New Jersey Medicaid Prior Authorization Requirements for PCA Services

Per the New Jersey Administrative Codes, prior authorization is mandatory for all Personal Care Assistance (PCA) services. These services are reviewed based on a written plan of care documenting the member’s certification of need for personal, hands-on care. A registered professional nurse uses the state-approved PCA Assessment Tool to determine the number of PCA hours required per calendar week.

Important: Unused PCA hours cannot be carried over or used on a later date, even in cases of:

• Member or home health aide illness
• Hospitalization of the member or aide

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 for more than the approved 30 hours.

Billing for unused hours in a subsequent week is considered noncompliance with New Jersey Medicaid regulations.