The following is a memorandum from Meghan Davey, Director of the Division of Medical Assistance and Health Services, and Josh Lichtblau, Director of the Medicaid Fraud Division of the New Jersey Department of Human Services (DHS).
A recent e-mail states that this September 18, 2017, memorandum is a revision the state of New Jersey’s “guidance with regard to DDD-funded habilitative therapies. Effective immediately, individuals enrolled or transitioned into a fee-for-service waiver program will not require a denial from the individual’s Medicaid managed care organization in order to access a DDD-funded therapy that is habilitative in nature. This includes physical therapy, occupational therapy, and speech, language and hearing therapy. As with all medically necessary services, the fact that the applicable service is necessary for habilitation must be documented by an appropriate health care professional.
“The September 18 memorandum supersedes the current applicable policies found in Section 17 of the Supports Program and Community Care Waiver (CCW) Policies and Procedures Manuals; and the policy manuals will be revised accordingly on their next iteration.”
“The Division of Medical Assistance and Health Services (DMAHS) and the Medical Fraud Division (MFD) have become aware of concerns presented by stakeholders related to the use of an individual’s Division of Developmental Disabilities (DDD) budget to fund occupational, physical, and speech therapy services for habilitation purposes. Specifically, stakeholders have complained that the process to make payments for habilitative services is unduly burdensome. To address these concerns, DMAHS and MFD (collectively “the State”) are issuing the guidance below.
“The State has identified specific DDD-funded waiver services that are habilitative in nature and, thus, should not require a denial from a Medicaid beneficiary’s managed-care organization (MCO) in order for DDD to authorize approved providers to submit claims and be reimbursed. These services include the following:
- Physical Therapy—Individual (S8990HI)
- Physical Therapy—Group–Blended (S8990HIUN)
- Speech, Language, and Hearing Therapy—Individual (92507HI)
- Speech, Language, and Hearing Therapy—Group–Blended (92507HIUN)
- Occupational Therapy—Individual (97535HI)
- Occupational Therapy—Group–Blended (97535HIUI)
“As with the provision of all medically necessary services, the fact that the services listed above are necessary for habilitation must be documented by an appropriate health care professional.
“When therapies are rehabilative in nature, an Explanation of Benefits (EOB) from the MCO will still be required prior to authorization to utilize DDD waiver funding.
“We trust that the above will reduce the administrative burden that exists with respect to the submission of claims for the above-listed habilitative services and the payment for such claims.”
The original memorandum is in PDF format on the DDD website.