New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 66 - INDEPENDENT CLINIC SERVICES
Subchapter 1 - GENERAL PROVISIONS
Section 10:66-1.5 - Basis for reimbursement
Universal Citation: NJ Admin Code 10:66-1.5
Current through Register Vol. 56, No. 18, September 16, 2024
(a) Except as indicated at (c) through (e) below, reimbursement to independent clinics is in accordance with the maximum fee schedule indicated at N.J.A.C. 10:66-6.2 and is based on the same fees, conditions, and definitions for corresponding services governing the reimbursement of Medicaid/NJ FamilyCare fee-for-service-participating practitioners in "private" (independent) practice. Reimbursement is made directly to the clinic.
1. An independent
clinic shall charge for services to all patients, except as provided by
legislation. No charge will be made directly to the Medicaid/NJ FamilyCare
fee-for-service beneficiary, and the charge to the New Jersey Medicaid/NJ
FamilyCare fee-for-service program may not exceed the charge by the clinic for
identical services to other groups or individuals in the community.
(b) The HCPCS procedure code system, N.J.A.C. 10:66-6, refers to procedure codes and maximum fee allowances corresponding to Medicaid/NJ FamilyCare fee-for-service-reimbursable services. An independent clinic may claim reimbursement for only those HCPCS procedure codes that correspond to the allowable services included in the clinic's provider enrollment approval letter, as indicated at N.J.A.C. 10:66-1.3(a).
1. If a HCPCS procedure code(s), approved for
use by a specific clinic, is assigned both a specialist and non-specialist
maximum fee allowance, the amount of the reimbursement will be based upon the
status (specialist or non-specialist) of the individual practitioner who
actually provided the billed service. To identify this practitioner, enter the
Medicaid/NJ FamilyCare fee-for-service Provider Services Number and the
National Provider Identifier in the appropriate section of the claim, as
indicated in the Fiscal Agent Billing Supplement, N.J.A.C. 10:66
Appendix.
(c) The basis for reimbursement of services provided in an ambulatory surgical center (ASC) is as follows:
1. Reimbursement shall be made
for services rendered by both the ASC facility and the attending physician, if
the physician is not reimbursed for surgical/medical services by the
facility.
2. For facility
reimbursement, surgical procedures performed in an ASC are separated into a
classification system as specified by CMS and published in the Federal Register
in accordance with
42 CFR
416.167 through
416.179,
the Federal regulations governing payment for ASC services.
i. A single payment is made to an ASC which
encompasses all facility services furnished by the ASC in connection with a
covered procedure performed on a patient in a single operative
session.
ii. If more than one
covered surgical procedure is performed on a patient during a single operative
session, payment is limited to two procedures, provided that the two procedures
are performed at separate operative body sites.
(1) Full payment shall be made for the
procedure with the highest Medicaid or NJ FamilyCare fee-for-service
reimbursement allowance. Payment for the other procedure shall be at 50 percent
of the applicable reimbursement allowance for that procedure. Total
reimbursement may not exceed 150 percent of the primary procedure
allowance.
iii. The ASC
facility payment for all procedures in each group is established at a single
rate, as follows:
| Group | Maximum Fee Allowance |
| 1 | $ 195.00 |
| 2 | $ 261.00 |
| 3 | $ 300.00 |
| 4 | $ 369.00 |
| 5 | $ 421.00 |
| 6 | $ 541.00 |
| 7 | $ 585.00 |
| 8 | $ 627.00 |
| 9 | $ 794.00 |
Note: Should the Centers for Medicare & Medicaid Services (CMS) amend the group designation for any procedure(s), the maximum fee allowance for the newly designated group shall apply and shall not be construed as a fee increase/decrease to the affected procedure(s).
3. Physician reimbursement shall
be in accordance with the New Jersey Medicaid/NJ FamilyCare fee-for-service
programs' Physician Maximum Fee Allowance for specialist and non-specialist,
N.J.A.C. 10:54, and the following:
i. When
submitting a claim, the physician performing the surgical procedure shall use
the applicable claim form, billing the New Jersey Medicaid/NJ FamilyCare
fee-for-service program either as an individual provider or as a member of a
physician's group.
ii. A physician
on salary for administrative duties (such as a medical director) shall be
permitted to submit claims for surgical/medical services performed.
Administrative duties shall be considered a direct cost of the facility and
shall be included in the clinic payment.
(d) The basis for reimbursement for services provided in an FQHC for periods beginning January 1, 2001 shall be as follows:
1. Effective with services performed on or
after January 1, 2001 and for each year thereafter, Medicaid payments to the
FQHCs shall be based on prospective payment rates, as determined in accordance
with this rule, and shall be used solely to reimburse for encounters.
i. PPS encounter rates effective January 1,
2001 through June 30, 2001 shall be calculated based on the FY 1999 and FY 2000
cost reports. The FY 1999 cost reports shall include individual FQHC fiscal
year cost reports with individual year-end dates ranging from June 1, 1999 to
May 31, 2000. The FY 2000 cost reports shall include individual FQHC fiscal
year cost reports with individual year-end dates ranging from June 1, 2000 to
May 31, 2001. The calculation of the PPS encounter payment rates to be used to
reimburse FQHC services performed on or after January 1, 2001 shall be based on
the following:
(1) Interim PPS encounter
rates for services provided from January 1, 2001 to June 30, 2001 shall be
calculated using the encounter rate from the most recent final cost report
settlement, derived by dividing the final Medicaid settled costs by the number
of final settled encounters, adjusted for a change in scope of services (in
accordance with (e)1vi(1)) and inflation using the percentage increase in the
Medicare Economic Index (MEI) (defined in section 1842(i)(3) of the Social
Security Act) applicable to primary care services (as defined in section
1842(i)(4)) furnished through December 31, 2000.
(2) The final PPS encounter rate for services
provided from January 1, 2001 to June 30, 2001 shall be calculated by adding
the final settled Medicaid costs of the FY 1999 and FY 2000 cost reports
together and dividing the total by the number of final settled encounters
provided to Medicaid beneficiaries during the FY 1999 and FY 2000 fiscal years,
adjusted for a change in scope of services (in accordance with (e)1vi(1)) and
inflation using the percentage increase in the MEI (defined in section
1842(i)(3) of the Social Security Act) applicable to primary care services (as
defined in section 1842(i)(4)) furnished through December 31, 2000. The final
settled Medicaid costs for the FY 1999 and FY 2000 cost reports shall be
calculated with the administrative and productivity screens and overall
Medicaid limit per encounter in accordance with the rule adopted July 15, 1996
(10:66-1.5, subchapter 4 and
Appendix).
(3) A financial
transaction will be processed through the Medicaid fiscal agent for the
difference between the interim and final PPS encounter rate for services
provided to Medicaid beneficiaries that were reimbursed at the interim
encounter rate. For FQHC obligations that are not paid within 30 days from the
date the recovery is initiated, interest shall be assessed in accordance with
30:4D-17(e), (f)
and 31:1-1(a).
(4) The alternative methodology to calculate
the final PPS encounter rate for services provided from January 1, 2001 to June
30, 2001 is as follows: the greater of the FY 1999 or FY 2000 encounter rates
adjusted for a change in scope of services (in accordance with (e)1vi(1) below)
and inflation using the percentage increase in the MEI (defined in section
1842(i)(3) of the Social Security Act) applicable to primary care services (as
defined in section 1842(i)(4)) furnished through December 31, 2000. The final
settled Medicaid costs of the FY 1999 and FY 2000 cost reports shall be
calculated with the administrative and productivity screens and overall
Medicaid limit per encounter in accordance with the rules adopted July 15, 1996
(N.J.A.C. 10:66-1.5, 10:66-4 and 10:66-4 Appendix A). Paragraphs (e)1i(1) and
(3) above shall be followed under the alternative methodology. In order to
qualify to receive the alternative methodology calculation of the PPS encounter
rate, an FQHC shall sign a written agreement with the State. The alternative
methodology shall result in a payment to the FQHC of an amount that is at least
equal to the PPS methodology and satisfies the BIPA requirements.
ii. The baseline PPS encounter
rates for services provided from July 1, 2001 to December 31, 2001 shall be
based on the FY 1999 and FY 2000 cost reports and shall be calculated based on
the following:
(1) Interim PPS encounter
rates shall be calculated using data from the most recent final cost report
settlement as follows:
(A) FQHC administrative
reimbursement shall be subject to an administrative cost limit of 30 percent of
total allowable cost;
(B) FQHC
reimbursement for productivity standards shall be based on those standards
applied by Medicare for cost reporting purposes in the base year;
(C) The overall per encounter limit on FQHC
Medicaid costs shall be the base year Medicare limit plus $ 14.42;
(D) Allowable costs shall be determined by
following Medicare principles of reasonable cost reimbursement;
(E) The encounter rate may be adjusted for a
change in scope of services (in accordance with (e)1vi(1)); and
(F) The encounter rate shall be adjusted for
inflation using the percentage increase in the MEI (defined in section
1842(i)(3) of the Social Security Act) applicable to primary care services (as
defined in section 1842(i)(4)) furnished through December 31, 2000.
(2) The final PPS encounter rate
for services provided from July 1, 2001 to December 31, 2001, shall be
calculated by adding the final settled Medicaid costs of the FY 1999 and FY
2000 cost reports together and dividing the total by the sum of the number of
final settled encounters for FY 1999 and FY 2000 provided to Medicaid
beneficiaries during the FY 1999 and FY 2000 fiscal years, adjusted for a
change in scope of services in accordance with (e)1vi(1) and inflation using
the percentage increase in the MEI (defined in section 1842(i)(3) of the Social
Security Act) applicable to primary care services (as defined in section
1842(i)(4)) furnished through December 31, 2000.
(A) The final settled Medicaid costs from the
FY 1999 and FY 2000 cost reports shall be adjusted as follows:
(i) FQHC administrative reimbursement shall
be subject to an administrative cost limit of 30 percent of total allowable
cost;
(ii) FQHC reimbursement for
productivity standards shall be based on those standards applied by Medicare
for cost reporting purposes in the base year;
(iii) The overall per encounter limit on FQHC
Medicaid costs shall be the base year Medicare limit plus $ 14.42;
and
(iv) Allowable costs shall be
determined by following Medicare principles of reasonable cost
reimbursement.
(3) A financial transaction will be processed
through the Medicaid fiscal agent for the difference between the interim and
final PPS encounter rate for services provided to Medicaid beneficiaries that
were reimbursed at the interim encounter rate. For FQHC obligations that are
not paid within 30 days from the date the recovery is initiated, interest shall
be assessed in accordance with
30:4D-17(e), (f)
and 31:1-1(a).
(4) The alternative methodology to calculate
final PPS encounter rate for services provided from July 1, 2001 to December
31, 2001 shall be calculated on the greater of the FY 1999 or FY 2000 final
settled Medicaid cost report, adjusted for a change in scope of services in
accordance with (e)1vi(1) and inflation using the percentage increase in the
MEI (as defined in section 1842(i)(3) of the Social Security Act) applicable to
primary care services (as defined in section 1842(i)(4)) furnished through
December 31, 2000. The alternative methodology shall result in a payment to the
FQHC of an amount that is at least equal to the PPS methodology and satisfies
the BIPA requirements. FQHCs that have elected the alternative methodology
shall have a single opportunity to request a change to the PPS methodology,
which shall be applied prospectively. Once an FQHC has opted out of the
alternative methodology, it is no longer eligible to receive the alternative
methodology.
(A) The final settled Medicaid
costs for the FY 1999 and FY 2000 cost reports shall be adjusted as follows:
(i) FQHC administrative reimbursement shall
be subject to an administrative cost limit of 30 percent of total allowable
cost;
(ii) FQHC reimbursement for
productivity standards shall be based on those standards applied by Medicare
for cost reporting purposes in the base year;
(iii) The overall per encounter limit on FQHC
Medicaid costs shall be the base year Medicare limit plus $ 14.42;
and
(iv) Allowable costs shall be
determined by following Medicare principles of reasonable cost
reimbursement.
(B)
Paragraphs (1) and (3) above shall be followed under the alternative
methodology. In order to qualify to receive the alternative methodology
calculation of the PPS encounter rate, an FQHC shall sign a written agreement
with the State.
iii. The final PPS encounter rate shall be
effective for services from July 1, 2001 through December 31, 2001. Each year
thereafter, the rate year will begin on January 1 and end on December 31.
(1) For both the PPS and the alternative
methodology, the interim PPS encounter rates effective January 1, 2002, will be
calculated using the encounter rate from the most recent final cost report
settlement, and will be adjusted for inflation using the MEI effective on
January 1, 2002 and for a change in scope of services (in accordance with
(e)1vi(1)). The interim PPS encounter rates will be adjusted to final PPS
encounter rates upon reconciliation of the FY 1999 and FY 2000 cost
reports.
(2) For rates effective
January 1, 2003 and every January 1, thereafter, the final PPS encounter rate
effective January 1, of the preceding year will be increased by the MEI
applicable to primary care services of the current year and adjusted for a
change in scope of services in accordance with (e)1vi below to calculate the
PPS final encounter rate.
(3) A
financial transaction will be processed through the Medicaid fiscal agent for
the difference between the interim and final encounter rate for services
provided to Medicaid beneficiaries that were reimbursed at the interim
encounter rate. For FQHC obligations that are not paid within 30 days from the
date recovery is initiated, interest shall be assessed in accordance with
30:4D-17(e), (f)
and 31:1-1(a).
iv. The reimbursement of donation
costs related to outstationed eligibility workers will be made on a lump-sum
basis once each calendar quarter.
v. FQHCs shall have a one-time option to
revise their FY 1999 and FY 2000 cost reports to include/exclude the direct and
indirect delivery costs, encounters and revenues associated with deliveries for
purposes of establishing the January 1, 2001 and July 1, 2001 PPS encounter
rates. The option chosen by the FQHC would apply to both FY 1999 and FY 2000
cost reports. The revisions to include/exclude direct and indirect delivery
costs, encounters and revenues from the cost report will be solely for the
calculation of the PPS encounter rate, and will not result in a revised
settlement for the period covered by the cost report.
vi. The PPS encounter payment rates may be
adjusted for increases or decreases in the scope of services furnished by the
FQHC during that fiscal year.
(1) A change in
scope of service is defined as follows:
(A)
The addition of a new FQHC covered service that is not incorporated in the
baseline PPS rate or a deletion of a FQHC covered service that is incorporated
in the baseline PPS rate;
(B) A
change in scope of service due to amended regulatory requirements or
rules;
(C) A change in scope of
service resulting from relocation, remodeling, opening a new clinic or closing
an existing clinic site; and/or
(D)
A change in scope of service due to applicable technology and medical
practice.
(2) "Change in
Scope of Service Applications" shall be governed by the following procedures:
(A) Providers shall follow the guidelines in
the "Change in Scope of Service Application Requirements" contained in N.J.A.C.
10:66-4 Appendix D, incorporated herein by reference. Providers shall notify
the Division of Medical Assistance and Health Services (DMAHS) in writing at
least 60 days prior to the effective date of any changes and explain the
reasons for the change.
(B)
Providers shall submit documentation or schedules which substantiate the
changes and the increase/decrease in services and costs (reasonable costs
following the tests of reasonableness used in developing the baseline rates)
related to these changes. The changes shall be significant with substantial
increases or decreases in costs, as defined in (d)1vi(3) below, and
documentation must include data to support the calculation of an adjustment to
the PPS rate. It is recognized that the change in scope of service will be
time-limited in most cases, due to start-up/phase-in costs or shut down/phase
out costs associated with the change in scope of service. The provider must
address this in the Change in Scope of Service Application.
(3) Providers may submit Change in
Scope of Service Applications either:
(A)
Once during a calendar year, by October 1, with an effective date of January 1
of the following year; or
(B) When
the change(s) in scope of service exceed(s) 2.5 percent of the allowable per
encounter rate as determined for the fiscal period. The effective date shall be
the implementation date of the change in scope of service that exceeds the 2.5
percent minimum threshold for a mid-year adjustment.
(4) The provider shall be notified by DMAHS
of any adjustment to the rate by written notification following a review of the
submitted documentation.
(5) The
provider shall be paid its PPS rate as initially determined by DMAHS, pending
the determination as to whether an adjustment is necessary and if so, the
amount of the adjustment. A payment or recovery shall be made for the period
from the effective date of the adjustment to the date the revised rate is
incorporated into the claims payment system.
(6) Providers may appeal DMAHS' determination
for an adjustment or the amount of the adjustment by writing to the Director,
DMAHS within 60 days of the date of the determination letter. The provider
shall identify the specific items of disagreement and the amount in question,
and provide reasons and documentation to support the provider's
position.
vii. For new
providers (entities first qualifying as FQHCs after December 31, 2000), interim
PPS encounter rates shall be calculated. These rates shall be subject to final
settlements through December 31 of the initial and second year of the FQHC's
existence. New FQHCs' rate years shall be calendar years, thus the initial year
may represent less than a full year of operation.
(1) The interim PPS encounter rates shall be
the Statewide average PPS encounter rate.
(2) In establishing the interim PPS encounter
rate, DMAHS may take into account existing costs, which may have occurred when
in operation as another healthcare facility.
(3) The final PPS encounter rates for the
initial and second years of operation shall be calculated from the FQHC's cost
report data contained in N.J.A.C. 10:66-4 Appendix C, "New FQHC Medicaid Cost
Reports for First and Second Years of Operation," incorporated herein by
reference:
(A) FQHC administrative
reimbursement shall be subject to an administrative cost limit of 30 percent of
total allowable cost;
(B) FQHC
reimbursement for productivity standards shall be based on those standards
applied by Medicare for cost reporting purposes in the base year;
(C) The overall per encounter limit on FQHC
Medicaid costs shall be the 2000 calendar year Medicare limit plus $ 14.42,
inflated by the MEI applicable to primary care services for all years up to the
year of operation; and
(D)
Allowable costs shall be determined by following Medicare principles of
reasonable cost reimbursement.
(4) Final settlements for the first two years
shall be processed in accordance with sections (3)(A) through (D)
above.
(5) For each year
thereafter, the PPS encounter rate shall be the final rate of the second year
of operations (possibly the first full year of operations) adjusted by the MEI
applicable to primary care services and changes in scope of services as
described above.
viii.
Managed care wrap-around payments shall be made on a quarterly basis.
(1) To qualify for wrap-around reimbursement,
the FQHC administration shall have a signed contract with the managed care
organization as of the time period covered, and for the time period covered,
and the FQHC shall comply with the reporting requirements below and contained
in N.J.A.C. 10:66-4 Appendix E, incorporated herein by reference.
(2) The FQHC shall provide to the Division,
upon request, copies of any and all managed care contracts the FQHC has entered
into during the cost report period. FQHCs shall provide copies of any requested
managed care contracts to the Division within 30 days of the date of the
Division's request. Failure to provide copies of the contract(s) as requested
shall result in suspension of interim payments or wrap-around payments until
the contract copy is received by the Division.
(3) For new providers (entities first
qualifying as FQHCs after December 31, 2000), the wrap-around shall be
calculated at the FQHC's interim PPS encounter rate until the final PPS
encounter rate is established. New FQHCs shall be reimbursed for 85 percent of
the difference between reasonable costs and the managed care receipts received
for services provided to Medicaid beneficiaries. After the final PPS encounter
rate is calculated, a financial transaction shall be processed for the
difference between the interim and final PPS encounter rate for encounters
provided to Medicaid managed care beneficiaries. In the event of an
underpayment, the Division shall reimburse the provider 100 percent of the
amount due. In the event of an overpayment, the provider shall reimburse the
Division 100 percent of the overpayment within 30 days of the due date of the
Managed Care Wraparound Report. For FQHC obligations that are not paid within
30 days of the date recovery is initiated, interest shall be assessed in
accordance with
30:4D-17(e), (f)
and 31:1-1(a).
(4) For FQHCs that have a final PPS encounter
rate established, all quarterly wrap-around reports shall be reconciled at 100
percent of the difference between the final rate and the managed care receipts
received for services provided to Medicaid and FamilyCare managed care
beneficiaries. In the event of an underpayment, the Division shall reimburse
the provider 100 percent of the amount due. In the event of an overpayment, the
provider shall reimburse the Division 100 percent of the overpayment within 30
days of the due date of the Managed Care Wrap-around Report. For FQHC
obligations that are not paid within 30 days of the date recovery is initiated,
interest shall be assessed in accordance with
30:4D-17(e), (f)
and 31:1-1(a).
(5) Reporting time periods shall be calendar
year quarters (March, June, September, and December), regardless of an FQHC's
fiscal year end.
(6) Reporting
Encounters: Medicaid and NJ FamilyCare managed care encounters provided during
the calendar year quarter shall be reported on the Medicaid Managed Care
Encounter Detail Report in N.J.A.C. 10:66-4 Appendix E, incorporated herein by
reference. For example, all managed care encounters provided to Medicaid and NJ
FamilyCare beneficiaries from October 1, 2003 through December 31, 2003 shall
be included on the Medicaid Managed Care Encounter Detail Reports for the
quarter ended December 31, 2003. Each Medicaid Managed Care Encounter Detail
Report shall contain encounters provided during one specific month. In total,
there are three Medicaid Managed Care Encounter Detail Reports for each
quarter.
(A) Effective for service dates on
and after July 11, 2008 for Medicaid/NJ FamilyCare fee-for-service
beneficiaries, FQHCs that provide deliveries and/or OB/GYN surgeries will be
required to comply with the encounter reporting requirements in (d)1viii(6)(B)
through (D) below and contained in N.J.A.C. 10:66-4 Appendix E, incorporated
herein by reference.
(B) The FQHC
must report all managed care encounters performed during the reporting period,
with the exception of the delivery and OB/GYN surgical encounters on Worksheet
2, Support Schedule A located in N.J.A.C. 10:66-4 Appendix E.
(C) The FQHC must report all managed care
delivery encounters performed during the reporting period on Worksheet 2,
Support Schedule C located in N.J.A.C. 10:66-4 Appendix E.
(D) The FQHC must report all managed care
OB/GYN surgical encounters performed during the reporting period on Worksheet
2, Support Schedule E located in N.J.A.C. 10:66-4 Appendix E.
(7) Reporting Receipts: All
Medicaid and NJ FamilyCare managed care payments received by the FQHC for the
quarter, including capitation, fee-for-service, supplemental or administration
fund, and any other managed care payments received from the first day of the
quarter to the 25th day following the end of the calendar year quarter, shall
be reported on the Medicaid Managed Care Receipts Report in N.J.A.C. 10:66-4
Appendix E.
(A) Effective for service dates
on and after July 11, 2008 for Medicaid/NJ FamilyCare fee-for-service
beneficiaries, FQHCs that provide deliveries and/or OB/GYN surgeries will be
required to comply with the receipt reporting requirements in (d)1viii(7)(B) to
(D) below and contained in N.J.A.C. 10:66-4 Appendix E, incorporated herein by
reference.
(B) The FQHC must report
all managed care receipts received during the reporting period with the
exception of receipts for delivery and OB/GYN surgical encounters on Worksheet
2, Support Schedule B located in Appendix E.
(C) The FQHC must report all managed care
delivery receipts received during the reporting period on Worksheet 2, Support
Schedule D located in Appendix E.
(D) The FQHC must report all managed care
OB/GYN surgical receipts received during the reporting period on Worksheet 2,
Support Schedule F located in Appendix E.
(8) Managed care organizations may use their
own funds to include financial incentives in their contracts with FQHCs.
Financial incentives are used as an incentive to reduce unnecessary utilization
of services or otherwise reduce patient costs. Such incentives may be negative,
such as withholding a portion of the capitation payments. In this example, if
utilization goals are not satisfied, the provider foregoes the withheld amount
in whole or part. Incentives may also be positive, such as a bonus that is paid
if desired utilization outcomes are achieved. These incentive amounts (whether
positive or negative) are separate from the managed care organization's payment
for services provided under the contract with the provider, and shall not be
included by the FQHC in the Medicaid Managed Care Receipts Report.
(9) Date of Quarterly Report requirements are
as follows: FQHCs shall submit the Medicaid Managed Care Encounter Detail
Reports and the Medicaid Managed Care Receipts Report with managed care
receipts data through the 25th day following the end of the calendar year
quarter. For example, the receipts report for the quarter ending December 31,
2003, shall be submitted with the receipts received through January 25, 2004.
This will allow for most, if not all, managed care receipts for the quarter to
be received by the submission date of the quarterly wrap-around report. These
reports are due to Medicaid by the 55th day following the end of each calendar
quarter. Failure to submit acceptable Medicaid Managed Care Encounter Detail
Reports and Medicaid Managed Care Receipts Reports by the due date may result
in suspension of interim payments. Payments for claims received on or after the
date of suspension may be withheld until acceptable Medicaid Managed Care
Encounter Detail Reports and Medicaid Managed Care Receipts Reports are
received.
(10) Adjustments for
prior periods requirements are as follows: A separate Medicaid Managed Care
Encounter Detail Report and/or Medicaid Managed Care Receipts Report shall be
prepared for receipts and/or encounters not previously reported. Use separate
Medicaid Managed Care Encounter Detail Reports and/or separate Medicaid Managed
Care Receipts Reports to report prior period adjustments. An adjustment for a
prior period is a correction to an earlier report. Managed care additions and
subtractions relating to prior periods will be adjusted in the State's payment
to the FQHC for the most recent quarter.
(11) The prior period adjustments shall be
separated by a provider's fiscal year. For example, a provider with a December
fiscal year end receives managed care receipts in June 2003 for services
rendered in December 2001 and January 2002. The provider shall prepare a
separate Medicaid Managed Care Receipts Report for each prior period: the
provider's fiscal years ending 2001 and 2002; these attachments shall be
clearly identified as adjustments for fiscal years 2001 and 2002. Similarly, if
a provider becomes aware of differences in encounters for prior fiscal year
periods, the provider shall prepare a separate Medicaid Managed Care Encounter
Detail Report for each prior fiscal year period.
ix. Effective for service dates on and after
July 11, 2008 for Medicaid/NJ FamilyCare fee-for-service beneficiaries, FQHCs
shall receive reimbursement for deliveries and OB/GYN surgeries, specified at
(d)1ix(1) below, at the higher of the Medicaid fee-for-service rate for the
particular code or the FQHC's PPS encounter rate. Reimbursement for surgical
assistants will be at the Medicaid fee-for-service rate for the particular
code.
(1) Delivery codes are listed on Table
A. OB/GYN surgical codes are listed on Table B. Tables A and B and annual
updates will be posted on the Unisys website:
www.njmmis.com.
(2) Antepartum and Postpartum encounters
provided to Medicaid/NJ FamilyCare fee-for-service beneficiaries that are not
included in the delivery code reimbursement, may be reimbursed to the FQHC at
the PPS encounter rate.
(3) Post
surgical encounters provided to Medicaid/NJ FamilyCare fee-for-service
beneficiaries that are not included in the OB/GYN surgical code reimbursement,
may be reimbursed to the FQHC at the PPS encounter rate.
(4) Effective for service dates on and after
July 11, 2008 for Medicaid/NJ FamilyCare managed care beneficiaries, FQHCs
shall receive reimbursement for deliveries and OB/GYN surgeries, specified at
(d)1ix(1) above from the managed care organization(s). FQHCs shall receive
reimbursement for surgical assistants related to these deliveries and OB/GYN
surgeries from the managed care organization(s). Deliveries, OB/GYN surgeries
and services provided by surgical assistants for deliveries and OB/GYN
surgeries are not eligible for wraparound reimbursement.
(5) Antepartum and Postpartum encounters
provided to Medicaid/NJ FamilyCare managed care beneficiaries that are not
included in the delivery code reimbursement are eligible for wraparound
reimbursement. Antepartum and postpartum encounters that are covered by the
managed care delivery reimbursement are not eligible for wraparound
reimbursement.
(6) Post surgical
encounters provided to Medicaid/NJ FamilyCare managed care beneficiaries that
are not included in the OB/GYN surgical code reimbursement are eligible for
wraparound reimbursement. Post surgical encounters that are covered by the
managed care OB/GYN surgical reimbursement are not eligible for wraparound
reimbursement.
x. FQHCs
shall maintain an accounting system, which identifies costs in a manner that
conforms to generally accepted accounting principles and maintain documentation
to support all data.
(1) On an annual basis
and no later than five months after the close of each facility's fiscal year,
an FQHC shall submit the annual cost report contained in N.J.A.C. 10:66-4
Appendix B, incorporated herein by reference.
(2) If all annual cost report items listed in
N.J.A.C. 10:66-4 Appendix B, incorporated herein by reference, are not received
by the due date, then all payments (including managed care wraparound payments)
for services shall be suspended until all items are received. One 30-day
maximum extension shall be granted upon written request only when a provider's
operations are significantly adversely affected due to extraordinary
circumstances beyond the control of the provider, as provided in Medicare
guidelines.
(3) Each provider shall
keep financial, statistical and medical records of the cost reporting year for
at least six years after submitting the cost report to the DMAHS, or as long as
an outstanding appeal exists, whichever is longer, and shall also make such
records available upon request to authorized State or Federal
representatives.
(4) DMAHS or its
fiscal agent may periodically conduct either on-site or desk audits of cost
reports, including financial, statistical, and medical records.
(5) The providers shall submit other
information (statistics, cost and financial data) when deemed necessary by the
Department.
(e) The basis for reimbursement of services provided in an ambulatory care/family planning facility is as follows:
1. Reimbursement for the services of an
ambulatory care/family planning/surgical facility shall be made for services
rendered by both the facility and the attending physician, if the physician is
not reimbursed for surgical/medical services by the facility.
2. The facility reimbursement rate shall
equal 70 percent of the applicable ambulatory surgical center rate for the
procedures, in accordance with reimbursement rates,
10:66-1.5 (c).
3. Physician reimbursement shall be in
accordance with the New Jersey Medicaid and NJ FamilyCare fee-for-service
programs' Physician Maximum Fee Allowance for specialist and non-specialist,
N.J.A.C. 10:54, and the following:
i. When
submitting a claim, the physician performing the surgical procedure shall use
the applicable claim form, billing the New Jersey Medicaid or NJ FamilyCare
fee-for-service program either as an individual provider or as a member of a
physician's group.
ii. A physician
on salary for administrative duties (such as a medical director) shall be
permitted to submit claims for surgical/medical services performed if outside
of his or her administrative duties and not billed by the facility.
Administrative duties shall be considered a direct cost of the facility and
shall be included in the clinic payment.
Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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