N.J. Admin. Code § 10:54-1.5 - Certification of physician services

(a) All physician providers shall be required to certify that the services billed on any claim were personally rendered by the physician or under his or her personal direction, except under the circumstances listed in (b) below.

(b) Physician services furnished by another physician who is not the primary physician during a period not exceeding 14 continuous days, in the case of an informal reciprocal arrangement, or for 90 continuous days, in the case of an arrangement involving per diem or other fee-for-service compensation, shall be permitted as exceptions to (a) above, in accordance with the following:

1. The primary physician may bill for physician services provided by the covering physician if the name of the covering physician is identified on the claim form and/or EPSDT form, as applicable; or

2. If the covering physician is a Medicaid/NJ FamilyCare physician provider in his or her own right, then the covering physician may bill under his or her own Medicaid/NJ FamilyCare Provider Service Number (MPSN) for services rendered during the "covering period," in accordance with 10:49-3.4.

(c) For the certification of a physician who provides services to a child under the age of 21 or to a pregnant woman, whether the service is pregnancy related or a service unique to children under 21 years of age, including a physician who provides prenatal care to a presumptively eligible pregnant woman, the following requirements shall be met:

1. Effective January 1, 1997, in order to receive reimbursement for services to a child under 21 years of age, a physician who is a Medicaid/NJ FamilyCare provider shall meet at least one of the specified criteria which follows:

i. Certification in family practice or pediatrics by the medical specialty board recognized by the American Board of Medical Specialties for family practice or pediatrics;

ii. Employment or affiliation with a Federally qualified health center, as the term is defined in Section 1905(l)(2)(B) of the Social Security Act ( 42 U.S.C. § 1396 (l));

iii. Admitting privileges at a hospital participating in an approved State Medicaid/NJ FamilyCare Plan;

iv. Membership in the National Health Service Corps;

v. Documentation of a current, formal consultation and referral arrangement with a pediatrician or family practitioner who has the certification described in (c)1i above for purposes of specialized treatment and admission to a hospital; or

vi. Certification by the Secretary of the Federal Department of Human Services as qualified to provide physician services to children under 21 years of age.

2. Effective January 1, 1997, in order to receive reimbursement for services to a pregnant woman, a physician who is a Medicaid/NJ FamilyCare provider shall meet at least one of the specified criteria listed in (c)2i through v below:

i. Certification in family practice or obstetrics by the medical specialty board recognized by the American Board of Medical Specialties for family practice or obstetrics;

ii. Employment or affiliation with a Federally qualified health center as defined in Section 1905(l)(2)(B) of the Social Security Act;

iii. Admitting privileges at a hospital participating in an approved State Medicaid/NJ FamilyCare Plan;

iv. Membership in the National Health Service Corps;

v. Documentation of a current, formal consultation and referral arrangement with an obstetrician or family practitioner who has the certification described in (c)2i above for purposes of specialized treatment and admission to a hospital; or

vi. Certification by the Secretary of the Federal Department of Human Services as qualified to provide physician services to pregnant woman.

Notes

N.J. Admin. Code § 10:54-1.5

Amended by R.2012 d.124, effective 7/2/2012.
See: 43 N.J.R. 1477(a), 44 N.J.R. 1884(a).
In (b)2, the introductory paragraph of (c)1, (c)1iii, the introductory paragraph of (c)2 and in (c)2iii, inserted "/NJ FamilyCare" throughout; in (b)2, inserted "or her"; in the introductory paragraph of (c)1 and (c)2, deleted the first sentence; in (c)1ii, inserted "§ "; and in the introductory paragraph of (c)2, substituted "(c)2i" for "i".