New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 62 - VISION CARE SERVICES MANUAL
Subchapter 2 - OPTICAL APPLIANCES AND SERVICES
Section 10:62-2.12 - Reimbursement policy
Current through Register Vol. 56, No. 18, September 16, 2024
(a) Instructions for submitting claims for payment of optical appliances are provided in the Fiscal Agent Billing Supplement.
(b) Optical appliances must be identified by means of procedure codes, utilizing the CMS Healthcare Common Procedure Coding System (HCPCS). The codes and maximum fee allowance schedule are listed in N.J.A.C. 10:62-3.
(c) The reimbursement policy of the New Jersey Medicaid/NJ FamilyCare fee-for-service programs provides for payment to the provider of the actual invoice cost of the optical appliance plus a dispensing fee. Providers are requested to indicate the actual invoice cost of the material when submitting a claim. Actual invoice cost is defined as the net amount paid by the provider, reflecting all discounts or special purchase agreements. The service (dispensing) fee, to which the provider is entitled, should be indicated as a separate item.
(d) The maximum allowable reimbursement for frames is not to exceed an allowance determined to be reasonable by the Commissioner, Department of Human Services. However, providers shall only bill the New Jersey Medicaid/NJ FamilyCare fee-for-service programs for the actual invoice cost of the frame when submitting a claim for payment. Actual invoice cost is defined as the net amount paid by the provider, reflecting all discounts or special purchase agreements. Frames are reimbursable only if they meet the criteria listed in N.J.A.C. 10:62-2.7.
(e) Optical appliances are reimbursable under the New Jersey Medicaid/NJ FamilyCare fee-for-service programs only when prescribed by a provider of professional eye services described in N.J.A.C. 10:62-1.3.
(f) Non-physician services and equipment/supplies furnished to hospital inpatients by outside providers shall not be billed directly to the New Jersey Medicaid/NJ FamilyCare fee-for-service programs. Providers shall submit a bill/invoice to the hospital for payment.
(g) The cost of intraocular lenses is reimbursable to hospitals or ambulatory surgical centers where the surgery is performed.
(h) Reimbursement by the New Jersey Medicaid/NJ FamilyCare fee-for-service programs shall be made for covered services provided to eligible beneficiaries only.
