N.J. Admin. Code § 10:71-3.13 - County welfare agency responsibility and procedures

(a) The CWA shall furnish the Medical Review Team with current, pertinent social and medical information, and obtain any special or additional reports on request.

(b) When it appears that an applicant meets the income and resources requirements for Medicaid Only, arrangements for obtaining medical evidence should be initiated immediately by whichever of the following procedures is applicable to the applicant's situation:

1. When the applicant is currently (within three months) under the care of a private physician, he or she shall be furnished with a copy of Form PA-5 (Examining Physician's Report) to take to the physician for completion;

2. If the applicant is currently receiving treatment in a hospital clinic, public health facility (that is, tuberculosis clinic, mental health clinic or other outpatient facility) on a regular basis for the medical condition related to his or her application for Medicaid Only, a copy or abstract of the clinic record may be submitted in lieu of the PA-5;

3. If the applicant has been hospitalized within three months for a condition related to the impairment for which he or she is applying for Medicaid Only, an abstract of the hospital record may be submitted for patients in long-term care facilities;

4. In the event none of the above are applicable, the CWA should assist the applicant in choosing a physician to complete the PA-5, who is competent to determine the nature and extent or degree of disability; or

5. When the applicant states that he or she is blind or that visual impairment is his or her primary disability, the CWA shall, prior to submission of the record to the Medical Review Team, obtain a Report of Eye Examination (Form PA-5A) from a qualified medical specialist in diseases of the eye (for example, ophthalmologist), or an optometrist, or from an eye clinic of a general hospital, whichever the individual may select. (The membership directory of the Medical Society of New Jersey is suggested as reference for identification of, in each municipality, physicians specializing in diseases of the eye.) Optometrists are listed in the yellow pages of local telephone directories under the heading "Optometrists--Doctors of Optometry." The Form PA-5A should be transmitted in duplicate to the Medical Review Team with any other pertinent medical evidence as outlined above. When appropriate, the Certification of Need for Patient Care in Facility Other Than Public or Private General Hospital (Form PA-4) will be submitted to the Medical Review Team.

(c) Other evidence, such as education, training, work experience and daily living activities, shall be submitted to the Medical Review Team by completion of the PA-6 (Medical-Social Information Report). The PA-6 shall be carefully and completely filled out.

(d) If the applicant refuses to furnish medical or other evidence concerning his or her disability, the application for Medicaid Only shall be referred to the Medical Review Team for recommendations.

(e) As soon as medical reports and the Medical Social Information Report (PA-6) are completed, one copy of each shall be stapled together for transmittal to the Medical Review Team. It shall be clearly indicated on the PA-6 that this is a Medicaid Only case. Records transmitted by the Medical Review Team on a given date shall be listed by registration number and name on an inventory sheet, prepared in duplicate, the cases being grouped by case status. One copy shall be attached to the submittal records, the duplicate retained as CWA control.

(f) The CWA will prepare a similar inventory and attach cases returned to the CWA on a given date. Attached to each will be Form PA-8 (Record of Action) containing the determination of eligibility by the Medical Review Team and any necessary instructions.

(g) Upon receipt of records from the Medical Review Team, the CWA shall examine the PA-8 (Record of Action) for the action of the Medical Review Team and for specific instructions or recommendations, and to note the review date.

(h) Recommendations will be made by the medical consultant to alert the CWA to the possibilities of adequate medical care for the client and to provide specific pertinent questions to be raised with the attending physician. The medical social work consultant will make recommendations to help the CWA staff recognize the social problems indicated in the client's situation and the relationship between these problems and his or her physical and mental adjustment.

(i) The following procedures shall be observed in respect to the Medical Review Team actions:

1. "Approved" cases:

i. CWA shall complete, as necessary, determination of eligibility in respect to other factors and, if applicant is eligible, take the necessary action to obtain Medicaid benefits.

ii. When an applicant is not eligible in respect to any other factor, although "approved" for the disability or blindness factor, the application shall be denied.

iii. The CWA shall establish and maintain a control file for "approved" cases in order that the date for determination review by the Medical Review Team will be observed and considered according to N.J.A.C. 10:71-5.

iv. The Medical Review Team (MRT) shall also maintain a control file in order to ensure appropriate and timely reevaluation by the MRT. The MRT will notify CWA one month in advance of cases scheduled for such review. Cases also for reevaluation will be listed on Form PA-655.

2. "Undetermined" cases:

i. If further medical and/or social information is required by the MRT for the initial determination of eligibility, the CWA shall obtain the information promptly and resubmit the case. Reports from medical specialists shall be submitted on their own letterheads.

ii. If the applicant fails or refuses to present himself/herself for required examinations or tests, the application shall be referred to the MRT for recommendations.

3. "Disapproved" cases:

i. Any case determined as not medically eligible for "Medicaid Only" by the MRT shall be denied Medicaid Only by the CWA.

ii. Appropriate notification shall be given to the applicant as well as any specific recommendations for follow-up care and treatment.

(j) When page 5 of Form PA-5 carries the signature of the medical consultant approving the payment of the examining physician, such payment shall be forwarded to the physician from administrative funds, regardless of whether the action on the record of action is "approved", "disapproved" or "undetermined". (In an "undetermined" case, if the request for additional information relates to an incomplete report from the examining physician, approval for payment will not appear on page 5 of the PA-5.)

(k) Payment for special diagnostic reports shall likewise be forwarded to the medical specialist or clinic from administrative funds regardless of whether the case is "approved", "disapproved", or "undetermined".

(l) Maximum allowances for examining physician (completion of PA-5) are as follows.

1. Examination at office or hospital: $ 20.00.

2. Examination at patient's home: $ 30.00.

3. Examination at public institution: No fee.

(m) Diagnostic examination services rules are:

1. This subsection is concerned with medical specialty consultant evaluation services and diagnostic studies (that is, clinical laboratory, diagnostic x-ray and special diagnostic examinations) incident thereto, authorized by a CWA upon recommendation of the MRT, when deemed essential as part of the initial determination of medical eligibility.

2. These examinations and procedures are exclusively for diagnostic eligibility, are chargeable as matchable administrative costs and a medical vendor payment should be promptly made upon approval of the consultant's report by the reviewing physician employed by the State agency.

3. The following schedule of fees is exclusive to laboratory, x-ray and other special diagnostic studies which may be required.

i. Diagnostic Consultation and Report (ophthalmologic includes refraction: otological includes audiometric screening) other than psychiatric or neurologic: $ 45.00.

ii. Diagnostic Consultation requiring complete psychiatric or complete neurological examination or complete neuropsychiatric examination, with detailed report: $ 50.00.

iii. Electrocardiogram with interpretation and report: $ 25.00.

(n) Payment of the above allowance is to be approved only when the specialist has received prior authorization to perform the diagnostic evaluation and when the examination is performed by a qualified specialist (that is, eligible for or certified by the appropriate American board; or recognized by hospital, community and peers as a specialist, and practice is limited to the specialty). See current membership directory of the Medical Society of New Jersey.

(o) The fee(s) listed in fees for professional and diagnostic services issued by the Medical-Surgical Plan of New Jersey (Revised 6-1-73) shall be approved when diagnostic x-ray or radioisotope studies, laboratory and/or special diagnostic studies are deemed essential by the medical specialist authorized to perform the diagnostic consultant evaluation. Payment based on the allowances listed by the Medical-Surgical Plan, Series 575, shall be limited to medical specialists as defined in the section.

Notes

N.J. Admin. Code § 10:71-3.13

As amended, R.1977 d.334, effective 10/1/1977.
See: 9 N.J.R. 340(a), 9 N.J.R. 479(c).
As amended, R.1978 d.212, effective 6/22/1978.
See: 10 N.J.R. 190(c), 10 N.J.R. 344(c).
As amended, R.1979 d.364, effective 11/1/1979.
See: 11 N.J.R. 379(b), 11 N.J.R. 519(e).
As amended, R.1979 d.449, effective 11/13/1979.
See: 11 N.J.R. 518(a), 11 N.J.R. 527(d).
Amended by R.1995 d.651, effective 12/18/1995.
See: 27 N.J.R. 3543(a), 27 N.J.R. 5046(a).
Amended by R.2000 d.415, effective 10/16/2000.
See: 32 N.J.R. 2565(a), 32 N.J.R. 3844(a).
Substituted references to CBOSSs for references to CWAs and substituted references to the Medical Review Team for the Disability Review Unit throughout.
Amended by R.2012 d.025, effective 2/6/2012.
See: 43 N.J.R. 804(a), 44 N.J.R. 230(a).
Section was "County board of social services responsibility and procedures". Rewrote the section.