New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 77A - ADULT MENTAL HEALTH REHABILITATION SERVICES PROVIDED IN/BY COMMUNITY RESIDENCE PROGRAMS
Subchapter 2 - PROGRAM OPERATIONS
Section 10:77A-2.5 - Basis of reimbursement

Universal Citation: NJ Admin Code 10:77A-2.5

Current through Register Vol. 56, No. 18, September 16, 2024

(a) Reimbursement for AMHR services provided in or by community residence programs to eligible Medicaid and NJ FamilyCare beneficiaries shall be based on the site-specific levels of care delivered by each provider, in accordance with this chapter.

(b) Reimbursement will be on a fee-for-service basis for each level of care, billable in either per-diem or quarter-hour units of service as applicable and as enumerated in this chapter and the billing supplement to this chapter. The rates shall be all-inclusive and shall be based on the range of services included in the service definition. The fee shall not include non-treatment and/or non-rehabilitation-related services, including, but not limited to, room and board, recreational and vocational services.

(c) Providers will be reimbursed on a per diem basis for services provided by all Level A+, A and D programs and those Level B programs that are group homes.

1. Providers shall seek reimbursement only for the dates that the beneficiary:
i. Received services;

ii. Was documented as being under the care of the facility; and

iii. Was physically present in the facility during at least part of the 24-hour period starting and ending at midnight.

2. Providers may seek reimbursement for services provided on the date that the beneficiary is admitted to the facility, but shall not seek reimbursement for services provided on the beneficiary's date of discharge.
i. The beneficiary's discharge date shall be the date the beneficiary is expected to permanently leave the residence. The discharge date shall not include dates that the beneficiary leaves, but is expected to return, including, but not limited to, absences due to vacations, visits with family, or temporary hospitalization.

3. Providers may bill for consecutive dates of service on the same billing form line, but shall not span dates from more than one calendar month on the same billing form line and shall not include in the consecutive dates of service any dates that a resident was not physically present.

(d) Providers shall be reimbursed for quarter-hour units of service for rendering services at all Level C programs and at those Level B programs that are supervised apartments. A quarter-hour unit of service is defined as 15 consecutive minutes of service.

1. Providers who bill in quarter-hour (15 minute) units shall complete a separate claim line on the CMS 1500 for each separate date on which services were provided and shall indicate the total number of units of service that were provided on that day.

2. Non-consecutive shorter time periods shall not be added together to total 15 minutes.

3. Non-consecutive multiple complete units of service rendered on the same day, when provided in accordance with this chapter, will be reimbursed.

(e) Medicaid/NJ FamilyCare reimbursement will not be provided for both mental health personal care assistant (PCA) services and AMHR services provided in or by a community residence program for the same beneficiary on the same date of service. Medical or physical PCA services rendered to a beneficiary will be reimbursed, if all other applicable requirements are met.

(f) Medicaid/NJ FamilyCare reimbursement will not be provided for Programs of Assertive Community Treatment (PACT) services provided to the same beneficiary on the same date of service.

(g) If a beneficiary is required to remain in a residence while awaiting transfer to a more appropriate facility (see N.J.A.C. 10:77A-2.3) , the provider shall request reimbursement at the lesser of:

1. The level of service approval for the site; or

2. The level of care which the resident requires.

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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