New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 75 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES FOR INDIVIDUALS UNDER AGE 21
Subchapter 1 - GENERAL PROVISIONS
Section 10:75-1.2 - Definitions
The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise:
"Active treatment" means the implementation of a professionally developed and supervised plan of care that is developed and implemented no later than 14 days after admission and designed to achieve the goal of the resident's appropriate discharge from the PRTF at the earliest possible date. (See 42 C.F.R. 441.154.)
"Beneficiary or eligible beneficiary" means any person who is a qualified applicant receiving benefits under the Medical Assistance and Health Services Act, 30:4D-1 et seq.
"Care Management Organization (CMO)" means the community-based Department of Children and Families/Division of the Children's System of Care (DCF/DCSOC) contracted entity that is responsible for creating, coordinating, and implementing an individualized plan of care for children with emotional and behavioral disturbances that are in need of intensive care coordination services.
"Centers for Medicare and Medicaid Services (CMS)" means the agency of the Federal Department of Health and Human Services which is responsible for the administration of the Medicaid program.
"Certification of need" means an evaluation made by an interdisciplinary medical review team to determine the level of care required to treat a resident with mental illness in the most effective manner in the least restrictive environment.
"Certified nurse practitioner/clinical nurse specialists (CNP/CNS)" means a person currently licensed as an advance practice nurse who is currently certified by the New Jersey State Board of Nursing in accordance with N.J.A.C. 13:37-7 and with N.J.S.A. 45:11-49a through d, or licensed through a comparable agency of the state in which he or she practices.
"Contract pricing" means the facility-specific rate, based on the rate determined in the contract negotiated with the DCF/DCSOC or the Department of Human Services.
"Contracted System Administrator (CSA)" means the entity contracted by the Department of Children and Families/DCSOC to provide utilization management and care coordination activities for services to children, including all mental health services provided to individuals as part of the DCSOC, to monitor the quality of care, to prior authorize mental health services, and approve continued lengths of stay in DCSOC's programs.
"Department (DHS)" means the New Jersey Department of Human Services.
"Department of Children and Families (DCF)" means the New Jersey Department of Children and Families, created by P.L. 2006, c. 47.
"Division of Medical Assistance and Health Services (DMAHS)" means the organizational component of the New Jersey Department of Human Services which is responsible for the administration of the State's medical assistance programs.
"Division of Mental Health and Addiction Services (DMHAS)" means the organizational component of the New Jersey Department of Human Services that is responsible for the administration of the State's mental health and addiction programs.
"Division of Mental Health Services (DMHS)" means the organizational component of the New Jersey Department of Human Services which is responsible for the administration of the State's mental health programs.
"Division of the Children's System of Care (DCSOC)" means the Department of Children and Families' division that provides a comprehensive system of care approach for the treatment of youth experiencing behavioral health challenges, services for youth with intellectual/developmental challenges, and services to youth with substance use challenges. DCSOC beneficiaries are those individuals under the age of 21 that have been determined by the Department of Children and Families/DCSOC to be eligible for enrollment into the DCSOC, independent of their eligibility for Medicaid/NJ FamilyCare coverage.
"Division of Youth and Family Services (DYFS)" means the organizational component of the New Jersey Department of Human Services which administers the Title IV-E program of the Social Security Act, 42 U.S.C. §§ 670 through 679b.
"Healthcare Common Procedure Coding System (HCPCS)" means a nationwide two-level coding system. Level I codes are adapted from codes published by the American Medical Association in the Common Procedure Terminology (CPT) and are utilized primarily by physicians and independent clinical laboratories. Level II codes are assigned by CMS for physician and non-physician services that are not in the CPT.
"Hospital leave" means a temporary absence from the facility for more than 24 consecutive hours due to the resident receiving inpatient treatment in a hospital, including treatment in a psychiatric unit of a hospital.
"Individual plan of care" means a written plan developed for each resident to improve his condition to the extent that inpatient care is no longer indicated.
"Interdisciplinary team," as described in Federal regulations in 42 CFR 441.156, is comprised of those employed by, or those who provide services to Medicaid/NJ FamilyCare or DCF/DCSOC beneficiaries in the PRTF, and is responsible for the review of the treatment needs of a resident receiving mental health services to ensure that the most appropriate level of care is provided. The team shall include, at a minimum, the professional staff listed at 10:75-2.5(b).
"Joint Commission on Accreditation of Healthcare Organizations (JCAHO)" means the nationwide, independent, not-for-profit organization that evaluates and accredits health care organizations and programs, including, but not limited to, behavioral health care organizations including, but not limited to, psychiatric residential treatment facilities.
"New Jersey Medicaid Management Information System (NJMMIS)" means the claims processing entity contracted by DMAHS to process claims for Medicaid/NJ FamilyCare and other health programs that are administered in whole or in part by the Division.
"Partnership for Children (PFC)" means the Department of Human Services' initiative developed to provide a comprehensive approach to the treatment of behavioral and mental disturbances in children, adolescents and young adults. PFC beneficiaries are those individuals under the age of 21 that have been determined by the Department of Human Services to be eligible for enrollment into the PFC, independent of their eligibility for Medicaid/NJ FamilyCare coverage.
"Physician" means a doctor of medicine (M.D.) or osteopathy (D.O.) licensed to practice medicine and surgery by the New Jersey State Board of Medical Examiners, or similarly licensed by comparable agencies of the State in which he or she practices.
"Psychiatric residential treatment facility (PRTF)" means a facility that is not licensed as a hospital, but which meets the requirements in 42 C.F.R. part 441 subpart D, 42 C.F.R. 483 subpart G, and has a provider agreement with the State Medicaid agency (the Division of Medical Assistance and Health Services).
"Resident" means a beneficiary who has been admitted to a PRTF on the recommendation of a physician and who receives services in the PRTF for a 24-hour period or longer in accordance with this chapter.
"Restraint" means a personal hold of any duration, a mechanical restraint, or a drug used as a restraint.
"Serious injury" means any significant impairment of the physical condition of the resident as determined by qualified medical personnel, including, but not limited to, burns, lacerations, bone fractures, substantial hematoma(s), and injuries to internal organs, whether self-inflicted or inflicted by someone else. (See 42 CFR 483.352.)
"Serious occurrence" means the death, suicide attempt or serious injury of a resident. (See 42 C.F.R. 483.374(b).)
"The Joint Commission (TJC)" means the nationwide, independent, not-for-profit organization that evaluates and accredits health care organizations and programs, including, but not limited to, behavioral health care organizations including, but not limited to, psychiatric residential treatment facilities.
"Therapeutic leave" means a temporary absence from the facility, greater than 24 consecutive hours, deemed therapeutic, approved by the treatment team and included in the resident's plan of care. Reasons for such absence include, but are not limited to, visits with parents, foster parents, guardians, or other caregivers, attendance at a residential camp, or residence in a temporary shelter.
"Utilization control" means an approved program instituted, implemented and operated by or under the authorization of a utilization review organization (URO) which effectively safeguards against unnecessary or inappropriate Medicaid services and assesses the quality of those services to Medicaid and NJ FamilyCare fee-for-service beneficiaries.
