New Jersey Medicaid: Prior Authorization is required for all Personal Care Assistance services

Requirement aligns with New Jersey administrative codes

Per the New Jersey Administrative Codes, prior authorization is required for all Personal Care Assistance (PCA) services. PCA services are reviewed in accordance with a written plan of care documenting the member’s certification of need for personal, hands-on services. PCA services are considered necessary when the member meets criteria in the state approved PCA Assessment Tool, as determined by a registered professional nurse. The purpose of this tool is to determine the number of PCA hours per calendar week needed by the member.

It’s important to note that New Jersey administrative code states that any unused PCA hours of service cannot be saved or carried over for use on a subsequent date. This applies even in cases of member or home health aide illness, or member or aide hospitalization. Use of any such unused hours of service is considered as noncompliance.

Example: A member is approved for 30 hours of PCA services per week. In week 1, the provider bills for 20 hours, leaving 10 hours unused. In week 2, the provider cannot bill in excess of the approved 30 hours per week.