Current through Register Vol. 56, No. 6, March 18, 2024
(a) No PACT services shall be provided to an eligible beneficiary without prior authorization. The eligible beneficiaries for PACT are described at 10:76-2.3(a).
(b) For the provision of PACT services, the provider shall obtain prior authorization as follows:
1. The provider shall complete the "DMHAS PACT Referral and Intake Outcome" form to request authorization to provide PACT services and shall submit the form to the DMHAS Regional Office in the county in which the provider is located.
2. The Regional DMHAS Program Analyst will evaluate the eligibility of the beneficiary for PACT services in accordance with 10:37J-2.3(b), and will advise the provider of results of the evaluation.
3. Upon receipt of this approval, the provider shall meet with the beneficiary, enroll the beneficiary into the PACT program, and return the signed and dated "DMHAS PACT Referral and Intake Outcome" form to the DMHAS Regional Office, confirming the enrollment of the beneficiary into the PACT program.
(c) For the provision of Partial Care/Partial Hospitalization (PC/PH) services to an eligible beneficiary enrolled in PACT, the provider shall obtain prior authorization as follows:
1. The PACT provider shall submit a written request to the Regional DMHAS Program Analyst requesting authorization to enroll a beneficiary receiving PACT services into a Partial Care/Partial Hospitalization program. The written request shall include:
i. A detailed justification for the necessity of the PC/PH services; and
ii. DMAHS prior authorization request forms (FD-07 and FD-07A) completed by the intended PC/PH provider requesting prior authorization of Partial Care or Partial Hospitalization services to a Medicaid/NJ FamilyCare beneficiary for a period not to exceed 30 days.
2. The Regional DMHS Program Analyst will evaluate the request, recommend services if appropriate, document the recommendation and forward their recommendations for approval of all requests for PC/PH services to: Division of Medical Assistance and Health Services, Office of Customer Service, Mental Health Services Unit, PO Box 712, Mail Code 25, Trenton, NJ 08625-0712.
3. The DMAHS Office of Customer Service will review the request and advise the Statewide PACT Coordinator of the approval or denial of the request.
i. PC/PH services shall not be approved for more than 30 days for an eligible beneficiary receiving PACT services.
ii. PC/PH services shall only be approved for the time period in which the eligible beneficiary is transitioning out of receiving PACT services.
iii. The providers will be notified by the Medicaid/NJ FamilyCare fiscal agent that services have been authorized. Such authorization should be received before providing services.
(d) All claims filed for reimbursement with the Division's fiscal agent shall include the prior authorization number for any services rendered in order to ensure appropriate reimbursement is made. The prior authorization shall cover all dates that services were rendered to ensure proper reimbursement.
