New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD)
Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES
Section 10:167A-1.27 - Point-of-sale (POS) claims adjudication system

Universal Citation: NJ Admin Code 10:167A-1.27

Current through Register Vol. 56, No. 18, September 16, 2024

(a) PAAD pharmacy claims shall be submitted through a POS system and adjudicated by the State's fiscal agent on-line and in real-time. The pharmacist shall be required to enter pharmacy claim detail data into a computer or POS device and transmit this data to the fiscal agent over a dedicated telephone line. Regardless of the method of claim submission, all claims will go through all New Jersey Medicaid Management Information System (NJMMIS) claims processing edits and the claims will be processed to determine their payment disposition (for example, paid or denied).

1. Pharmacy services provided to nursing facility and residential care residents utilizing 24 hour unit-dose or modified unit-dose delivery systems are precluded from the POS system.

(b) In order for a PAAD-approved pharmacy provider, in accordance with N.J.A.C. 10:167A-1.5, to submit pharmacy claims through a POS system, the provider shall enter into an agreement with a POS intermediary or shall directly provide a similar telecommunications network approved by the Division.

1. In order to become an approved POS intermediary or provider established network, a firm shall notify the Division at the following address:

Division of Medical Assistance and Health Services

Office of Information Systems

PO Box 712

Trenton, New Jersey 08625-0712

Telephone: (609) 588-2802

2. The Division shall send the interested party a summary of the program and instructions on how to submit an application.

3. The Division shall consider the following in evaluating an application:

i. The applicant's general approach and plans to meet the requirements of the POS project;

ii. The applicant's detailed approach and plans to meet the requirements of the POS project;

iii. The applicant's documented qualifications, expertise, and experience on similar projects;

iv. The applicant's proposed staff's documented qualifications, expertise, and experience on similar projects; and

v. The applicant's adherence to the requirements of CMS.

(c) A POS participating pharmacy or intermediary shall supply the computer hardware or POS device and required software to generate electronic media claims (EMC) in a format consistent with POS standards adopted by the PAAD program.

(d) A POS participating pharmacy or intermediary shall supply modem capability required to properly transmit claim detail data to the approved POS intermediary or to participate in the provider established telecommunication network.

(e) All PAAD pharmacy providers shall submit claims in the EMC format, and transmit these claims on-line for adjudication by the fiscal agent's POS computer system.

(f) Claim data requirements for EMCs generated by POS participating pharmacies include:

1. The first five alpha characters of the last name and the first three alpha characters of the PAAD beneficiary's first name;

2. The 12 digit PAAD identification number;

3. The date of birth, if applicable;

4. The date of service or dispense date;

5. The pharmacy prescription number;

6. The actual 11 digit National Drug Code (NDC) of the drug dispensed;

7. The metric quantity dispensed;

8. The days supply;

9. The prescriber's Medicaid provider service number;

10. The third party payment, if applicable;

11. The provider's usual and customary charge; and

12. The pharmacy provider number.

(g) Additional supplementary data requirements, which are claim specific, include:

1. The medical certification indicator;

2. The nursing facility residency indicator;

3. The compound drug indicator;

4. The other insurance indicator, if applicable; and

5. The carrier code(s), if applicable.

(h) A POS participating pharmacy or intermediary shall be required to implement software changes requested by the Division within 60 days of notification of such a request to ensure the generation of electronic claims acceptable to the PAAD program.

(i) Pharmacy software must have the capability to display on-line adjudicated claim data returned to the pharmacy by the fiscal agent, including:

1. Payment disposition;

2. Error code messages; and

3. Claim pricing data, including drug cost reimbursement, dispensing fee and applicable copayment amounts.

(j) Pharmacy software must provide the pharmacy with the capability of claim reversal and resubmission, if required by Federal or State laws or regulations, or as follows:

1. A pharmacy may initiate a claim reversal of a previously submitted pharmacy claim for a period of 12 months from the initial date of claim service.

2. Pharmacies are required to initiate claim reversals for those services in which a claim was generated and adjudicated to payment by the fiscal agent's POS computer and the service was not subsequently provided to a PAAD beneficiary.

3. Upon notification by PAAD, the pharmacy shall reverse and reprocess a claim where the primary payer is Medicare Part D, the claim was denied for payment by the Medicare Part D provider and where the claim is successfully appealed through the Medicare Part D appeal process.

4. All prescriptions adjudicated to payment by the fiscal agent's computer shall be subsequently dispensed and their receipt by PAAD beneficiaries properly documented on a PAAD approved certification statement/signature log. (See N.J.A.C. 10:49-9.6) During a public health emergency, a PAAD beneficiary is not required to provide a signature at the time a prescription is dispensed or delivered. The pharmacist must document in the patient's profile the date the beneficiary received the prescription.

(k) Pharmacies are required to interact with prescribers and beneficiaries at POS to resolve matters related to on-line messages resulting from claim adjudication by the fiscal agent.

Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.

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