New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL
Subchapter 7 - RECOVERIES AND LIENS
Section 10:167B-7.2 - Recoveries for benefits incorrectly paid

Universal Citation: NJ Admin Code 10:167B-7.2

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

(a) As provided in 30:4D-1 et seq., the Department may take all necessary action to recover the cost of benefits incorrectly paid on behalf of a beneficiary in accordance with 30:4D-45.1.

1. The term "incorrect payment" includes, but is not limited to:
i. Payment made on behalf of a beneficiary whose drug costs are wholly covered by another source;

ii. Payment made on behalf of a beneficiary who is no longer eligible or has been incorrectly determined to be eligible to receive benefits; and

iii. Payment made as a result of fraud perpetrated by a beneficiary, his or her authorized agent and/or provider.

(b) The Department shall take all reasonable measures to ascertain the legal liability of third parties to pay for prescription drugs arising out of injury, disease, or disability, where it is known that a third party is or may be liable to pay all or part of the drugs of a beneficiary. Payment on behalf of an eligible individual shall not be withheld because of the liability of third parties, if third party resources are not currently available to pay the individual's expenses. The Department shall recover from any such third party the full amount of payments made. Upon request of the Department, the Attorney General may enforce such right, institute legal proceedings against the third party who is or may be liable for the payment for drugs, or intervene in any proceedings in the name of the Commissioner or in the name of the injured person, his or her guardian, executor, administrator or other appropriate representative.

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