N.J. Admin. Code § 10:54-1.3 - Provider participation criteria

(a) All physicians, licensed doctors of medicine or surgery (M.D.) or doctors of osteopathy (D.O.) or podiatric medicine pursuant to N.J.A.C. 13:35 (incorporated herein by reference), authorized to provide medical and surgical services by the State of New Jersey, who are an approved Medicaid/NJ FamilyCare program participating provider in accordance with (b) below, and who comply with all the rules of the New Jersey Medicaid/NJ FamilyCare program, are eligible to provide medical and surgical services for Medicaid/NJ FamilyCare program beneficiaries.

1. Any out-of-State physician may provide medical and surgical services under this Program if he or she meets the comparable documentation and licensing requirements in the State in 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 and current certification at the time of the application for enrollment.

(b) In order to participate in the Medicaid/NJ FamilyCare program as a physician, the physician shall apply to, and be approved by, the New Jersey Medicaid/NJ FamilyCare program. An applicant for approval by the New Jersey Medicaid/NJ FamilyCare program as a physician provider shall complete and submit the "Medicaid/NJ FamilyCare Provider Application" (FD-20) and the "Medicaid/NJ FamilyCare Provider Agreement" (FD-62). These forms can be downloaded free of charge or completed and filed online at www.njmmis.com. The FD-20 and FD-62 can also be found as Forms #8 and #9 in the Appendix at the end of the Administration chapter (N.J.A.C. 10:49) and may be obtained from and submitted to:

Molina Medicaid Solutions

Provider Enrollment

PO Box 4804

Trenton, New Jersey 08650-4804

(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 physician will receive written notification of approval or disapproval. If approved, the physician 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.

1. Each physician, or each Certified Nurse Midwife or Advanced Practice Nurse (APN), who is the provider of the service or member of the group practice, shall place a Medicaid/NJ FamilyCare Provider Service Number (MPSN) on all written prescriptions and shall provide the MPSN with all telephone orders. The MPSN shall be entered on all claims submitted by the provider, to expedite the processing of claims. The Medicaid/NJ FamilyCare Provider Billing Number is also required on all Medicaid/NJ FamilyCare claim forms as a condition of payment. (See also 10:49-3.4.) In the case of a physician/practitioner group, the group number is the Medicaid/NJ FamilyCare Provider Billing Number.

(d) In order to participate as a provider of HealthStart services, the physician practicing independently or as part of a group shall be a Medicaid provider and shall meet the requirements as specified at N.J.A.C. 10:54-6, including the provider participating criteria specified in 10:54-6.3. The physician shall also possess a valid HealthStart Certificate, issued by the New Jersey State Department of Health and Senior Services. An application for a HealthStart Provider Certificate is available from:

New Jersey Department of Health and Senior Services

Division of Family Health Services

50 East State Street

PO Box 364

Trenton, New Jersey 08625-0364

Notes

N.J. Admin. Code § 10:54-1.3

Amended by R.2001 d.51, effective 2/5/2001.
See: 32 N.J.R. 3929(a), 33 N.J.R. 555(a).
In (a), inserted a reference to podiatric medicine and substituted "beneficiaries" for "recipients" in the introductory paragraph.
Amended by R.2004 d.334, effective 9/7/2004.
See: 36 N.J.R. 312(a), 36 N.J.R. 4136(a).
In (c), inserted "/NJ FamilyCare" following "Medicaid" throughout and substituted "APN" for "CNP/CNS" in the first sentence of 1.
Amended by R.2012 d.124, effective 7/2/2012.
See: 43 N.J.R. 1477(a), 44 N.J.R. 1884(a).
In the introductory paragraph of (a), deleted a comma following "(M.D.)" and inserted "/NJ FamilyCare program" following the first and third occurrence of "Medicaid" and "/NJ Family Care" following the second occurrence of "Medicaid"; in (a)1 and in the introductory paragraph of (b), inserted "/NJ FamilyCare" throughout; in the introductory paragraph of (b), inserted the third sentence, inserted "also", substituted "chapter" for "Chapter" and deleted a comma preceding "and may"; in the address in (b), substituted "Molina Medicaid Solutions" for "Unisys Corporation"; in the introductory paragraph of (c), deleted a comma following the second occurrence of "Number"; and in (c)1, substituted "Advanced Practice Nurse (APN)" for "APN".