N.J. Admin. Code § 10:49-9.8

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

Section 10:49-9.8 - Provider certification and recordkeeping

(a) All program providers, except institutional, pharmaceutical, and transportation providers, shall be required to certify that the services billed on any claim were rendered by or under his or her supervision (as defined and permitted by program regulations); and all providers shall certify that the information furnished on the claim is true, accurate, and complete.

1. All claims for covered services must be personally signed by the provider or by an authorized representative of the provider (for example, hospital, home health agency, independent clinic) unless the provider is approved for electronic media claims (EMC) submission by the Fiscal Agent. The provider must apply to the Fiscal Agent for EMC approval and sign an electronic billing certificate.

i. The following signature types are unacceptable:

(1) Initials instead of signature;

(2) Stamped signature; and

(3) Automated (machine-generated) signature.

(b) Providers shall agree to the following:

1. To keep such records as are necessary to disclose fully the extent of services provided, and, as required by 30:4D-12(d), to retain individual patient records for a minimum period of five years from the date the service was rendered;

2. To furnish information for such services as the program may request;

3. That where such records do not document the extent of services billed, payment adjustments shall be necessary;

4. That the services billed on any claim and the amount charged therefore, are in accordance with the requirements of the New Jersey Medicaid and/or NJ FamilyCare programs;

5. That no part of the net amount payable under any claim has been paid, except that all available third party liability has been exhausted, in accordance with program requirements; and

6. That payment of such amount, after exhaustion of third party liability, will be accepted as payment in full without additional charge to the Medicaid or NJ FamilyCare beneficiary or to others on his behalf.

(c) When a Medicaid or NJ FamilyCare provider employs, contracts or subcontracts with an individual or entity that is not an enrolled Medicaid or NJ FamilyCare provider, the services provided to Medicaid or NJ FamilyCare beneficiaries by that employee, contractor or subcontractor shall meet all the requirements of the Medicaid or NJ FamilyCare programs as defined at N.J.A.C. 10:49-5 and 6 and 10:49-9.8(a) and (b), and the pertinent provider chapters of the New Jersey Administrative Code, which requirements include, but are not limited to, availability of services, range of services, quality of care, licensure, non-exclusion under 10:49-11.1 and completeness of documentation. Failure to do so may result in either or both of the following consequences:

1. The Division may recover from the enrolled Medicaid or NJ FamilyCare provider the Medicaid or NJ FamilyCare reimbursement paid by the Program to the provider for any service rendered by an employee, contractor, subcontractor or a contractor's or subcontractor's employee not meeting such requirements; and/or

2. The provider, contractor, subcontractor or other responsible party may be subject to any applicable civil or criminal sanctions and/or penalties.

(d) A Medicaid or NJ FamilyCare provider shall ensure that any individuals or entities employed by or under contract to a contractor or subcontractor performing services for the provider, fully satisfy all applicable State, Federal, and any other licensure and certification requirements. This shall include, but not be limited to, any equipment and/or vehicles relating to services provided to Medicaid or NJ FamilyCare beneficiaries. Failure to assure that all such requirements are met may result in either or both consequences specified in (c)1 and 2 above.

N.J. Admin. Code § 10:49-9.8

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), deleted "form" following "furnished on the claim"; in (b)1, inserted ", and, as required ... service was rendered"; and in (b)6, substituted "beneficiary" for "recipient".
Recodified from N.J.A.C. 10:49-9.5 and 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 (b), inserted references to NJ KidCare in 4 and 6. Former N.J.A.C. 10:49-9.8, Fraud and abuse, recodified to N.J.A.C. 10:49-9.11.
Amended by R.1998 d.327, effective 7/6/1998.
See: 30 N.J.R. 511(a), 30 N.J.R. 2486(a).
Added (c) and (d).
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).
In (b), substituted "requirements" for "regulations" in 4 and 5; in (c), substituted "an individual or" for "a health care" following "subcontracts with", inserted "non-exclusion under N.J.A.C. 10:49-11.1" following "quality of care, licensure" in the introductory paragraph and rewrote 1 and 2; in (d), inserted "or under a contract to" following "employed by".