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1 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES


N.J.A.C. 10:56 (2014)
Title 10, Chapter 56 -- Chapter Notes
CHAPTER AUTHORITY:

N.J.S.A. 30:4D-1 et seq. and 30:4J-8 et seq.



2 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES

SUBCHAPTER 1. DENTAL SERVICES; GENERAL PROVISIONS
N.J.A.C. 10:56-1.1 (2014)
§ 10:56-1.1 Purpose and scope
This chapter describes the requirements of the New Jersey Medicaid/NJ FamilyCare fee-for-service programs pertaining to the provision of, and reimbursement for, medically-necessary dental services to eligible beneficiaries. In addition to the provider's private office, dental services may be provided in the home, hospital, ambulatory surgical center, approved independent clinic, nursing facility, intermediate care facility for the mentally retarded (ICF/MR), residential treatment center, or elsewhere.


3 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES

SUBCHAPTER 1. DENTAL SERVICES; GENERAL PROVISIONS
N.J.A.C. 10:56-1.2 (2014)
§ 10:56-1.2 Definitions
The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise.

"Ambulatory Surgical Center (ASC)" means any distinct entity that: operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization; has an agreement with the Centers for Medicare & Medicaid Services (CMS) as a Medicare participating provider for ambulatory surgical services; is licensed, if required, by the New Jersey State Department of Health and Senior Services, or is similarly licensed by a comparable agency of the state in which the facility is located; and meets the enrollment and participation requirements of the New Jersey Medicaid/NJ FamilyCare programs as indicated at N.J.A.C. 10:49-3.2, and 10:66-1.3.

"Attending dentist" means one who assumes the primary and continuing dental care of the beneficiary. The services of only one attending dentist will be recognized at a given time.

"Clinical laboratory services" means professional and technical laboratory services ordered by a dentist within the scope of practice as defined by the laws of the state in which the dentist practices and, which are provided by a laboratory.

"Concurrent care" means that type of service rendered to a beneficiary by practitioners where the dictates of dental necessity require the services of dentists of different specialties in addition to the attending dentist so that needed care can be provided.

"Consultation" means that service rendered by a qualified dentist upon request of another practitioner in order to evaluate through personal examination of the beneficiary, history, physical findings and other ancillary means, the nature and progress of a dental or related disease, illness, or condition and/or to establish or confirm a diagnosis, and/or to determine the prognosis, and/or to suggest treatment. A consultation should not be confused with "referral for treatment" when one practitioner refers a beneficiary to another practitioner for treatment, either specific or general, for example, "Endodontic treatment on teeth No.'s 3 and 5"; or "Extract teeth No.'s 7, 8, 9, and 10"; or "Extract tooth or teeth causing pain."

"Dental Services" means any diagnostic, preventive, or corrective procedures administered by or under the direct personal supervision of a dentist in the practice of the practitioner's profession. Such services include treatment of the teeth, associated structures of the oral cavity and contiguous tissues, and the treatment of disease, injury, or impairment which may affect the oral or general health of the individual. Such services shall maintain a high standard for quality and shall be within the reasonable limits of those services which are customarily available, accepted by, and provided to most persons in the community within the limitations, and exclusions hereinafter specified.

"Direct personal supervision" means the actual physical presence of the dentist on the premises.

"Division" means the Division of Medical Assistance and Health Services.

"Emergency" means a specific condition of the oral cavity and/or contiguous tissues which causes severe and/or intractable pain and/or could compromise the life, health, or safety of the beneficiary unless treated immediately. For example:

1. Pain or acute infection from a restorable or a non-restorable tooth;

2. Pain resulting from injuries to the oral cavity and related structures;

3. Extensive, abnormal bleeding;

4. Fractures of the maxilla or mandible or related structures or dislocation of the mandible.

"Non-routine dental service" means any dental service that requires prior authorization by a Medicaid/NJ FamilyCare dental consultant in order to be reimbursed by the New Jersey Medicaid/NJ FamilyCare program.

"Nursing facility" means a long-term care facility or an intermediate care facility for the mentally retarded (ICF/MR).

"Participating dentist" means any dentist licensed to and currently registered to practice dentistry by the licensing agency of the State where the dental services are rendered, who accepts the promulgated requirements of the New Jersey Division of Medical Assistance and Health Services, and signs a provider agreement with the Division.

"Program" means the New Jersey/NJ FamilyCare program.

"Prior authorization" means approval by a dental consultant to the New Jersey Medicaid/NJ FamilyCare program before a service is rendered.

"Referral" means the directing of the beneficiary from one practitioner to another for diagnosis and/or treatment.

"Routine dental service" means any dental service that is reimbursable by the New Jersey Medicaid/NJ FamilyCare program without authorization by a Medicaid/NJ FamilyCare dental consultant.

"Specialist" means one who is licensed to practice dentistry in the state where treatment is rendered, who limits his or her practice solely to his or her specialty, which is recognized by the American Dental Association and is registered as such with the licensing agency in the state where the treatment is rendered.

"Transfer" means the relinquishing of responsibility for the continuing care of the beneficiary by one dentist and the assumption of such responsibility by another dentist.


4 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES

SUBCHAPTER 1. DENTAL SERVICES; GENERAL PROVISIONS
N.J.A.C. 10:56-1.3 (2014)
§ 10:56-1.3 Provisions for provider participation
(a) A Doctor of Dental Medicine (DMD) or a Doctor of Dental Surgery (DDS), pursuant to N.J.A.C. 13:35 (incorporated herein by reference), who is authorized to provide dental and surgical services by the State of New Jersey, who is an approved Medicaid/NJ FamilyCare fee-for-service participating provider in accordance with (b) below, who complies with all of the rules of the New Jersey Medicaid/NJ FamilyCare fee-for-service programs, shall be eligible to provide dental and surgical dental services to Medicaid/NJ FamilyCare fee-for-service beneficiaries.

1. Any out-of-State dentist may provide dental and surgical services under this program if he or she meets the documentation and licensing requirements in the State which he or she is practicing, and is a New Jersey Medicaid/NJ FamilyCare participating provider.

2. An applicant shall provide the Division with a photocopy of the current license at the time he or she applies for enrollment.

(b) In order to participate in the Medicaid/NJ FamilyCare program as a dentist, a dental practitioner shall apply to, and be approved by the New Jersey Medicaid/NJ FamilyCare program. An applicant shall complete and submit the "Medicaid Provider Application" (FD-20) and the "Medicaid Provider Agreement" (FD-62). The FD-20 and FD-62 can be found as Forms #8 and #9 in the Appendix at the end of Administration Chapter (N.J.A.C. 10:49), and may be obtained from and submitted to:

Unisys Corporation

Provider Enrollment

PO Box 4804

Trenton, NJ 08640-4804

(c) Upon signing and returning the Medicaid/NJ FamilyCare Provider Application, the Provider Agreement and other enrollment documents to the fiscal agent for the New Jersey Medicaid/NJ FamilyCare program, the dentist will receive written notification of approval or disapproval. If approved, the dentist will be assigned a Medicaid/NJ FamilyCare Provider Billing Number, a Medicaid/NJ FamilyCare Provider Service Number, and will be provided with an initial supply of pre-printed claim forms.


5 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES

SUBCHAPTER 1. DENTAL SERVICES; GENERAL PROVISIONS
N.J.A.C. 10:56-1.4 (2014)
§ 10:56-1.4 Prior authorization
(a) For dental services that require prior authorization, a Prior Authorization Form, (MC-10A), and the Dental Claim Form (MC-10), shall be submitted to:

Division of Medical Assistance and Health Services

Office of Utilization Management

Bureau of Dental Services, Mail Code 21

PO Box 713

Trenton, New Jersey 08625-0713

Telephone: (609) 588-7136

1. Requests for prior authorization should include recent diagnostic radiographs. When appropriate for the service requested, documentation to substantiate or demonstrate the need for the requested dental services shall also be included.

(b) Oral hygiene devices require prior authorization, regardless of cost.

(c) Consideration for prior authorization shall be based on the least costly appliance fulfilling the requirements of the specific situation or the extenuating circumstances.

(d) Dental services which require prior authorization and are defined as "non-routine services" are specified at N.J.A.C. 10:56-3 and are designated by one of the following indicators:

1. A single asterisk (*); or

2. A double asterisk (**); and/or

3. A crosshatch (#).

(i) The crosshatch denotes that a special authorization requirement(s) exists. The requirements are listed adjacent to the procedure codes involved.

4. Those services which do not require prior authorization have no asterisk or crosshatch indicators and are those basic services defined by Medicaid/NJ FamilyCare as "routine services."

(e) Prior authorization requests cannot be transferred from one dentist to another.

(f) Situations which require prior authorization for services which would otherwise be considered routine services include:

1. Services involving more than one supernumerary tooth;

2. The extraction of restorable teeth or teeth with no carious lesions;

3. Extractions in conjunction with orthodontic treatment not being reimbursed by the Medicaid/NJ FamilyCare program; and

4. Services to teeth that were denied as having been previously extracted.

(g) Prior authorization for additional and/or amended services that are found to be necessary after the original dental treatment plan has been prior authorized may be requested by recording such need on the Dental Prior Authorization Form (MC-10A). Providers shall submit a copy of the Dental Claim Form (MC-10) for the approved services and a second prior authorization request for the new services, indicating that a change in treatment plan has occurred. Providers shall include recent radiographs and any pertinent documentation to assist in consideration of the new services.

(h) Providers shall complete all dental procedures in both arches before impressions are taken for dentures. Payment for prior authorized dentures will be denied unless all dental procedures are completed in both arches before impressions are taken.

(i) Prior authorizations shall be effective for one year from the date of authorization and for the three months immediately preceding the date of authorization. Prior authorized ("non-routine") services shall be completed within one year of the date of the original authorization by the Division dental consultant.

1. If providers are unable to complete the services within the prior authorized period, providers may contact the Division dental consultant and request an extension of the authorized effective period, in accordance with (g) above.

2. All requirements of N.J.A.C. 10:49-7.2, regarding timeliness of claim submission and inquiry requirements shall apply to all prior authorized services. Dental providers shall direct all questions regarding the status of a prior authorization request and denials of prior authorization requests to the Bureau of Dental Services, Mail Code 21, PO Box 713, Trenton, New Jersey 08625-0713, Telephone: (609) 588-7136.


6 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES

SUBCHAPTER 1. DENTAL SERVICES; GENERAL PROVISIONS
N.J.A.C. 10:56-1.5 (2014)
§ 10:56-1.5 Basis for reimbursement
(a) Reimbursement for covered services furnished under the New Jersey Medicaid/NJ FamilyCare fee-for-service programs shall be the customary and usual fee of the provider when it does not exceed Federal regulatory maximums and reasonable rates as determined by the Commissioner of Human Services. In no instance shall the charge to the program exceed the usual and customary fee of the provider for identical services to other governmental agencies or other groups or individuals in the community.

1. If a beneficiary receives care from more than one member of a partnership or corporation in the same discipline for the same service, the total maximum payment allowance would be the same as that of a single attending dentist. The allowance fee for a given service shall constitute full payment. No additional charge shall be made by the dentist to, or on behalf of, the covered Medicaid/NJ FamilyCare fee-for-service beneficiary.

2. The procedure codes which are used when submitting claims are listed in N.J.A.C. 10:56-3--Health Care Financing Administration (HCFA) Common Procedure Coding System (HCPCS). The Fiscal Agent Billing Supplement that follows N.J.A.C. 10:56-3 in Appendix A provides information about the claim form and billing instructions. The provider, when submitting claims for services rendered, shall comply with the provisions of N.J.A.C. 10:56, Appendix A, which is incorporated herein by reference.

(b) A fee will be paid only for services rendered. If an eligible beneficiary does not return for completion of the treatment plan, only those services provided shall be billed.

(c) If circumstances involving an eligible beneficiary, over which the provider has no control, preclude completion of a service and/or authorized appliance, the New Jersey Medicaid/NJ FamilyCare fee-for-service programs will reimburse the provider of services an amount consistent with the stage of completion of the authorized service and/or appliance.

1. The stage of completion of the service shall be detailed on the Dental Claim Form (MC-10), or in the case of an appliance, denture or crown, the case (to the point of completion) shall be forwarded to a dental consultant for proration as determined by the Division dental consultant. The case will be returned to the provider and shall be retained for at least one year pending possible return of the beneficiary.

i. Requests for prorated reimbursement shall be submitted with all appropriate dental forms (either the dental claim for previously approved services or both the dental claim and the prior authorization form), a copy of the treatment plan and pertinent treatment records, any lab work to stage of completion and a written explanation of why the services were not completed. Payment will be delayed when requests for prorated reimbursement are incomplete.

ii. Should a patient return and completion of the prorated case occurs, the balance can be reimbursed. Prior authorization for the additional fee shall be submitted for review by a Division dental consultant. The provider shall include in the request documentation that the patient has returned and that the prorated work has been completed.

(d) Partial reimbursement for an appliance completed but not delivered to the beneficiary because of circumstances beyond the control of the provider will be authorized by the New Jersey Medicaid/NJ FamilyCare program. An amount equivalent to the professional component for inserting and adjusting the appliance will be deducted from the total reimbursement for such appliance. In the event the beneficiary returns and the service is completed, the provider may request reimbursement for the deducted amount. Procedures as outlined in (c) above will apply.

(e) Reimbursement is not made for, and beneficiaries shall not be asked to pay for, broken appointments.

(f) Reimbursement will be made only for dental treatment provided during the period of beneficiary eligibility, except that the treatment listed in paragraphs 1 through 5 below, if authorized and actually in the process of being rendered during such period, may be completed and payment allowed, provided the services are completed within 60 calendar days following the termination of eligibility, unless indicated below.

1. Prostheses (to include, for example, dentures, crowns, space maintainers, and appliances, but not comprehensive orthodontic appliances or services) actually in process of fabrication;

2. Extractions and such ancillary services as general anesthesia and radiographs, in conjunction with the insertion of an immediate denture when initial impressions have been taken during the period of eligibility;

3. Endodontic treatment if pulp has been extirpated and treatment authorized and those services necessary to complete the restoration of that tooth such as filling restoration(s) or, if authorized during a period of eligibility, post and core and crown.

4. Notwithstanding any rule in this chapter to the contrary, payment may be made for a denture(s) furnished after termination of eligibility of an individual where the last tooth in any specific arch is extracted during the period of eligibility.

i. A denture, complete or partial, may be furnished in the opposing arch as described at N.J.A.C. 10:56-2.13, Prosthodontic treatment, if it meets the guidelines of the program as specified in this chapter, and is authorized in conjunction with the above denture.

ii. In order to obtain reimbursement for this denture(s), the primary impression(s) shall be initiated within 120 days and the denture(s) inserted within 180 days after the extraction of the last tooth. Authorization procedures set forth in these rules are applicable.

5. For immediate dentures, similar to provisions for dentures inserted subsequent to the healing period, prior authorization shall have been obtained during the eligibility period and all preliminary extractions completed during that same period. Authorized immediate complete dentures shall be completed within 180 days of termination of eligibility.

i. A denture, complete or partial, may be furnished in the opposing arch as described at N.J.A.C. 10:56-2.13, Prosthodontic treatment, if it meets the guidelines of the program as specified in this chapter, and is authorized in conjunction with the above denture.

ii. In order to receive reimbursement for this denture(s), primary impression(s) shall be initiated within 120 days and the denture inserted 180 days after the last preliminary extraction. Prior authorization procedures set forth in this chapter shall apply as described at N.J.A.C. 10:56-1.4.

(g) When other health or liability insurance is available, the Medicaid/NJ FamilyCare program requires that such benefits be utilized first and to the fullest extent. See N.J.A.C. 10:49-7.3, Third party liability (TPL) benefits, for further information. Supplemental payment shall be made by the Medicaid/NJ FamilyCare program up to the provider's customary and usual fee, if the combined total does not exceed the amount payable under the Medicaid/NJ FamilyCare program.

1. When other health insurance is involved, claims should not be filed with the Program unless accompanied by a statement of payment or denial from any other carriers.

2. Medicare coinsurance and deductible shall be payable by the New Jersey Medicaid/NJ FamilyCare program in combination Medicare/ Medicaid cases.

(h) Failure to comply with documentation requirements will result in denial of claims, delays in payment and recovery of any payments made prior to determinations of non-compliance.

(i) Authorization of dental treatment or services shall not guarantee payment by the Medicaid/NJ FamilyCare fee-for-service programs. The provider shall assure, at the time of each visit, that the beneficiary being treated is eligible for the Medicaid/NJ FamilyCare programs, and for the dental services to be rendered, by using the beneficiary's health benefits identification card with one of the eligibility verification systems available to the provider. See N.J.A.C. 10:49-2 for beneficiary eligibility information.


7 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES

SUBCHAPTER 1. DENTAL SERVICES; GENERAL PROVISIONS
N.J.A.C. 10:56-1.6 (2014)
§ 10:56-1.6 Reimbursement based on specialist designation
(a) To obtain reimbursement as a specialist in the Medicaid/NJ FamilyCare programs, a specialist shall:

1. Obtain a specialty certification from the licensing agency of the State of New Jersey or of the state where dental services are to be rendered; or

2. In those states not requiring specialty certification:

i. The specialist shall be a diplomate of a specialty board recognized by the American Dental Association or shall meet the minimum requirements for that specialty as stipulated by the American Dental Association.

(b) Any provider who meets the qualifications in (a) above and desires specialist reimbursement shall submit proof of specialist certification as described above to:

Unisys


Provider Enrollment Unit

PO Box 4801

Trenton, New Jersey 08650-4801

(c) Specialist reimbursement shall be limited to the following specialties:

1. Oral and Maxillofacial Surgery;

2. Endodontics;

3. Pedodontics--Pediatric Dentistry;

4. Orthodontics;

5. Periodontics; and/or

6. Prosthodontics.



8 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES

SUBCHAPTER 1. DENTAL SERVICES; GENERAL PROVISIONS
N.J.A.C. 10:56-1.7 (2014)

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