during a consecutive 365-day span.
2. Mental health services provided in an outpatient hospital shall be limited to 20 visits during a consecutive 365-day span. One inpatient day may be exchanged for two additional days of outpatient services, for a maximum of 70 additional outpatient hospital visits during a consecutive 365-day span.
3. Mental health services provided in a mental health clinic shall be limited to 20 visits during a consecutive 365-day span. Up to a maximum of 10 inpatient days can be exchanged, at the rate of one inpatient for four additional outpatient days, for a total of up to 40 additional outpatient days during a consecutive 365-day span.
