1 of 46 documents new jersey administrative code



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§ 10:56-2.16 Pediatric dental services
(a) In recognition of the unique needs of providing dental care for children, and in conformance with the Federally mandated Early and Periodic Screening, Diagnosis and Treatment program for providing services for children, a special HCPCS code has been defined, "D0150 EP," to be used by dental providers when billing for comprehensive clinical oral evaluations of children.

(b) A dental provider shall bill using the HCPCS code for a comprehensive clinical oral evaluation provided to a child.

1. This evaluation may be either an initial or a periodic evaluation.

2. For determining when this HCPCS code may be used, a child is defined as a person under the age of 21 years.

(c) The HCPCS code D0150 EP is reimbursed at an enhanced rate of $ 26.00 for a specialist and $ 22.00 for a non-specialist. Reimbursement for a comprehensive clinical oral evaluation of a child, through age 20 years, shall be limited to once every six months, except as authorized by a Division dental consultant. At a minimum, the evaluation shall include:

1. Thorough observation of all conditions present in the oral cavity and contiguous structures including an oral cancer screening;

2. Assessment of dental development;

3. Charting of all abnormalities;

4. Development of a complete treatment plan to be recorded in its entirety, including provisions for further treatment and follow-up, by referral if necessary;

5. Anticipatory guidance concerning dental health to the patient or parent/guardian;

6. Assessment of the caries index and nutritional needs relating to oral health and oral hygiene practices; and

7. Assessment of systemic or topical fluoride needs.



28 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 2. PROVISIONS FOR SERVICES
N.J.A.C. 10:56-2.17 (2014)
§ 10:56-2.17 Adjunctive general services
(a) General anesthesia, parenteral conscious sedation, enteral sedation and analgesia rules are as follows:

1. For general anesthesia, parenteral conscious sedation, enteral sedation and analgesia, dental providers shall comply with all applicable rules, including, but not limited to, the permit requirements of N.J.A.C. 13:30-8.1A, 13:30-8.2, 13:30-8.3, 13:30-8.4 and 13:30-8.20 for the service, or similar requirements of the state in which the service is rendered. A valid copy of the permit issued by the New Jersey State Board of Dentistry or the state in which the service is rendered shall be on file with the Division's Provider Enrollment Unit in order for the Medicaid/NJ FamilyCare fee-for-service programs to reimburse a dentist for administering anesthesia, sedation or analgesia. Providers of dental services shall, within 30 days after receiving such original or renewal permit, forward a copy of the permit by certified mail, return receipt requested, to the following address:


Unisys


Provider Enrollment Unit

PO Box 4804

Trenton, New Jersey 08650-4804

2. In any setting exclusive of a hospital, when general anesthesia is provided by the dentist, such may be reimbursed subject to the following:

i. Necessity for same is demonstrated.

ii. The administration of local anesthesia is considered part of the operative or surgical procedure and no additional fee will be paid.

iii. When general anesthesia is administered by a dentist, such service is reimbursable provided:

(1) Anesthetic management is necessary to perform the dental services.

(2) Special general anesthesia codes are utilized (see N.J.A.C. 10:56-3).

(3) An anesthesia record is maintained and a copy is submitted with the Dental Claim Form (MC-10) for anesthesia and treatment.

(A) The anesthesia record submitted shall show elapsed anesthesia time, pinpoint the time and amounts of drugs administered, pulse rate and character, blood pressure, and respiration.

(B) Elapsed anesthesia time means the time from induction of the general anesthesia to the point in time when the anesthetist is no longer in personal attendance.

3. Reimbursement for the administration of parenteral conscious sedation shall be subject to the following conditions:

i. Such sedation is in effect continuously during the dental procedure.

ii. No reimbursement will be made for injections given as preoperative medication.

iii. The practitioner shall record the need for this service.

iv. There shall be only one charge for intravenous sedation per visit.

4. Reimbursement for enteral sedation shall be subject to the following conditions:

i. Oral sedation is in effect continuously during the dental procedures.

ii. Reimbursement shall be on a flat fee basis and shall be all inclusive of the cost of the service and the drug.

iii. The provider shall record the need for the service in the provider's record for the beneficiary.

iv. This service can be provided four times a year per beneficiary without prior authorization, in those situations where prior authorization would otherwise be required.

v. The appropriate procedure code, name of the drug and dosage shall be noted on the Dental Prior Authorization Form (MC-10A) and the Dental Claim Form MC-10. Documentation explaining the need for the service shall be submitted with the request.

5. An inhalation anesthetic for the purposes of analgesia shall be reimbursable as part of a dental procedure, subject to the following conditions:

i. Analgesia is administered, as needed, continuously during the operative or surgical procedure.

ii. No reimbursement shall be made for an injection given as pre-operative medication.

iii. The provider shall state the need for this service in the provider's record for the beneficiary.

iv. There can be only one charge for analgesia per visit.

(b) Within the scope of accepted dental practice, and in accordance with all applicable rules, including, but not limited to, N.J.A.C. 13:30-8.4, intradermal, subcutaneous, intramuscular, and intravenous injections shall be reimbursable in the office or home as follows:

1. Reimbursement for the above injections shall be on a flat fee basis and shall include the cost of the service and the drug.

2. A visit for the sole purpose of an injection shall be reimbursable for the injection only. If other dental procedures are performed that are reimbursable, an injection may, if medically indicated, be reimbursed in addition to the other procedures. The drug administered shall be consistent with the diagnosis and shall conform to accepted medical and pharmacological principles in respect to dosage, frequency, and route of administration.

3. Intravenous injections shall be reimbursable only when performed by the dentist.

4. No reimbursement shall be made for vitamins, liver or iron injections or combinations thereof except in laboratory proven deficiency states requiring parenteral therapy.

5. No reimbursement shall be made for placebos or any injections containing amphetamines or derivatives thereof.

6. No reimbursement shall be made for an injection given as a preoperative medication in conjunction with general anesthesia or as a local anesthetic which is part of an operative or surgical procedure.

7. Prior authorization shall be required for such injections. The provider shall submit the Dental Prior Authorization Form, (MC-10A), and the Dental Claim Form (MC-10) with the appropriate procedure code, name of the drug injected, dosage and route of administration, along with the complete diagnosis for which the injection was given shall be documented under "Description of Service."

(c) Drugs, biologicals, or supplies used, administered or provided by the dentist shall be considered part of the professional service and no additional fee will be authorized.


29 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 2. PROVISIONS FOR SERVICES
N.J.A.C. 10:56-2.18 (2014)
§ 10:56-2.18 Adjunctive general services: prescriptions
(a) This section is intended to describe the practitioner's responsibility in the writing of prescriptions in order to maintain the traditional beneficiary-prescriber-provider relationship, and to insure the beneficiary free choice of provider. Practitioners are urged to familiarize themselves with all aspects of this section in order to effect economies consistent with good medical/dental practices and to facilitate prompt payment to the provider.

1. The New Jersey Medicaid/NJ FamilyCare program will reimburse pharmaceutical providers for prescriptions prescribed by a dentist within the scope of their practice as defined by the State of New Jersey or the state in which they are practicing.

2. The New Jersey Medicaid/NJ FamilyCare program has an approved generic formulary (see N.J.A.C. 8:71). The prescriber shall give preference to generic drugs of equal therapeutic effectiveness if available at a lower cost than proprietary or brand named drugs. When prescribing a brand named multi-source drug product for which a maximum allowance cost (MAC) limitation has been established by the Secretary of the Department of Health and Human Services, the prescriber shall write "brand medically necessary" on each written prescription. When prescribing a non-MAC brand named drug, the prescriber may initial either "substitution allowed" or "dispense as written (DAW)" on each written prescription.

i. For claims with service dates on or after July 1, 1999, the pharmacist shall dispense the least expensive, therapeutically effective nutritional supplement or specialized infant formula, at the time of dispensing, unless the prescriber indicates in his or her own handwriting on each written prescription, or follow-up written prescription to a telephone rendered prescription, the phrase "Brand Medically Necessary."

(b) The practitioner's individual Medicaid/NJ FamilyCare Provider Service Number shall appear on all prescriptions, and shall be given to the pharmacist with all telephone orders. The appearance of this number in addition to the practitioner's name serves to expedite the mechanical aspects of processing the prescription claim. This requirement is a necessary and efficient step in computing each claim.

(c) The beneficiary's full name, address, and age shall appear on all prescriptions.

(d) The practitioner shall include specific directions on all drug prescriptions or the prescription will not be eligible for payment. Examples of non-acceptable directions are prn, as directed, and ad lib.

(e) The choice of prescription drugs remains at the discretion of the prescribing practitioner. However, the practitioner should be aware that pharmacies will not receive payment for certain prescription drugs. (See (g) below.)

1. The practitioner should give preference to:

i. Drugs listed in the latest edition of the United States Pharmacopoeia (U.S.P.), National Formulary (N.F.), A.M.A. Drug Evaluation, and Accepted Dental Therapeutics;

ii. Oral medication, when as effective as injectable preparations.

(f) The quantity of medication prescribed should provide a sufficient amount of medication necessary for the duration of the illness or an amount sufficient to cover the interval between visits, but shall not exceed a 34-day supply for initial prescriptions or 34-day supply or 100 dosage units, whichever is greater, for refill prescriptions.

1. Any drug used continuously (that is, daily, three times daily, every other day, and so forth) for 14 days or more is considered to be a sustaining drug or maintenance medication and should be prescribed in sufficient quantities to treat the beneficiary for up to 34 days for initial prescriptions or provide a 34-day supply or 100 dosage units, whichever is greater, for refill prescriptions.

2. In long term medical care facilities (that is, nursing facilities, intermediate care facilities, or inpatient psychiatric programs for children under the age of 21), if the quantity of sustaining drug or maintenance medication is not indicated in writing by the prescriber, the pharmacy provider shall dispense an appropriate quantity of medication not to exceed a one month supply.

3. The quantity of medication prescribed shall provide a sufficient amount of medication necessary for the anticipated duration of the illness, or if required, an amount sufficient to provide medication during intervals between prescriber visits. The amount of medication dispensed shall not exceed a 34-day supply for initial prescriptions, or 34-day supply or 100 dosage units, whichever is greater, for refill prescriptions.

(g) Pharmaceutical services not eligible for payment shall be as follows:

1. Drugs for which adequate literature, that is, package inserts, and so forth and price catalogues are not readily available;

2. Experimental drugs;

3. Drugs administered or directly furnished by the practitioner. (Payment for drugs will be made only when dispensed by a registered pharmacist in a licensed pharmacy).

4. Preventive drugs and biologicals provided without charge through programs of other public or voluntary agencies (that is, New Jersey State Department of Health and Senior Services and so forth).

5. Medications prescribed for use by hospital inpatients.

6. Prescribed non-legend over-the-counter drugs for beneficiaries in nursing facilities.

7. Prescriptions written and dispensed with nonspecific directions.

8. Medications prescribed for a Title XIX (Medicaid) covered person who is receiving benefits under part A of Title XVIII (Medicare) as a beneficiary in a nursing facility.

9. Prescribed non-legend drugs unless listed below:

i. Exceptions shall include non-legend drugs other than antacids; contraceptive devices and contraceptive supplies; diabetic testing materials; over-the-counter (OTC) family planning supplies; inhalation devices (pharmaceutical); insulin; and insulin needles and/or syringes;

ii. Coverage of non-legend drugs for beneficiaries under the age of 21 shall include: Analgesics, Salicylates; Analgesics/Antipyretics, Non-salicylate; Antidiarrheals; Anti-Emetics; Antiflatulents; Antihistamines; Antipruritics; Antitussives, non-narcotic; Cathartics; Cough and cold preparations; Emetics; Expectorants; Hematinics; Iron replacement supplements; Laxatives; Multiple vitamin preparations; Pediatric vitamin preparations; Vitamins A, B, C, D, E, K, B1, B2, B6, B12 preparations; Polymyxin and derivatives; Topical preparations, antibacterial; Topical antibiotics; and Topical anti-inflammatory preparations.

10. Drugs for which final orders have been published by the Food and Drug Administration, withdrawing the approval of their new drug application (NDA).

(h) Prescriptions may be telephoned or faxed to the pharmacist when in accordance with all applicable Federal and State laws and regulations, and shall include the prescriber's individual Medicaid Provider Service Number.

1. When a dentist chooses to certify that a brand is medically necessary, for a MAC listed drug product, the dentist shall fax or submit a written prescription order to the pharmacist, containing the certification within seven days of the date of the telephone order.

(i) Prescription refill requirements are as follows:

1. Refill instructions shall be indicated by the practitioner on the original prescription.

2. Prescriptions shall be limited to a maximum of five refills within a six month period. If additional quantities of the same medications are required, a new prescription shall be written by the practitioner.

3. Refill instructions indicating "refill PRN" shall be honored for payment only up to the limits imposed in this subsection.



30 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 2. PROVISIONS FOR SERVICES
N.J.A.C. 10:56-2.19 (2014)
§ 10:56-2.19 Adjunctive general services: medical supplies
Following receipt of a prescription from the dentist, prior authorization from the Medical Assistance Customer Center shall be obtained by the medical supplier for certain medical supplies; therefore, the practitioner shall be prepared to certify and document dental necessity to the Division dental consultant.


31 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 2. PROVISIONS FOR SERVICES
N.J.A.C. 10:56-2.20 (2014)
§ 10:56-2.20 Consultations
(a) Consultations shall be subject to the following conditions:

1. A written report which includes diagnosis and recommendations for future management shall be provided to the referring practitioner. A copy shall be retained with the beneficiary's records and must be available, upon request, to the New Jersey Medicaid/NJ FamilyCare fee-for-service programs or any of their authorized representatives.

i. When the practitioner rendering the consultation services assumes the continuing care of the beneficiary, any subsequent services rendered by him or her will no longer be considered as consultation.

ii. When consultation services are requested, the referring practitioner shall include on the clinical records the name of the consulting practitioner to whom the beneficiary is being referred. The consulting practitioner shall note the diagnosis under Remarks (Item 20) and the name and the Medicaid/NJ FamilyCare Provider Services number of the referring practitioner on the clinical records and on the Dental Claim Form (MC-10) under Referring Practitioner (Item 14).

iii. A consultation shall be disallowed if either or both diagnosis or referring practitioner is missing. However, an examination may be billed alone or in conjunction with other treatment if the beneficiary makes an appointment on his or her own.

iv. A consultation shall be disallowed if performed on the same beneficiary by the same practitioner, members of the same group, members of a shared health care facility, or practitioners sharing a common record within a 12 month span of a prior claim for the same or related disease, illness or condition.

v. A consultation shall be declined in any setting, if the consultation occurs between members of the same group, shared health care facility, or practitioners sharing common records.

vi. If a consultation is billed in an inpatient setting and the beneficiary is then transferred to the service of the consultant, the consultant shall not bill for a Hospital Call.



32 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 2. PROVISIONS FOR SERVICES
N.J.A.C. 10:56-2.21 (2014)
§ 10:56-2.21 Pharmaceutical: program restrictions affecting payment for prescribed drugs
(a) The choice of prescribed drugs shall be at the discretion of the prescriber within the limits of applicable laws. However, the prescriber's discretion is limited for certain drugs. Reimbursement shall be denied (except for dentist's prescriptions) if the requirements of the following rules are not met:

1. Covered and non-covered pharmaceutical services as listed in the Pharmaceutical Services chapter at N.J.A.C. 10:51-1.11 and 1.12, respectively, incorporated herein by reference;

2. Pharmaceutical services requiring prior authorization (see N.J.A.C. 10:51-1.13, incorporated herein by reference);

3. Quantity of medication (see N.J.A.C. 10:51-1.14, incorporated herein by reference);

4. Dosage and directions (see N.J.A.C. 10:51-1.15, incorporated herein by reference);

5. Telephone-rendered original prescriptions (see N.J.A.C. 10:51-1.16, incorporated herein by reference);

6. Changes or additions to the original prescription (see N.J.A.C. 10:51-1.17, incorporated herein by reference);

7. Prescription refill (see N.J.A.C. 10:51-1.18, incorporated herein by reference);

8. Prescription Drug Price and Quality Stabilization Act (N.J.S.A. 24:6E-1 et seq.) (see N.J.A.C. 10:51-1.20, incorporated herein by reference);

i. Products listed in the New Jersey Drug Utilization Review Council (DURC) Formulary, N.J.A.C. 8:71, (hereafter referred to as, "the Formulary"); and

ii. Non-proprietary or generic dispensing (see N.J.A.C. 10:51-1.9, incorporated herein by reference).

9. Federal regulations (42 CFR 447.301, 447.331-447.333) that set the aggregate upper limits on payment for certain multi-source drugs if Federal Financial Participation (FFP) is to be made available. The limit applies to all "maximum allowable cost" drugs (see N.J.A.C. 10:51-1.5, Basis of payment, incorporated herein by reference);

10. Drug Efficacy Study Implementation (DESI): "less than effective drugs" subject to a Notice of Opportunity for Hearing (NOOH) by the Federal Food and Drug Administration (see N.J.A.C. 10:51-1.20 and listing of DESI drugs in Appendix A of N.J.A.C. 10:51, incorporated herein by reference);

11. Drug Manufacturers' Rebate Agreement with the Centers for Medicare & Medicaid Services of the United States Department of Health and Human Services (see N.J.A.C. 10:51-1.21, incorporated herein by reference);

12. Medical exception process (see N.J.A.C. 10:56-2.22); and

13. Diabetic testing materials, including blood glucose reagent strips, urine monitoring strips, tapes, tablets, and lancets. Electronic blood glucose monitoring devices or other devices used in the monitoring of blood glucose levels are considered medical supplies and are covered services by Medicaid/NJ FamilyCare. These services require prior authorization from the Medical Assistance Customer Center (MACC). (See Medical Supplier Services chapter, N.J.A.C. 10:59.)



33 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 2. PROVISIONS FOR SERVICES
N.J.A.C. 10:56-2.22 (2014)
§ 10:56-2.22 Medical exception process (MEP)
(a) For pharmacy claims with service dates on or after September 1, 1999, which exceed PDUR standards recommended by the New Jersey DUR Board and approved by the Commissioners of DHS and DHSS, the Division of Medical Assistance and Health Services has established a Medical Exception Process (MEP).

(b) The medical exception process (MEP) shall be administered by a contractor, referred to as the MEP contractor, under contract with the Department of Human Services.

(c) The medical exception process shall apply to all pharmacy claims, regardless of claim media, unless there is a recommended exemption by the New Jersey DUR Board which has been approved by the Commissioners of DHS and DHSS, in accordance with the rules of those Departments.

(d) The medical exception process (MEP) is as follows:

1. The MEP contractor shall contact prescribers of conflicting drug therapies, or drug therapies which exceed established PDUR standards, to request written justification to determine medical necessity for continued drug utilization.

i. The MEP contractor shall send a Prescriber Notification Letter which includes, but may not be limited to, the beneficiary name, HSP identification number, dispense date, drug quantity, drug description. The prescriber shall be requested to provide the reason for medical exception, diagnosis, expected duration of therapy, and expiration date for medical exception.

ii. The prescriber shall provide information requested on the Prescriber Notification to the MEP contractor.

2. Following review and approval of a prescriber's written justification, if appropriate, the MEP contractor shall override existing PDUR edits through the issuance of a prior authorization number.

3. The MEP contractor shall notify the pharmacy and prescriber of the results of their review and include at a minimum, the beneficiary's name, mailing address, HSP number, the reviewer, service description, service date, and prior authorization number, if approved, the length of the approval and the appeals process if the pharmacist does not agree with the results of the review.

4. Prescribers may request a fair hearing to appeal decisions rendered by the MEP contractor concerning denied claims (see N.J.A.C. 10:49-10, Notices, Appeals and Fair Hearings).



34 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 3. HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS)
N.J.A.C. 10:56-3.1 (2014)

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