N.J. Admin. Code § 10:54-4.1

Current through Register Vol. 56, No. 19, October 7, 2024

Section 10:54-4.1 - General payment methodology

(a) Payment for physician services covered under the New Jersey Medicaid or NJ FamilyCare program is based upon the customary charge prevailing in the community for the same service but shall not exceed a "Maximum Fee Allowance Schedule" which has been determined reasonable by the Commissioner and set forth in N.J.A.C. 10:54-9 and as limited by Federal policy relative to the payment of physicians and other licensed health care practitioners.

1. In no event shall the charge to the New Jersey Medicaid or NJ FamilyCare program exceed the charge by the provider for identical services to other governmental agencies or other groups or individuals in the community.

2. Effective July 20, 1998, for services provided to beneficiaries eligible for both Medicare Part B and Medicaid or NJ FamilyCare, including Qualified Medicare Beneficiaries, Medicaid or NJ FamilyCare shall reimburse physicians and practitioners the Medicare Part B coinsurance and deductible amount or the Medicaid or NJ FamilyCare maximum fee allowable (less any third party payments, including Medicare reimbursement), whichever is less.

(b) The "Maximum Fee Allowance Schedule" differentiates rates according to whether the physician is a specialist or nonspecialist. (See 10:54-1.2 through 1.5 of this manual for regulations for specialist.)

(c) For reimbursement for injections and immunizations, see 10:54-4.3(a)6 and 10:54-9.8(h).

(d) For reimbursement for services of advanced practice nurses employed by a physician or physician group, see 10:58A-4.1 through 4.5, incorporated herein by reference.

N.J. Admin. Code § 10:54-4.1

Amended by R.1998 d.154, effective 2/27/1998 (operative March 1, 1998; to expire August 31, 1998).
See: 30 N.J.R. 1060(a).
In (a), inserted references to NJ KidCare throughout.
Amended by R.1998 d.382, effective 7/20/1998.
See: 30 N.J.R. 1255(b), 30 N.J.R. 2646(b).
In (a)2, inserted "Effective 7/20/1998," at the beginning, inserted references to NJ KidCare throughout, and substituted "less" for "greater" at the end.
Adopted concurrent proposal, R.1998 d.487, effective 8/28/1998.
See: 30 N.J.R. 1060(a), 30 N.J.R. 3519(a).
Readopted the provisions of R.1998 d.154 without change.
Amended by R.2004 d.334, effective 9/7/2004.
See: 36 N.J.R. 312(a), 36 N.J.R. 4136(a).
Amended by R.2006 d.237, effective 7/3/2006.
See: 38 N.J.R. 907(a), 38 N.J.R. 2803(a).
In (a), substituted "FamilyCare" for "KidCare" throughout.