N.J. Admin. Code § 10:49-7.1

Current through Register Vol. 56, No. 23, December 2, 2024

Section 10:49-7.1 - General provisions

(a) The following information outlines the policies and regulations of the New Jersey Medicaid/NJ FamilyCare program that the provider shall adhere to when submitting a claim and requesting payment for services provided to a New Jersey Medicaid/NJ FamilyCare beneficiary. (To identify a Medicaid/NJ FamilyCare beneficiary, see N.J.A.C. 10:49-2.)

1. Each Provider Services Manual has information relevant to the basis of payment for services and items of payment provided that is usually found in the second chapter of each manual.

2. For requirements of the Division of Medical Assistance and Health Services and the New Jersey State Department of Health and Senior Services when submitting a claim to be considered for the charity care component of the disproportionate share subsidies for hospital services and other rules regarding eligibility for these services, see N.J.A.C. 10:52-11, 12 and 13.

3. The rules of this subchapter shall also apply when submitting a claim for services provided to Medicaid/NJ FamilyCare beneficiaries who are enrolled in managed care programs but who are provided certain services through the regular Medicaid program. See N.J.A.C. 10:49-5 for a list of services that are eligible to be reimbursed on a fee-for-service basis when provided to Medicaid/NJ FamilyCare beneficiaries enrolled in managed care programs.

(b) In addition to information in this subchapter about submitting claims for payment, a Fiscal Agent Billing Supplement is included following each Provider Services Manual. Included in the Supplement are prior authorization forms and instructions; information for the proper completion and submission of claim forms; the procedure to follow when claims are rejected and returned to the provider by the Fiscal Agent during the adjudication process; third party liability verification, procedure for submitting crossover claims, and examples of timely submission of claims; electronic media claims (EMC) submission; Remittance Advice Statements; procedures for Electronic Funds Transfer (EFT); adjustments for overpayment of claims, and adjustments by Medicare; procedure to follow when a claim is paid in error (voids); procedure for inquiries about claims; procedure for ordering forms; information about provider services; and item-by-item instructions for completing the claim form and other forms.

1. The Fiscal Agent Billing Supplement is not published in the New Jersey Administrative Code (N.J.A.C.) but is referenced as an appendix and is thus, not a legal description of the New Jersey Medicaid program's rules. Should there be any conflict between the Fiscal Agent Billing Supplement and the pertinent laws or rules governing the Medicaid program or the charity care program, the laws and rules of the Medicaid program and the charity care program, as appropriate, take precedence.

N.J. Admin. Code § 10:49-7.1

Amended by R.1997 d.354, effective 9/2/1997.
See: 29 N.J.R. 2512(a), 29 N.J.R. 3856(a).
In (a), substituted "beneficiary" for "recipient"; in (b), deleted "form" or "forms" following "claim" and "claims".
Amended by R.1997 d.520, effective 1/5/1998.
See: 29 N.J.R. 1006(a), 30 N.J.R. 232(a).
Inserted (a)2; in (b), clarified precedence of Medicaid rules over Fiscal Agent Billing Supplement, and added references to "charity care program."
Amended by R.2003 d.82, effective 2/18/2003.
See: 34 N.J.R. 2650(a), 35 N.J.R. 1118(a).
In (a)2, amended the N.J.A.C. references.
Amended by R.2003 d.485, effective 12/15/2003.
See: 35 N.J.R. 509(a), 35 N.J.R. 5568(a).
In (a)2, amended N.J.A.C. references.
Amended by R.2008 d.230, effective 8/4/2008.
See: 40 N.J.R. 984(a), 40 N.J.R. 4531(a).
In the introductory paragraph of (a), inserted "/NJ FamilyCare" three times and substituted "beneficiary" for "recipient" twice; and added (a)3.