N.J. Admin. Code § 11:22-9.5 - Installment reimbursement

(a) For providers electing to be reimbursed for maternity services on an installment basis, carriers shall remit at least three equal installment payments during the term of the covered person's pregnancy as follows:

1. Following the 12th week of pregnancy;

2. Following the 28th week of pregnancy; and

3. Following delivery.

(b) Carriers shall accept billings under the CPT codes most current to the date of billing for services established by the American Medical Association indicating a request for installment payments prior to delivery. The CPT codes as of July 5, 2011 are as follows:

1. 59425--Antepartum care only (4-6 visits); and

2. 59426--Antepartum care only (7 or more visits).

(c) Carriers shall accept billings under the CPT codes most current to the date of billing for services established by the AMA for a final installment payment following delivery. The CPT codes for such services as of July 5, 2011 include the following:

1. 59410--Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care;

2. 59515--Cesarean delivery only; including postpartum care;

3. 59614--Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care; and

4. 59622--Cesarean delivery, following attempted vaginal delivery after previous cesarean delivery; including postpartum care.

(d) The total of all installment payments received by an obstetrical provider shall not be less than the amount the provider would have received under the carrier's global payment for routine maternity care.

(e) If an obstetrical provider receives one or more installment payments from a carrier that include payment for services not actually rendered by the provider (for example, in the event the pregnancy is terminated or the delivery is performed by a different provider), the carrier may retroactively adjust the installment payments to the prevailing rates applicable to the services actually rendered.

Notes

N.J. Admin. Code § 11:22-9.5