Current through Register Vol. 56, No. 18, September 16, 2024
(a) The CWA
shall furnish the Medical Review Team with current, pertinent social and
medical information, and obtain any special or additional reports on
request.
(b) When it appears that
an applicant meets the income and resources requirements for Medicaid Only,
arrangements for obtaining medical evidence should be initiated immediately by
whichever of the following procedures is applicable to the applicant's
situation:
1. When the applicant is currently
(within three months) under the care of a private physician, he or she shall be
furnished with a copy of Form PA-5 (Examining Physician's Report) to take to
the physician for completion;
2. If
the applicant is currently receiving treatment in a hospital clinic, public
health facility (that is, tuberculosis clinic, mental health clinic or other
outpatient facility) on a regular basis for the medical condition related to
his or her application for Medicaid Only, a copy or abstract of the clinic
record may be submitted in lieu of the PA-5;
3. If the applicant has been hospitalized
within three months for a condition related to the impairment for which he or
she is applying for Medicaid Only, an abstract of the hospital record may be
submitted for patients in long-term care facilities;
4. In the event none of the above are
applicable, the CWA should assist the applicant in choosing a physician to
complete the PA-5, who is competent to determine the nature and extent or
degree of disability; or
5. When
the applicant states that he or she is blind or that visual impairment is his
or her primary disability, the CWA shall, prior to submission of the record to
the Medical Review Team, obtain a Report of Eye Examination (Form PA-5A) from a
qualified medical specialist in diseases of the eye (for example,
ophthalmologist), or an optometrist, or from an eye clinic of a general
hospital, whichever the individual may select. (The membership directory of the
Medical Society of New Jersey is suggested as reference for identification of,
in each municipality, physicians specializing in diseases of the eye.)
Optometrists are listed in the yellow pages of local telephone directories
under the heading "Optometrists--Doctors of Optometry." The Form PA-5A should
be transmitted in duplicate to the Medical Review Team with any other pertinent
medical evidence as outlined above. When appropriate, the Certification of Need
for Patient Care in Facility Other Than Public or Private General Hospital
(Form PA-4) will be submitted to the Medical Review Team.
(c) Other evidence, such as education,
training, work experience and daily living activities, shall be submitted to
the Medical Review Team by completion of the PA-6 (Medical-Social Information
Report). The PA-6 shall be carefully and completely filled out.
(d) If the applicant refuses to furnish
medical or other evidence concerning his or her disability, the application for
Medicaid Only shall be referred to the Medical Review Team for
recommendations.
(e) As soon as
medical reports and the Medical Social Information Report (PA-6) are completed,
one copy of each shall be stapled together for transmittal to the Medical
Review Team. It shall be clearly indicated on the PA-6 that this is a Medicaid
Only case. Records transmitted by the Medical Review Team on a given date shall
be listed by registration number and name on an inventory sheet, prepared in
duplicate, the cases being grouped by case status. One copy shall be attached
to the submittal records, the duplicate retained as CWA control.
(f) The CWA will prepare a similar inventory
and attach cases returned to the CWA on a given date. Attached to each will be
Form PA-8 (Record of Action) containing the determination of eligibility by the
Medical Review Team and any necessary instructions.
(g) Upon receipt of records from the Medical
Review Team, the CWA shall examine the PA-8 (Record of Action) for the action
of the Medical Review Team and for specific instructions or recommendations,
and to note the review date.
(h)
Recommendations will be made by the medical consultant to alert the CWA to the
possibilities of adequate medical care for the client and to provide specific
pertinent questions to be raised with the attending physician. The medical
social work consultant will make recommendations to help the CWA staff
recognize the social problems indicated in the client's situation and the
relationship between these problems and his or her physical and mental
adjustment.
(i) The following
procedures shall be observed in respect to the Medical Review Team actions:
1. "Approved" cases:
i. CWA shall complete, as necessary,
determination of eligibility in respect to other factors and, if applicant is
eligible, take the necessary action to obtain Medicaid benefits.
ii. When an applicant is not eligible in
respect to any other factor, although "approved" for the disability or
blindness factor, the application shall be denied.
iii. The CWA shall establish and maintain a
control file for "approved" cases in order that the date for determination
review by the Medical Review Team will be observed and considered according to
N.J.A.C. 10:71-5.
iv. The Medical
Review Team (MRT) shall also maintain a control file in order to ensure
appropriate and timely reevaluation by the MRT. The MRT will notify CWA one
month in advance of cases scheduled for such review. Cases also for
reevaluation will be listed on Form PA-655.
2. "Undetermined" cases:
i. If further medical and/or social
information is required by the MRT for the initial determination of
eligibility, the CWA shall obtain the information promptly and resubmit the
case. Reports from medical specialists shall be submitted on their own
letterheads.
ii. If the applicant
fails or refuses to present himself/herself for required examinations or tests,
the application shall be referred to the MRT for recommendations.
3. "Disapproved" cases:
i. Any case determined as not medically
eligible for "Medicaid Only" by the MRT shall be denied Medicaid Only by the
CWA.
ii. Appropriate notification
shall be given to the applicant as well as any specific recommendations for
follow-up care and treatment.
(j) When page 5 of Form PA-5 carries the
signature of the medical consultant approving the payment of the examining
physician, such payment shall be forwarded to the physician from administrative
funds, regardless of whether the action on the record of action is "approved",
"disapproved" or "undetermined". (In an "undetermined" case, if the request for
additional information relates to an incomplete report from the examining
physician, approval for payment will not appear on page 5 of the
PA-5.)
(k) Payment for special
diagnostic reports shall likewise be forwarded to the medical specialist or
clinic from administrative funds regardless of whether the case is "approved",
"disapproved", or "undetermined".
(l) Maximum allowances for examining
physician (completion of PA-5) are as follows.
1. Examination at office or hospital: $
20.00.
2. Examination at patient's
home: $ 30.00.
3. Examination at
public institution: No fee.
(m) Diagnostic examination services rules
are:
1. This subsection is concerned with
medical specialty consultant evaluation services and diagnostic studies (that
is, clinical laboratory, diagnostic x-ray and special diagnostic examinations)
incident thereto, authorized by a CWA upon recommendation of the MRT, when
deemed essential as part of the initial determination of medical
eligibility.
2. These examinations
and procedures are exclusively for diagnostic eligibility, are chargeable as
matchable administrative costs and a medical vendor payment should be promptly
made upon approval of the consultant's report by the reviewing physician
employed by the State agency.
3.
The following schedule of fees is exclusive to laboratory, x-ray and other
special diagnostic studies which may be required.
i. Diagnostic Consultation and Report
(ophthalmologic includes refraction: otological includes audiometric screening)
other than psychiatric or neurologic: $ 45.00.
ii. Diagnostic Consultation requiring
complete psychiatric or complete neurological examination or complete
neuropsychiatric examination, with detailed report: $ 50.00.
iii. Electrocardiogram with interpretation
and report: $ 25.00.
(n) Payment of the above allowance is to be
approved only when the specialist has received prior authorization to perform
the diagnostic evaluation and when the examination is performed by a qualified
specialist (that is, eligible for or certified by the appropriate American
board; or recognized by hospital, community and peers as a specialist, and
practice is limited to the specialty). See current membership directory of the
Medical Society of New Jersey.
(o)
The fee(s) listed in fees for professional and diagnostic services issued by
the Medical-Surgical Plan of New Jersey (Revised 6-1-73) shall be approved when
diagnostic x-ray or radioisotope studies, laboratory and/or special diagnostic
studies are deemed essential by the medical specialist authorized to perform
the diagnostic consultant evaluation. Payment based on the allowances listed by
the Medical-Surgical Plan, Series 575, shall be limited to medical specialists
as defined in the section.
