N.J. Admin. Code § 10:49-8.2
Current through Register Vol. 56, No. 23, December 2, 2024
Section 10:49-8.2 - Medicaid claims payment and charity care claims pricing(a) The Fiscal Agency will process Medicaid claims daily and produce provider payments and associated Remittance Advice (RA) statements once each week. The RA is the provider's account statement and reflects the status of all Medicaid claims currently entered into the Medicaid Management Information System. Provider payments in the form of checks and electronic funds transfers will be released following approval by the New Jersey Medicaid program. For charity care claims pricing information, see N.J.A.C. 10:52-11, 12 and 13. 1. The Remittance Advice (RA) is the major vehicle for communicating to the provider the status of all Medicaid claims received by the fiscal agent. All of the provider's claims are processed and supporting records are updated during each payment cycle. RA statements are generated as a result of a payment cycle. All claims processed (entered into the Medicaid Management Information System) fall into one of three classifications: paid; in process; or denied. i. A claim that is correctly completed for a covered service provided to a Medicaid beneficiary by an approved provider will be paid. The claim will appear on the RA Claims Status page, or pages, along with all other claims for which a provider is being paid in that payment cycle. If the amount differs from the billed charges, an explanation will appear on the RA.ii. In process claims or processed but unpaid claims are those claims held for prepayment review by the Division or by the Fiscal Agent. The review will result in a claim or group of claims being paid, denied, or additional information being requested. If additional information is required, a letter and/or a Claim Correction Form (CCF) will be forwarded to the provider. (Additional billing information is provided in the Fiscal Agent Billing Supplement following the second chapter of each Provider Services Manual).iii. Reasons for denial of a claim will be provided on the RA in the form of an error/edit code. (1) Messages explaining all codes reflected on the Remittance Advice will be printed on a separate page.(b) A unique 13 digit Internal Control Number (ICN) is assigned to each Medicaid claim received by the Fiscal Agent. The ICN is reflected on the RA and can be used to track the status of a claim. For more information about the ICN, see Fiscal Agent Billing Supplement following the second chapter of each Provider Services Manual.(c) For each claim processed in a payment cycle, the ICN, beneficiary name, dates of service and other claim information is printed on the RA. On the line immediately below this information, a code is printed representing a denial reason, and other information that might be useful to the provider and payment reduction reasons, if any. Messages explaining all codes found on the RA will be found on a separate page following the status listing of all claims. For more information about Remittance Advice see the Fiscal Agent Billing Supplement following the second chapter of each Provider Services Manual.(d) Claims may be paid beyond 12 months of the date of receipt with Federal financial participation (FFP) in the following situations:1. When the claim invoice or retroactive adjustment is paid to a provider reimbursed under a retrospective payment system;2. For a Medicare/Medicaid claim or Medicare/NJ FamilyCare claim, timely filed, payment may be made for services within six months after the program or provider receives notice of the Medicare claim disposition for a timely filed Medicare/Medicaid or Medicare/NJ FamilyCare claim;3. For claims from providers under investigation for fraud or abuse; or4. For claims associated with administrative or legal actions pursuant to a hearing action or agency corrective action mandate, whether for an eligible individual or for all those eligibles affected in a similar manner.N.J. Admin. Code § 10:49-8.2
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)1 and (a)1ii, substituted "in process" for "suspended"; in (a)1i and (c), substituted "beneficiary" for "recipient"; in (a)1iii, substituted "an error/edit code" for "a code"; and in (c), deleted "suspense reasons," following "a denial reason,", inserted "other information that might be useful to the provider and", and deleted reference that only a claim status paid as a bill will not have a code.
Amended by R.1997 d.520, effective 1/5/1998.
See: 29 N.J.R. 1006(a), 30 N.J.R. 232(a).
In (a), inserted reference to charity care claims pricing.
Amended by R.2001 d.329, effective 9/17/2001.
See: 33 N.J.R. 1889(a), 33 N.J.R. 3334(a).
Added (d).
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), amended the N.J.A.C. references in the introductory paragraph and rewrote 1ii.
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), 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 (d)2, substituted "FamilyCare" for "KidCare" twice.