New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 66 - INDEPENDENT CLINIC SERVICES
Subchapter 4 - FEDERALLY QUALIFIED HEALTH CENTER (FQHC)
Section 10:66-4.1 - Federally qualified health center (FQHC) services
Universal Citation: NJ Admin Code 10:66-4.1
Current through Register Vol. 56, No. 18, September 16, 2024
(a) Federally qualified health center (FQHC) services are services provided by physicians, physician assistants, advanced practice nurses, nurse midwives, psychologists, dentists, clinical social workers, and services and supplies incident to such services as would otherwise be covered if furnished by a physician or as incident to a physician's services.
1. FQHCs shall accommodate an outstationed
county board of social services (CBOSS) employee(s) for the purpose of
determining Medicaid and NJ FamilyCare eligibility, pursuant to
42 U.S.C. §
1396a(a)(55).
2. A medical encounter is a face-to-face
contact between a beneficiary and a physician or other licensed practitioner
acting within his or her respective scope of practice, including a podiatrist,
optometrist, chiropractor, advanced practice nurse, or nurse midwife.
i. Normally, only one medical encounter is
covered per beneficiary, per day. More than one medical encounter is covered,
however, when the beneficiary is seen by more than one licensed practitioner
for the prevention, treatment or diagnosis of different injuries or illnesses,
and practitioners of appropriate different specialties are involved.
ii. More than one medical encounter is also
allowed if a beneficiary leaves the center after having been seen by a
practitioner, then returns to the center and is seen by another practitioner on
the same day.
iii. More than two
medical encounters during a week for a beneficiary require clear documentation
in the beneficiary's medical record demonstrating the medical necessity of the
encounter(s).
iv. Interpretation of
results of tests or procedures not requiring face-to-face contact between a
beneficiary and a practitioner, and referrals to specialists, do not constitute
a medical encounter.
3.
A psychiatric encounter is a face-to-face contact between a beneficiary and a
licensed mental health professional in which a covered mental health clinic
service is provided.
4. A dental
encounter is a face-to-face contact between a beneficiary and a dentist or a
licensed dental professional in which a covered dental procedure is provided.
All procedures shall be administered by or under the direct supervision of a
dentist.
i. Normally, only one dental
encounter is covered per beneficiary, per day. Only one dental encounter is
covered when the beneficiary is seen by a licensed general practitioner and a
dental hygienist or when the beneficiary is seen by two general practitioners
on the same date of service.
ii.
More than one dental encounter is covered, however, when the beneficiary is
seen by a licensed general practitioner and a licensed specialist, such as an
oral surgeon or an endodontist.
iii. More than two dental encounters during a
week for a beneficiary require clear documentation in the beneficiary's dental
record demonstrating the medical necessity for the multiple
encounters.
iv. Interpretation of
results of tests or procedure results not requiring face-to-face contact
between the beneficiary and practitioner and referrals to specialists do not
constitute a dental encounter.
5. An Early and Periodic Screening, Diagnosis
and Treatment (EPSDT) medical encounter is a face-to-face contact between a
beneficiary and a physician or other licensed practitioner acting within his or
her respective scope of practice, including a podiatrist, optometrist,
chiropractor, nurse, practitioner, or nurse midwife in which a covered EPSDT
service is provided.
6. An OB/GYN
encounter is a face-to-face contact between a beneficiary and a physician or
other licensed practitioner acting within his or her respective scope of
practice, including, but not limited to, a certified nurse midwife, in which a
delivery or approved OB/GYN surgical procedure listed on Table A or Table B on
the Molina website is performed.
Delivery codes are listed on Table A. OB/GYN surgical codes are listed on Table B. Tables A and B and annual updates are posted on the Molina website: www.njmmis.com.
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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