New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 59 - MEDICAL SUPPLIER MANUAL
Subchapter 1 - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT
Section 10:59-1.6 - Prior authorization (PA)
Current through Register Vol. 56, No. 18, September 16, 2024
(a) Prior authorizations issued by the Medicaid/NJ FamilyCare program are intended to reflect decisions regarding medical necessity and purchase/rental options. The issuance of prior authorization is not a guarantee of Medicaid/NJ FamilyCare payment. Payment is determined based on the satisfaction of all applicable claims processing edits established by the Division of Medical assistance and Health Services. Payment is made, based on the satisfaction of the conditions of this chapter.
(b) When a procedure code requires PA, the provider shall first obtain authorization from the appropriate Medical Assistance Customer Center (MACC). (See a list of MACCs at N.J.A.C. 10:49, Appendix Form #17.) The Division will provide written notification of the disposition of the PA request.
(c) When the purchase price of a DME item is $ 300.00 or more, prior authorization shall be required for purchase or rental, as described in Appendix A, incorporated herein by reference, except as described in (e) below.
(d) When the purchase price for medical supplies is $ 100.00 or more, prior authorization is required as described in Appendix A, incorporated herein by reference.
(e) Certain DME items and medical supplies require prior authorization regardless of purchase price, indicated in Appendix A, incorporated herein by reference.
(f) All medical supplies and DME items purchased or rented for use by nursing facility residents require prior authorization. Items included in the NF's per diem are not covered (see 10:59-1.4) .
(g) Medicare/Medicaid claims do not require prior authorization (See 10:59-1.9) .