N.J. Admin. Code § 10:49-7.3

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

Section 10:49-7.3 - Third-party liability (TPL) benefits

(a) Third-party liability (TPL) exists when any person, institution, corporation, insurance company, health insurer, self-insured plan, group health plan as defined in section 607(1) of the Federal Employee Retirement and Income Security Act of 1974, 29 U.S.C. § 1167(1), service benefit plan, managed care organization or other prepaid health plan, pharmacy benefits manager, third-party administrator as defined in 17B:27B-1, absent parent, Medicare program, or any other public, private, or governmental entity or party is or may be liable in contract, agreement, tort, or otherwise by law or equity to pay all or part of the cost of medical assistance payable by the Medicaid or NJ FamilyCare program.

1. It is a violation of section 1902(a)(25)(D) of the Federal Social Security Act to refuse to furnish covered services to any Medicaid beneficiary because of a third party's potential liability to pay for services.

(b) Medicaid and NJ FamilyCare benefits are last-payment benefits. All TPL, for example, health insurance, Medicare, CHAMPUS, prepaid health plans, workers' compensation, and auto insurance, shall, if available, be used first and to the fullest extent in meeting the cost of the medical needs of the Medicaid or NJ FamilyCare beneficiary, subject to the exceptions listed in (h) below. If, at the time the provider's claim is filed, either the existence of third-party liability cannot be established or third-party benefits are not available to pay the beneficiary's medical expenses at the time the provider's claim is filed, then the Division will pay the full amount allowed under its payment schedule and seek post-payment recovery in accordance with 42 CFR 433.139(c), (d)(2), and (d)(3).

(c) The New Jersey Medicaid/NJ FamilyCare program will supplement the amount paid by a third party, but the combined total paid to the provider shall not exceed the total amount payable under the program in the absence of any TPL, except as provided below:

1. Medicare: The program will make payment in the full amount of the deductible and co-insurance for Part B outpatient hospital services. For services rendered on or after July 20, 1998, payment for Part B coinsurance and deductible for other non-hospital services shall be paid only up to the Medicaid or NJ FamilyCare maximum allowable.

2. No program payments shall be made when the third-party payer requires a contracting or participating provider to accept that third-party payer's payment as payment in full.

3. When Medicaid/NJ FamilyCare is not the primary payer on a claim, payment by Medicaid/NJ FamilyCare will be made at the lesser of:

i. The Medicaid/NJ FamilyCare allowed amount minus any other payment(s); or

ii. The patient liability, including denied charges, deductible, co-insurance, copayment, and non-covered charges.

4. The State will perform reviews of claims regarding beneficiaries for whom any third-party liability exists. Based on the reviews, the Division will determine whether paying the patient's liability for the service will result in a lower cost to the Division. If paying the patient's liability results in a lower cost to the Division, the provider will be notified and the excess provider payments will be recouped by the Division.

(d) Medicaid and NJ FamilyCare participating providers are prohibited from billing Medicaid or NJ FamilyCare beneficiaries for any amount, except:

1. For services, goods, or supplies not covered or authorized by the New Jersey Medical Assistance and Health Services Act (30:4D-1 et seq.), as amended and supplemented, or not covered or authorized by the Division of Medical Assistance and Health Services under this chapter or N.J.A.C. 10:74, if the beneficiary elected to receive the services, goods, or supplies with the knowledge that they were not covered or authorized;

2. For payments made to the beneficiary by a third party on claims submitted to the third party by the provider;

3. For NJ FamilyCare-Plan C enrollee's contribution to care responsibility; or

4. For NJ FamilyCare-Plan D enrollee's required copayment.

(e) When a Medicaid or NJ FamilyCare-Plan A beneficiary has other health insurance, the program requires that such benefits be used first and to the fullest extent, subject to the exceptions in (h) below. Supplementation may be made by the program, but the combined total paid shall not exceed the amount payable under the program in the absence of other coverage. The program shall not supplement covered services rendered by a participating or contracting practitioner with any private health coverage program where the private plan calls for the practitioner to accept that plan's payment as payment in full. When other health insurance is involved, supplementation claims shall not be filed with the program unless accompanied by a statement of payment, Explanation of Benefits (EOB), or denial from the other carrier. Attachment of such information will expedite Medicaid and NJ FamilyCare claim processing.

1. Medicare is a health insurance program which covers certain aged and disabled persons. When rendering Medicare-covered services to any Medicaid or NJ FamilyCare beneficiary, providers shall inquire about Medicare eligibility especially if the third digit of the Eligibility Identification Number is a 1, 2, 5, or 7. Medicaid or FamilyCare supplementation of available Medicare benefits shall be as follows:

i. Medicare (Title XVIII): For any Medicaid or NJ FamilyCare beneficiary who is covered under Medicare, responsibility for payment by the New Jersey Medicaid Agent or the NJ FamilyCare program for non-hospital Part B services shall be limited to the unsatisfied deductible and/or coinsurance to the extent that the combined total of payments does not exceed the maximum allowable under the Medicaid or NJ FamilyCare program in the absence of other coverage for services rendered on or after July 20, 1998.

(f) When a Medicaid or NJ FamilyCare beneficiary has benefits available, such as those described above or from any other liable third party, an approved Medicaid or NJ FamilyCare provider shall be authorized to sign an insurance claim for the Commissioner, based on the third party assignment of rights, in order to receive direct payment from the insurer. This is done pursuant to 30:4D-7.1(c). The following language shall be used by the provider when completing insurance claims: "(signature of authorized provider), Assignee for the Commissioner, New Jersey Department of Human Services."

(g) When recovery of benefits is sought by the Medicaid or NJ FamilyCare program from a liable third-party, the Commissioner shall authorize the Director or his designee(s) to sign the recovery demand.

(h) Payment will be made by the Division in accordance with the requirements of 42 CFR 433.139(b)(3)(i) and (ii) in either of the following circumstances:

1. The TPL benefits are derived from a parent whose obligation to pay support is being enforced by the State Title IV-D agency; or

2. The claim is for prenatal care for a pregnant woman or for preventive pediatric services (include Early Periodic Screening, Diagnosis, and Treatment (EPSDT) services) that are covered by the program.

(i) TPL may be exhausted, but is not required to be, before a claim is submitted for Medicaid or NJ FamilyCare payment in any of the following circumstances:

1. The claim is for labor, delivery, and post-partum care; however, costs associated with the inpatient hospital stay for labor, delivery, and post-partum care must be cost-avoided in accordance with 42 CFR 433.139(b)(2);

2. The claim involves a service for which CMS has granted a waiver of the TPL cost avoidance requirements in accordance with 42 CFR 433.139(e). Waivers have been granted for services covered by Medicare Part B which are rendered at State and county governmental psychiatric hospitals, State and private ICFs/MR, and Vineland Special Hospital; or

3. Rehabilitation services provided by a local school district under a child's Individualized Education Program (IEP).

(j) In those situations in which a Medicare or health insurance payment is received after Medicaid or NJ FamilyCare has been billed and has made payment, the provider shall reimburse the Medicaid or NJ FamilyCare payment to the Division and not to the Medicaid or NJ FamilyCare beneficiary. Reimbursement shall be made immediately to comply with Federal regulations. In the event a provider is apprised or otherwise is on notice that a duplicate or excessive payment has been made by the Division as a result of the provider's receipt of a Medicare or health insurance payment, the provider shall have 60 days to refund such overpayments to the Division. To initiate the process, providers shall submit an MMIS Claim Adjustment Request Form. (See Fiscal Agent Billing Supplement following the second chapter of each Provider Services Manual).

1. In situations involving tort matters where liability has not been established at the time of billing, providers may elect to bill the Medicaid program. However, if they choose to do so, they are precluded from returning Medicaid payments for their services, and may not seek reimbursement from any proceeds resulting from the tort matter. Conversely, providers may elect not to bill the Medicaid program, and await the outcome of the tort matter. However, should the tort matter not result in an award to the beneficiary, and the deadline for timely filing of a Medicaid claim by the provider passes, the provider shall not bill either the Medicaid program or the beneficiary.

2. This subsection in no way precludes the Division from seeking reimbursement for Medicaid payments made on behalf of the beneficiary or from any third party liability source, including a tort liability recovery, which may be awarded the beneficiary.

(k) Regardless of the status of a provider's claim with other third parties, all claims for Medicaid or NJ FamilyCare reimbursement must be received by the Fiscal Agent within the time frames specified in 10:49-7.2, Timeliness of claim submission.

(l) Any individual who undertakes to legally represent any Medicaid or NJ FamilyCare beneficiary in an action for damages against any third party when medical expenses have been paid by the Division shall be required to give written notice to the Division within 20 days of filing or commencing the action.

1. The term "legal representative" shall include, but not be limited to, an attorney, administrator/administratrix, executor/executrix, conservator, guardian or guardian ad litem.

N.J. Admin. Code § 10:49-7.3

Petition for Rulemaking.
See: 27 N.J.R. 770(b), 27 N.J.R. 1320(a).
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" and "beneficiaries" for "recipient" and "recipients" throughout; in (a), substituted "by the Medicaid program" for "under this act"; in (b), inserted "the exceptions listed in"; in (e)1, substituted "Medicaid Eligibility Identification Number" for "HSP (Medicaid) Case Number"; deleted (e)1i and (e)1i(1); added (h)5; and in (i), substituted "a health insurance payment is received" for "an insurance payment is received from another payer" and "MMIS Claim Adjustment Request Form" for "Adjustment/Void Request Form".
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).
Inserted references to NJ KidCare throughout; in (d)1, inserted ", as amended and supplemented," following "et seq.)" and added 3; and in (e), inserted a reference to NJ KidCare-Plan A beneficiaries in the first sentence.
Amended by R.1998 d.382, effective 7/20/1998.
See: 30 N.J.R. 1255(b), 30 N.J.R. 2646(b).
In (c), inserted a reference to the NJ KidCare Program in the introductory paragraph and rewrote 1; and in (e), added a new 1i, and inserted references to NJ KidCare, Medicare and Medicaid throughout.
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 with changes, effective 9/21/1998.
Amended by R.1999 d.211, effective 7/6/1999 (operative August 1, 1999).
See: 31 N.J.R. 998(a), 31 N.J.R. 1806(a), 31 N.J.R. 2879(b).
Amended by R.2003 d.82, effective 2/18/2003.
See: 34 N.J.R. 2650(a), 35 N.J.R. 1118(a).
In (h)4, deleted i; rewrote (i).
Amended by R.2014 d.030, effective 2/3/2014.
See: 45 N.J.R. 103(a), 46 N.J.R. 295(a).
Section was "Third party liability (TPL) benefits". Rewrote the section.