New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 167C - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE SENIOR GOLD PROGRAM
Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES
Section 10:167C-1.22 - Claim submission
Universal Citation: NJ Admin Code 10:167C-1.22
Current through Register Vol. 56, No. 18, September 16, 2024
(a) An approved pharmacy provider may choose to:
1. Submit a properly completed hard copy pharmacy claim form approved by
the New Jersey Division of Medical Assistance and Health Services (DMAHS);
2. Submit an electronic media claim (EMC) by modem, diskette or magnetic
tape in an electronic format approved by DMAHS.
i. In order for a pharmacy
provider to be eligible to submit an EMC claim to the Medicaid and/or programs, a pharmacy provider or vendor
of EMC services shall complete the "New Jersey Medicaid Provider Electronic Billing Agreement."
ii. The completed agreement shall be submitted to the fiscal agent and
approved by the Division of Medical Assistance and Health Services.
iii. The pharmacy provider or vendor of EMC services shall submit
electronic media claims under an approved submitter identification number and comply with EMC requirements
contained in the N.J.A.C. 10:51, Appendix E, incorporated herein by reference.
iv. For the purposes of this subchapter, all electronically submitted
claims, including POS claims, shall commonly be referred to as EMC claims; or
3. Enter into an agreement with a point-of-sale (POS) intermediary or
directly provide a similar telecommunication network approved by DMAHS to submit claims to the fiscal agent
for adjudication. POS claims require an electronic format which complies with the National Council
Prescription Drug Program standard, Version 3.2, as amended and supplemented, incorporated herein by
reference. The Council's address is 4201 North 24th Street, Suite 365 Phoenix, Arizona 85016.
i. The approved POS intermediary or provider established network shall
enter into an agreement with the State of New Jersey to provide on-line telecommunication services, including
transmission of pharmacy claim detail data, access to the fiscal agent's POS computer and return of
adjudicated claim data to the provider.
(b) A properly completed claim form or a properly formatted electronic media claim (EMC) may be submitted to the fiscal agent, or transmitted by an approved POS intermediary or provider established telecommunication network to the fiscal agent for claims adjudication.
1. A single claim form
shall be completed manually or by computer or an EMC claim shall be transmitted in the approved EMC format
for each Senior Gold prescription dispensed. See N.J.A.C. 10:51, Appendix D. incorporated herein by
reference, Fiscal Agent Billing Supplement for instructions concerning the completion and submission of the
specified claim form, and N.J.A.C. 10:51, Appendix E, incorporated herein by reference, regarding the proper
EMC claim format;
2. All claim forms and EMC claims must contain
the National Drug Code (NDC) of the actual drug dispensed. The 11-digit NDC has three components. The first
five digits are the manufacturer's labeler code, the next four digits are the product code, and final two
digits are the package size code. For claim submission, leading zeros shall be included in all fields. For
example, 00003-0234-01.
i. The dispenser shall always report the actual
labeler code and drug product code of the drug dispensed. The package size code reported on the
claim.
3. All Senior Gold pharmacy claims submitted to
the fiscal agent for payment consideration shall be adjudicated based on the outcome of established POS and
PDUR edits, regardless of the mode of claim submission.
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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