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)

Universal Citation: NJ Admin Code 10:59-1.6

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.

1. An exception is provided for orthopedic footwear not attached to a bar or brace. In these situations, the PA shall be submitted to the Podiatric Consultant in the Medicaid/NJ FamilyCare Central Office (See N.J.A.C. 10:57).

2. Urgent requests may be made by telephone, but the provider shall submit the written PA request within five calendar days (see 10:49-6.1) .

3. For procedure codes L3000 through L3003, L3010, L3020, L3030, L3040, L3050, L3060, L3070, L3080 and L3090, up to four units of orthotics may be provided by the same provider to the same beneficiary during a 12-month period.

4. For procedure codes L3201 through L3207, L3215 through L3217, L3219, L3221 and L3222, up to two units may be provided by the same provider to the same beneficiary during a 12-month period.

5. For procedure code L3260, up to four units may be provided by the same provider to the same beneficiary during a 12-month period.

6. HCPCS procedure codes L3001, L3002, L3003, L3010, L3020, L3030, L3040, L3050, L3060, L3070, L3080, L3090, L3215 through L3223, and L3201 through L3207 do not require prior authorization for the following diagnosis codes: 343.0 to 343.9, 707.0 to 707.9, 711.0 to 712.9, 715.0 to 722.9, 724.0 to 728.9, 730.0 to 737.9, 754.2 to 754.79, 755.0 to 755.39, 755.6 to 755.69, 756.1 to 756.19, 756.8 to 756.89, and 892.0 to 897.7.

(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) .

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