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New Jersey Department of Children and Families Policy Manual

 

Manual:

CP&P

Child Protection and Permanency

Effective Date:

Volume:

V

Health Services

Chapter:

A

Health Services

12-18-2000

Subchapter:

2

Medicaid

Issuance:

700

Medicaid Coverage for Children Placed Out of State

 

 

Policy                        6-30-97

 

CP&P ensures that each child under its care and supervision in a placement situation is provided with adequate medical care through the utilization of the New Jersey Health Services Program (Medicaid).

 

A CP&P Medicaid eligible child continues to be covered by the Medicaid Program when the child is placed out-of-state in a CP&P-approved resource home or residential placement.  Some children will be eligible to receive Medicaid from their new state of residence.  See CP&P-V-A-2-600, Medicaid Coverage for IV-E Children Moving Out of or Into New Jersey.

 

A CP&P child is also covered by Medicaid when he travels outside New Jersey with his resource parent(s) or a residential caregiver during vacations or temporary absences.  Services provided outside the United States and its territories are not covered by the New Jersey Medicaid program.

 

Workers have the responsibility of advising resource parents and other caregivers taking children out of New Jersey of the policy and procedures outlined in this subsection before they leave the state.  Resource parents and other caregivers must also be reminded to carry the Medicaid Eligibility Identification (M.E.I.) card with them when traveling out of state.  The card may be produced as verification of coverage when dealing with out of state medical providers unfamiliar with the New Jersey Program.

 

Administration of the Program   6-30-97

 

Out-of-state medical provider claims for services rendered to Medicaid eligible children are processed through the New Jersey Medicaid Program.

 

The Program is administered by the Division of Medical Assistance and Health Services through its Central Office and through Medical Assistance Customer Centers (MACC) located throughout the State of New Jersey.  See the list of MACCs at http://www.state.nj.us/humanservices/dmahs/info/resources/macc/MACC_Directory.pdf.The MACC is a valuable resource for field staff regarding Medicaid policy and procedures on handling Medicaid problems.  The MACC gives out-of-state providers and CP&P field offices assistance and directions in resolving out-of-state Medicaid issues.

 

Reimbursement to medical care providers is accomplished through the New Jersey Medicaid contractor, UNISYS Corporation.

 

Securing Medical Providers Out-of-State        12-18-2000

 

When a resource parent or residential treatment center provides placement services to a CP&P child outside of New Jersey, the Worker advises them to contact the Medical Society in that state and ask their assistance in locating medical providers who are willing to accept reimbursement through the New Jersey Medicaid Program.  In situations involving foster children residing out-of-state with their resource family, with an out-of-state social service agency providing CP&P with courtesy supervision, the Worker or resource parent may request assistance from the courtesy supervision agency in securing medical providers willing to accept reimbursement through New Jersey Medicaid.

 

When out-of-state providers are available and willing to provide services to a CP&P Medicaid eligible child, the child's caregiver, Worker, or the courtesy supervision agency advises the provider to make a written request for an application to become a New Jersey Medicaid provider from:

 

Provider Enrollment

UNISYS Corporation

P.O. Box 4804

Trenton, NJ  08650-4804

(Telephone #: 1-800-776-6334)

 

Approval of Provider Participation        1-17-92

 

Out-of-state medical providers approved for participation in the New Jersey Medicaid Program are required to sign an agreement with Medicaid.  The agreement acknowledges that the provider will comply with all regulations of the Program and that the provider accepts the Medicaid fee as payment in full for services and items furnished to eligible persons.

 

The out-of-state provider must sign and return the agreement to the New Jersey Medicaid Program contractor.  The provider is sent the appropriate claim forms and the appropriate Medicaid Providers Manual furnished by the New Jersey Medicaid Program.  The Medicaid Providers Manual contains information and procedures relative to participation in the Medicaid Program and the submission of claims.

 

Submission of Claims       1-17-92

 

Non-institutional providers have 90 days from the last date of service provided to a Medicaid eligible person in which to submit a claim to the Medicaid contractor.

 

Institutional claims for inpatient and outpatient hospital services are submitted to the Medicaid contractor within 12 months from the date of discharge as an inpatient or from the last date of service provided for outpatient care.

 

Pharmaceutical claims must be filed within 90 days from the date the service was provided to the patient.

 

Care and Services Requiring Prior Authorization     9-2-97

 

Reimbursement for certain medical care and services requires authorization from the New Jersey Medicaid Program prior to the provision of service.  Services requiring prior authorization include, but are not limited to:

 

·         Speech therapy,

 

·         Physical therapy,

 

·         Dental care, other than routine,

 

·         Mental health services after the Medicaid payments have reached the $900.00 limit in any 12 month service year; $400.00 for patients residing in a nursing facility or a residential health care facility; and

 

·         Certain medical supplies and equipment.

 

In accordance with N.J.A.C. 10:49-6.2, the following applies for out-of-state medical care and services:

 

“(a)  Any covered service that requires prior authorization as a prerequisite for reimbursement to New Jersey Medicaid providers shall also require prior authorization if it is to be provided in any other state.

 

1.   Services which require prior authorization are described in the specific Medicaid Provider Services Manual.”

 

The procedures for obtaining prior authorization are described in the appropriate New Jersey Medicaid Program Providers Manual.  Obtaining prior authorization is the responsibility of the provider.  However, out-of-state providers do not routinely deal with the New Jersey Medicaid Program and therefore the Worker assists providers in obtaining prior authorization when necessary.  The Worker must advise out-of-state caregivers that when there is a question as to the need for extensive medical care for a CP&P child, the caregiver is to inform the Worker.

 

The Worker consults the Medical Assistance Customer Center to obtain clarification regarding the need to obtain prior authorization.  See the list of MACCs at http://www.state.nj.us/humanservices/dmahs/info/resources/macc/MACC_Directory.pdf. When it is required, the Worker advises the child's caregiver and the provider that prior authorization is necessary and that the necessary information will be provided by the MACC.

 

Reimbursement Rates      1-17-92

 

All providers will be reimbursed at the established New Jersey Medicaid Program rate or the rate charged by the provider, whichever is lower.  Requests by the providers to resource parents, natural parents, residential treatment centers, or CP&P to supplement a New Jersey Medicaid Program payment are not honored.

 

Requests for reimbursement above Medicaid rates are reported by the Worker to the MACC.

 

Emergencies                       6-30-97

 

When a foster child, or child in an out-of-state resource home or residential treatment placement, requires emergency medical attention, the child's caregiver locates and obtains medical services from any provider.  The caregiver must explain to the provider that the child is covered by the New Jersey Medicaid Program and request that the provider submit the bill through the Medicaid Program.

 

In order to receive payment from New Jersey Medicaid the provider must either be a NJ Medicaid provider, or complete the necessary paperwork to become one.  The provider and the Worker may contact the Medical Assistance Customer Center for assistance in this process.

 

If the provider absolutely refuses to accept Medicaid as the method of payment and demands immediate payment, the child's caregiver may pay for the service(s) and request reimbursement from CP&P.  The caregiver's request for reimbursement must contain the following:

 

·         A receipt from the provider for payments made,

 

·         The child's Medicaid number,

 

·         Diagnosis,

 

·         The date the service was rendered,

 

·         Treatment given, and

 

·         The providers' name and address.

 

Although they are not necessary for billing purposes, recommendations for follow-up care may be included as they are often helpful for case management purposes.

 

Upon receipt of the caregiver's request for reimbursement, the Worker submits a CP&P Form 16-76, Special Approval Request, through his immediate supervisor for approval by the LO Manager, or his/her designee.  A copy of the Agreement Between the New Jersey Division of Child Protection and Permanency and Adoption Parents Regarding Subsidy Payments, CP&P Form 14-184, or CP&P Form 14-188, Annual Notice Regarding Adoption Subsidy, may take the place of the CP&P Form 16-76 if the Agreement specifies that CP&P is responsible for the medical expense.  See CP&P-IV-C-8-100.  The Worker forwards CP&P Form K-100, Client Service Invoice, to the caregiver for completion.  The caregiver completes the form, signs it, attaches appropriate receipts and returns the form to the Local Office for processing. 

 

If the resource parent or caregiver is unable to pay for emergency medical service out of pocket, the medical provider must forward the bill to the child's Local Office of supervision.  The Local Office processes the bill according to the CP&P Form K-100 procedures.  As noted above, a Special Approval Request, CP&P Form 16-76, or a copy of CP&P Form 14-184 or CP&P Form 14-188, is required to authorize the payment.