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-1.25 - Point-of-sale (POS) claims adjudication system
Current through Register Vol. 56, No. 18, September 16, 2024
(a) Senior Gold pharmacy claims may be submitted through a point-of-sale (POS) system and adjudicated by the State's fiscal agent on-line and in real-time. The POS system is an alternative to other methods of claim submission, including magnetic tape, diskette and paper claims. The pharmacist would 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).
(b) In order for a Senior Gold approved pharmacy provider, in accordance with 10:167C-1.3, 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 New Jersey Division of Medical Assistance and Health Services (Division).
Division of Medical Assistance and Health Services
Office of Information Systems
PO Box 712-Mail Code #4
Trenton, New Jersey 08625-0712
Telephone: (609) 588-2802
(c) A POS participating pharmacy or intermediary must 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 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 Senior Gold pharmacy providers choosing to submit claims through the POS system shall submit claims in the approved electronic format, and transmit these claims online for adjudication by the fiscal agent's POS computer system.
(f) Claim data requirements for electronic media claims (EMC) generated by POS participating pharmacies include:
(g) Additional supplementary data requirements, which are claim specific, include:
(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 Program.
(i) Pharmacy software must have the capability to display on-line adjudicated claim data returned to the pharmacy by the fiscal agent, including:
(j) Pharmacy software must provide the pharmacy with the capability of claim reversal and resubmission, if required.