N.J. Admin. Code § 10:49-7.5

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

Section 10:49-7.5 - Use of service bureau and/or management agency

(a) Payment may be made to a business agent, such as a billing service or an accounting firm, that furnishes statements and receives payment in the name of the provider if the agent's compensation for this service is:

1. Related to the cost of processing the billing;

2. Not related on a percentage or other basis to the amount that is billed or collected; and

3. Not dependent upon the collection of the payment.

(b) If a NJ Medicaid or FamilyCare participating provider wishes to designate a business agent to perform management, clerical and/or other services related to the claims payment process, approval is required from the New Jersey Medicaid or NJ FamilyCare program.

(c) In order to obtain approval the provider/agent shall submit a copy of the signed agreement and power-of-attorney, if any, between the provider and the agent which shall contain a detailed statement of the powers and duties of the agent (including the power to sign Medicaid or NJ FamilyCare claims on behalf of the provider and the compensation arrangement) to Provider Enrollment, New Jersey Medicaid or NJ FamilyCare program.

(d) Approval shall be obtained for each provider/agent agreement. Approval of an agent agreement with one provider does not confer an automatic approval of any additional provider/agent agreement.

(e) Provider claims 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. Procedures are detailed in the appropriate Provider Services Manual.

1. If hard copy claim forms are required and standard Medicaid or NJ FamilyCare claim forms are not utilized, the provider/agent shall first obtain approval from the New Jersey Medicaid or NJ FamilyCare program.

2. In order to obtain approval, the provider/agent shall submit a printer's prototype of an exact replica of the Medicaid or NJ FamilyCare claim form and the programming instructions for completion of the form to the Fiscal Agent.

3. The provider/agent shall assume the entire cost of printing duplicate forms at all times.

(f) The New Jersey Medicaid or NJ FamilyCare program in approving any provider/agent agreement, assumes no responsibility for the performance of the provider or agent. In the event that any error of the provider/agent requires special programming to be made by the Fiscal Agent in order to have claims paid correctly, the provider/agent shall assume the entire cost of the special program.

N.J. Admin. Code § 10:49-7.5

Amended by R.1997 d.354, effective 9/2/1997.
See: 29 N.J.R. 2512(a), 29 N.J.R. 3856(a).
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.
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.2003 d.82, effective 2/18/2003.
See: 34 N.J.R. 2650(a), 35 N.J.R. 1118(a).
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).
Rewrote the introductory paragraph of (e); and in (e)1, inserted "hard copy claim forms are required and" and "first".