N.J. Admin. Code § 10:49-7.2

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

Section 10:49-7.2 - Timeliness and method of Medicaid claim or other claim submission

(a) A Medicaid claim is defined as a request for payment from the New Jersey Medicaid program for a Medicaid reimbursable service provided to a Medicaid recipient.

1. A Medicaid claim or any other provider claim submitted for payment from or through the Division of Medical Assistance and Health Services shall be submitted by means of an approved method of automated data exchange unless an attachment to the claim is required, in which case the claim for payment instead shall be submitted using an approved hard copy claim form.

2. It is the responsibility of each provider to ensure that each Medicaid/NJ FamilyCare-Plan A claim submitted by that provider is received by the New Jersey Medicaid/NJ FamilyCare program's Fiscal Agent within the time periods indicated in this section. Providers shall reconcile their claims submission records with the Remittance Advice they receive from the Division's Fiscal Agent in order to verify that the Division's Fiscal Agent has received their claims. Providers shall resubmit any claims for reimbursement, which the provider determines have been submitted previously, but which do not appear on the Remittance Advice.

i. The New Jersey Medicaid program shall not reimburse for a claim received outside the prescribed time periods. This policy also applies to inquiries concerning a claim or claim related information received outside the prescribed time periods.

ii. For retroactive eligibility cases, a claim associated with a retroactive eligibility application will be considered as received on the date of receipt of the application at the appropriate eligibility determination agency on behalf of the applicant. For information about retroactive eligibility, see 10:49-2.9.

(b) "Prospective" medical bill(s) are bills submitted to the Retroactive Eligibility Unit with an Application for Retroactive Medicaid Eligibility (FD-74) on the assumption that they were incurred during the retroactive eligibility period but were actually incurred during the month of application for Medicaid or later. These bills were incurred during a time period when Medicaid eligibility already existed or should have existed (except that the individual experienced a delayed determination of Medicaid eligibility).

(c) Under the circumstances in (c)1 through 3 below, the Division of Medical Assistance and Health Services' Retroactive Medicaid Eligibility Unit will generate letters to providers whose bills were included with an Application for Retroactive Medicaid Eligibility, allowing the one-year timely submission requirements to be bypassed.

1. These "prospective" claims must not have already been submitted to the Fiscal Agent within one-year of the date that services were rendered;

2. The Application for Retroactive Medicaid Eligibility that these "prospective" bills are associated with must have been received at the Retroactive Eligibility Unit within 60 days of the date of the above mentioned letter (with the original letter attached); and

3. In order for payment to be made, these claims must remain outstanding and any collection action against the Medicaid beneficiary must be withdrawn.

(d) An institutional claim is a claim submitted by a hospital; home health agency; nursing facility; intermediate care facility/mental retardation (ICF/MR); residential treatment center; or governmental psychiatric hospital. The time requirements for submitting an institutional claim is as follows:

1. For claims submitted by home health agencies and hospitals (excluding governmental psychiatric hospitals), a claim for payment of a service provided to any Medicaid beneficiary shall be received by the New Jersey Medicaid Fiscal Agent within:

i. One year of the date of discharge on an inpatient hospital claim;

ii. One year of the date of service entered on an outpatient hospital claim or home health claim;

iii. One year of the earliest date of service entered on an outpatient hospital claim or home health claim, if the claim carries more than one date of service; or

iv. For Early and Periodic Screening, Diagnosis and Treatment (EPSDT) including pediatric HealthStart services, claims must be submitted to the Fiscal Agent within 30 days of the provision of services.

2. For claims submitted by a nursing facility; an intermediate care facility for the mentally retarded; a residential treatment center; or a governmental psychiatric hospital, a claim for payment for services shall be received by the fiscal agent no later than one year after the "from date of service" as indicated on the claim.

(e) A non-institutional claim is a claim submitted by all providers except a hospital, home health agency, nursing facility, intermediate care facility/mental retardation (ICF/MR), residential treatment center, or governmental psychiatric hospital. The time requirements for submitting a non-institutional claim are as follows:

1. A claim for payment of a non-institutional service provided to any Medicaid beneficiary shall be received by the New Jersey Medicaid Fiscal Agent within:

i. One year of the date of service;

ii. One year of the earliest date of service entered on the claim if the claim carries more than one date of service;

iii. One year (365 days) of the dispensing date on a pharmacy claim; or

(f) The time requirements for submitting a combination Medicare/Medicaid or Medicare/NJ FamilyCare claim are as follows (Under Federal regulations this applies only to Medicare/Medicaid or Medicare/NJ FamilyCare claims and does not extend to claims involving any other third party insurance.):

1. A combination Medicare/Medicaid claim is defined as a request for payment from the New Jersey Medicaid program for a medical service provided to any Medicare/Medicaid beneficiary.

i. The claim shall contain the Medicaid Eligibility Identification Number, the Medicare three digit carrier/payor code, and the Medicare HIC Number.

2. A combination Medicare/Medicaid claim shall be received by the Medicare Intermediary/Carrier within the applicable Medicaid timely submission period (see (d) and (e) above) to be considered for further payment by the New Jersey Medicaid program.

i. The provider shall continue to have one year from the date of service for a claim to be received by the Medicaid Fiscal Agent. A claim received by the Medicaid Fiscal Agent after Medicare adjudication and within one year from the date of service shall be considered timely submitted.

ii. For combination Medicare/Medicaid claims received by the Medicare Intermediary/Carrier within the applicable Medicaid timely submission period and where Medicare adjudication occurs beyond the one year of the date of service, the provider shall submit a claim to be received by the Medicaid Fiscal Agent within 90 days of the date of the Medicare adjudication.

iii. For Medicare/Medicaid claims where the Medicare adjudication occurs within one year from the date of service, but less than 90 days remain within the timely filing period, the provider shall submit the claim to be received by Medicaid within the one year timely filing period or 90 days, whichever is later.

iv. A combination Medicare/Medicaid claim received outside the applicable Medicaid timely submission period shall not be reimbursed by the New Jersey Medicaid program.

3. In most cases, when a beneficiary is eligible for both Medicare and Medicaid, or Medicare and NJ FamilyCare, a Medicare/Medicaid approved claim will crossover from the Medicare Carrier/Intermediary to the program's Fiscal Agent. The provider is requested to allow 45 days from Medicare adjudication for the Medicaid or NJ FamilyCare program to receive and process crossover claims. Failure to allow the 45 days for the transition from Medicare to Medicaid or NJ FamilyCare will result in claim denials due to duplicate claim errors. There are instances, however, where claims will not cross over from Medicare. In those instances, or when a Medicare/Medicaid or Medicare/NJ FamilyCare crossover is not reflected on the provider's Medicaid Remittance Advice within 45 days of the Medicare Explanation of Benefits (EOB), the provider shall follow the billing instructions in the Fiscal Agent Billing Supplement following the second chapter of the provider services manual.

(g) If additional information is required in order to process a Medicaid claim, the provider shall supply the information as soon as possible but not more than 30 days after the end of the timely submission period.

(h) Regarding a Medicaid claim submitted timely that has been adjudicated and denied, a provider may resubmit the claim within one year of the date of service or 30 days of the date of adjudication as indicated in the Remittance Advice Statement, whichever is later.

(i) If it appears that an individual is eligible for Supplemental Security Income (SSI), the Medicaid provider or a designee should, but is not required to, assist the patient in completing and submitting an application for SSI. The application for SSI shall be submitted to the Social Security Administration (SSA) so that it is received by the SSA within the time requirements for claim submission contained in (a) through (h) above. For institutional and non-institutional claims for services provided to an individual who was not found to be eligible for Medicaid as of the date of service and who thereafter is determined to be eligible for SSI (for that date of service) by the SSA, and, therefore, also eligible for Medicaid (for that date of service), the following requirements shall apply:

1. If the individual's application for SSI is received by the SSA within the time requirements for claim submission contained in (a) through (h) above, the Medicaid provider or a designee shall file a claim for services rendered to the individual so that it is received by the State's fiscal agent within the later of the following:

i. The applicable time requirements for claim submission contained in (a) through (h) above;

ii. Six months from the date of the SSI eligibility determination; or

iii. Six months from the date that the SSI/Medicaid eligibility data appears on the New Jersey Medicaid Management Information System.

N.J. Admin. Code § 10:49-7.2

Amended by R.1997 d.354, effective 9/2/1997.
See: 29 N.J.R. 2512(a), 29 N.J.R. 3856(a).
Substituted "beneficiary" for "recipient" and deleted "form" following "claim" throughout; and in (b)2, substituted "Medicaid Eligibility Identification Number" for "HSP (Medicaid) Case Number" and inserted reference to three digit carrier/payer.
Amended by R.1997 d.520, effective 1/5/1998.
See: 29 N.J.R. 1006(a), 30 N.J.R. 232(a).
Rewrote (a), inserted new (a)1 and recodified existing (a)1 as (a)2.
Amended by R.1998 d.116, effective 1/30/1998 (operative February 1, 1998; to expire July 31, 1998).
See: 30 N.J.R. 713(a).
In (d), inserted references to Medicare/NJ KidCare and to NJ KidCare, and made corresponding language changes, throughout, and inserted a reference to Medicare and NJ KidCare in the first sentence of 3.
Amended by R.1998 d.154, effective 2/27/1998 (operative March 1, 1998; to expire August 31, 1998).
See: 30 N.J.R. 1060(a).
In (d)3, inserted a reference to Medicare/NJ KidCare approved claims in the first sentence and deleted "Medicaid" following "provider's" in the last sentence; and in (h)2, inserted references to Medicare/NJ KidCare claims throughout, and deleted "Medicaid" following "filed,".
Adopted concurrent proposal, R.1998 d.426, effective 7/24/1998.
See: 30 N.J.R. 713(a), 30 N.J.R. 3034(a).
Readopted provisions of R.1998 d.116 without change.
Adopted concurrent proposal, R.1998 d.487, effective 8/28/1998.
See: 30 N.J.R. 1060(a), 30 N.J.R. 3519(a).
Readopted the provisions of R.1998 d.154 without change.
Amended by R.2001 d.329, effective 9/17/2001.
See: 33 N.J.R. 1889(a), 33 N.J.R. 3334(a).
Rewrote (a)2; in (a)2ii, revised N.J.A.C. reference; in (d)3, substituted "KidCare may result in payment delays" with "FamilyCare will result in claim denials", and substituted "Advise" with "Advice"; in (e), substituted "30" for "90"; rewrote (f); deleted (g) and (h).
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)2ii, inserted ", that was submitted to the Medicaid Assistance and Health Services' Retroactive Eligibility Unit" following "retroactive eligibility application"; added a new (b) and (c) and recodified existing (b) through (f) as (d) through (h).
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), deleted the last two sentences in the introductory paragraph; rewrote (e) and (f).
Administrative correction.
See: 36 N.J.R. 5352(b).
Amended by R.2006 d.337, effective 9/18/2006.
See: 38 N.J.R. 2002(a), 38 N.J.R. 3899(b).
Added (i).
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)2, inserted a comma following "reimbursement"; in (a)2ii, deleted ", that was submitted to the Medicaid Assistance and Health Services' Retroactive Eligibility Unit" following the first occurrence of "application" and inserted "at the appropriate eligibility determination agency"; and in (d)1iv and (e)1iv, substituted "Early" for "early".
Amended by R.2011 d.290, effective 12/5/2011 (operative January 1, 2012).
See: 43 N.J.R. 1129(a), 43 N.J.R. 3182(b).
Section was "Timeliness of Medicaid claim submission". Rewrote (a)1.