N.J. Admin. Code § 10:66-1.3 - Provisions for provider participation

(a) Each independent clinic, including each satellite, shall be individually approved by the New Jersey Medicaid and NJ FamilyCare fee-for-service programs and enrolled with the Division's fiscal agent, for approved service(s). If a clinic wishes to add a service(s), approval from the New Jersey Medicaid and NJ FamilyCare fee-for-service programs shall be obtained before reimbursement for the service(s) may be claimed. For additional details, see the Administration chapter, N.J.A.C. 10:49-3.2, Enrollment process, and N.J.A.C. 10:49-3.3, Providers with multi-locations.

1. All clinical practitioners directly affiliated with the clinic shall enroll in the New Jersey Medicaid and NJ FamilyCare fee-for-service programs, as indicated in the Administration chapter at N.J.A.C. 10:49-3.4, in order to obtain an individual Medicaid and NJ FamilyCare fee-for-service Provider Number(s).

2.

(Reserved)

(b) Each independent clinic seeking enrollment in the New Jersey Medicaid and NJ FamilyCare fee-for-service programs shall possess a certificate of need and/or license, if required, from the New Jersey State Department of Health, or the Division of Mental Health and Addiction Services, or from both agencies, or possess similar documentation by a comparable agency of the state in which the facility is located.

1. The facility shall provide only those services for which it is licensed or authorized to provide by the New Jersey State Department of Health or the Division of Mental Health and Addiction Services, or both, if applicable, or for which the facility is similarly licensed or authorized by a comparable agency of the state in which the facility is located.

2. A photocopy of the license shall be forwarded to the New Jersey Medicaid and NJ FamilyCare fee-for-service programs as an attachment to the clinic's initial application for enrollment and when the license is renewed on an annual basis.

(c) In addition to (a) and (b) above, each independent clinic shall obtain approval from the relevant Federal and State agencies, as required by law, rule, and/or regulation, including, but not limited to, the following:

1. For an ambulatory surgical center, an agreement with the Centers for Medicare & Medicaid Services (CMS) under Medicare to participate as an ambulatory surgical center and licensure as an ambulatory surgical center, by the New Jersey State Department of Health or by a comparable agency of the state in which the facility is located;

2. For a Federally qualified health center, approval by the Centers for Medicare & Medicaid Services as a Federally qualified health center and licensure, by the New Jersey State Department of Health or by a comparable agency of the state in which the facility is located, as an ambulatory care facility;

3. For an ambulatory care/family planning/surgical facility, licensure as an ambulatory care/family planning/surgical facility by the New Jersey State Department of Health or by a comparable agency of the state in which the facility is located;

4. For a dental clinic, a permit to operate shall be obtained from the State Board of Registration and Examination in Dentistry (see N.J.A.C. 13:30-4.2) or from a comparable agency of the state in which the facility is located, prior to enrollment as a dental clinic provider, and shall remain in effect;

5. For a mental health clinic or substance use disorder treatment facility, approval by the Division of Mental Health and Addiction Services or by a comparable agency of the state in which the facility is located; and

6. For child health conferences, approval by the New Jersey State Department of Health in accordance with N.J.A.C. 8:52 and as indicated at N.J.A.C. 10:66-3, or by a comparable agency of the state in which the facility is located.

(d) Each out-of-State clinic seeking reimbursement for services provided to New Jersey Medicaid and NJ FamilyCare fee-for-service beneficiaries shall enroll, if the clinic is approved by Title XIX (Medicaid) in its own state, in the New Jersey Medicaid and NJ FamilyCare fee-for-service programs as indicated in the Administration chapter at N.J.A.C. 10:49-3.2(c).

(e) Each Medicaid or NJ FamilyCare fee-for-service beneficiary's care in an independent clinic shall be under the supervision of a physician directly affiliated with the clinic. The Medical Director or his or her designee shall assume professional responsibility for the services provided and thus assure that the services are medically appropriate.

(f) A physician affiliated with a clinic shall spend as much time in the facility as is necessary to assure that Medicaid and NJ FamilyCare fee-for-service beneficiaries are receiving services in a safe and efficient manner in accordance with accepted standards of medical and dental practice.

(g) For a physician to be affiliated with a clinic, there shall be a contractual agreement or some other type of formal, written arrangement on file at the facility between the physician and the facility by which the physician is obligated to supervise the care provided to the clinic's Medicaid and NJ FamilyCare fee-for-service beneficiaries.

1. The contractual agreement or formal, written arrangement shall indicate the physician's responsibilities and compensation.

(h) The clinic's medical staff, including physicians, dentists, and other practitioners, shall be appropriately licensed in order to provide the medical care delivered to Medicaid and NJ FamilyCare fee-for-service beneficiaries.

Notes

N.J. Admin. Code § 10:66-1.3

Amended by 49 N.J.R. 1405(a), effective 6/5/2017