N.J. Admin. Code § 10:52-2.15

Current through Register Vol. 57, No. 1, January 6, 2025

Section 10:52-2.15 - Termination of pregnancy

(a) The Division shall reimburse for medically necessary termination of pregnancy procedures on Medicaid/NJ FamilyCare beneficiaries when performed by a physician in accordance with N.J.A.C. 13:35-4.2. These services are reimbursed fee-for-service for all beneficiaries, including individuals enrolled in an MCO.

(b) A physician may take the following factors into consideration in determining whether a termination of pregnancy is medically necessary:

1. The termination of the pregnancy is necessary to save the life of the mother;

2. The pregnancy was the result of an act of rape;

3. The pregnancy was the result of an act of incest; or

4. In the physician's professional judgment, the termination was medically necessary, consistent with the following factors:

i. Physical, emotional, and psychological factors;

ii. Family reasons; and

iii. The age of the mother.

(c) The determination of medical necessity is subject to review by the Division in accordance with the rules of the Division. In addition, the procedure must be performed consistent with N.J.A.C. 13:35-4.2.

(d) A "Physician Certification (Form FD-179)" shall be attached to the hospital's Medicaid claim form, either for inpatient or outpatient services, if any of the procedures on the claim relate to a voluntary elective abortion.

i. A copy of the completed FD-179 shall also be attached to:

(1) The physician's Medicaid claim form; and,

(2) The anesthesiologist's Medicaid claim form.

(e) Any New Jersey hospital with electronic billing capabilities shall submit a "hard copy" of the UB-92 claim form (inpatient or outpatient) for all termination of pregnancy claims with the "Physician Certification (Form FD-179)" attached to the UB-92 claim form and must not submit the claim through the electronic billing system.

N.J. Admin. Code § 10:52-2.15

Amended by 50 N.J.R. 1261(a), effective 5/21/2018