N.J. Admin. Code § 10:49-8.3

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

Section 10:49-8.3 - Adjustments following payment of claims

(a) If a claim is incorrectly paid, so that the provider receives an overpayment or underpayment, within 60 days of such receipt, the provider shall correctly adjust the claim by utilizing the web-based claims resolution process or another approved method of automated data exchange, unless an attachment to the claim is required, in which case the provider shall instead use an MMIS Claim Adjustment Request Form, (FD-999). (For the procedure to follow, see Fiscal Agent Billing Supplement following the second chapter of each Provider Services Manual). However, a provider shall immediately adjust all incorrectly overpaid claims that are discovered subsequent to the expiration of the 60-day deadline, also utilizing the web-based claims resolution process or another approved method of automated data exchange, unless an attachment to the claim is required, in which case the provider shall instead use an MMIS Claim Adjustment Request Form (FD-999).

(b) On occasion, a claim will be paid that should not have been paid. If a claim is paid in error, within 60 days of such receipt, the provider shall utilize the web-based claims resolution process or another approved method of automated data exchange to void the claim. (For the procedure to follow, see the Fiscal Agent Billing Supplement following the second chapter of each Provider Services Manual.) However, a provider shall immediately void all claims paid in error that are discovered subsequent to the expiration of the 60-day deadline, also utilizing the web-based claims resolution process or another approved method of automated data exchange.

(c) Any adjustment made by Medicare will not cross over to Medicaid. If Medicare makes an adjustment that results in an overpayment or underpayment by Medicaid, within 60 days of receipt of any such overpayment or under payment, the provider shall notify the Fiscal Agent. (For the procedure to follow, see the Fiscal Agent Billing Supplement following the second chapter of each Provider Services Manual).

N.J. Admin. Code § 10:49-8.3

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 "MMIS Claim Adjustment Request Form" for "Adjustment/Void Request Form" and inserted "(FD-999(9/91)".
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), inserted "within 60 days of such receipt" following "underpayment"; in (b), inserted "within 60 days of such receipt" following "paid in error"; in (c), rewrote the second sentence.
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 (a) and (b).