N.J. Admin. Code § 10:58-1.7 - Basis of reimbursement
(a) Reimbursement
for certified nurse midwifery services shall be based upon the provider's usual
and customary charge or the allowance determined by the Commissioner of the
Department of Human Services and contained in N.J.A.C. 10:58-3, whichever is
less.
(b) A certified nurse midwife
who is approved as a provider of services by the New Jersey Medicaid or the NJ
FamilyCare programs, and who practices independently and not as part of a
physician group or other organized medical care entity, may be directly
reimbursed by the New Jersey Medicaid/NJ FamilyCare-Plan A fee-for-service
programs, in accordance with the provisions of this chapter.
(c) The basis for reimbursement of services
provided in a birth center is as follows:
1.
The birth center shall receive a facility fee of $ 1,300, exclusive of
laboratory, drugs, and professional fees, for beneficiaries attended on-site
during labor and delivery.
2. A
birth center shall receive a facility fee of $ 500.00, exclusive of laboratory,
drugs, and professional fees, for beneficiaries who are admitted to the birth
center in labor but subsequently transferred to a hospital.
3. The HCPCS codes for billing for birth
center facility services are described in
N.J.A.C.
10:58-3.5(g).
4. A birth center shall be reimbursed for
professional CNM services provided by a CNM employed by the birth center in
accordance with
N.J.A.C.
10:58-1.6(a). The birth
center shall not be reimbursed for professional CNM services provided by a CNM
who is an independent provider.
5.
A physician who provides professional services in a birth center shall bill for
his or her services in accordance with
N.J.A.C.
10:54-4.33 in order to receive reimbursement
for professional services.
6. A
birth center billing for laboratory services shall meet all requirements found
in N.J.A.C. 10:58-2.9 through
2.13.
7. A birth center billing for
medications shall meet all requirements found in
N.J.A.C.
10:58-2.17.
8. A birth center may bill for certain
injections relative to maternity care or provided to the newborn at the time of
delivery, in accordance with
N.J.A.C.
10:58-3.5(c).
(d) A certified nurse midwife who
is salaried and whose services are reimbursed as part of the hospital's cost
shall not bill fee-for-service to the New Jersey Medicaid/NJ FamilyCare-Plan A
fee-for-service program. A certified nurse midwife who is practicing in a
hospital outpatient department and whose reimbursement is not part of the
hospital's cost may bill fee-for-service to the New Jersey Medicaid/NJ
FamilyCare-Plan A fee-for-service program, independent of the hospital charges,
if the arrangement with the hospital permits it.
(e) When a certified nurse midwife is
employed by a physician, nurse midwifery services shall be identified as
separate and distinct from physician services by utilization of procedure codes
with the "WM" modifier, as designated under the CMS Healthcare Common Procedure
Coding System (HCPCS) in N.J.A.C. 10:58-3.
(f) When a certified nurse midwife is
employed by a clinic, nurse midwifery services shall be identified by
utilization of the procedure code with the "WM" modifier as designated under
the Healthcare Common Procedure Coding System (HCPCS) in N.J.A.C.
10:66.
(g) For the requirements for
HealthStart Maternity providers, see
N.J.A.C.
10:58-2.5, 3.5 and 3.6(h).
(h) Reimbursement shall not be made for, and
clients shall not be asked to pay for, broken appointments.
Notes
See: 30 N.J.R. 1060(a).
Amended by R.1998 d.209, effective
See: 30 N.J.R. 57(a), 30 N.J.R. 1613(a).
Inserted a new (c) and recodified former (c) through (g) as (d) through (h).
Adopted concurrent proposal, R.1998 d.487, effective
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.2001 d.204, effective
See: 33 N.J.R. 1160(a), 33 N.J.R. 2188(a).
Substituted "FamilyCare-Plan A fee-for-service" for "KidCare" throughout.
Amended by R.2006 d.338, effective
See: 38 N.J.R. 2003(a), 38 N.J.R. 3900(a).
In (e), substituted "CMS Healthcare" for "HCFA"; and in (f), substituted "Healthcare" for "HCFA".
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