New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 49 - ADMINISTRATION MANUAL
Subchapter 14 - RECOVERY OF PAYMENTS AND SANCTIONS
Section 10:49-14.2 - Sanctions-Special Status Program
Universal Citation: NJ Admin Code 10:49-14.2
Current through Register Vol. 56, No. 18, September 16, 2024
(a) The "Special Status Program" either restricts the Medicaid or NJ FamilyCare beneficiary(s) listed on the HBID Card to a single provider, except in a medical emergency, or warns providers that the beneficiary's card has been used by an unauthorized person or persons, or for an unauthorized purpose. If a warning letter is issued to a beneficiary, a message will be included in the eligibility message on the REVS/MEVS/eMEVS system alerting the provider to ask the Medicaid or NJ FamilyCare beneficiary for additional identification or to take other appropriate action.
1. The restriction is
issued to Medicaid or NJ FamilyCare beneficiaries determined to have misused,
abused or overutilized their Medicaid or NJ FamilyCare benefits.
Overutilization occurs when a beneficiary has utilized Medicaid or NJ
FamilyCare services or items at a frequency or amount that is not medically
necessary. Examples of misuse or abuse include, but are not limited to,
medically harmful or inappropriate use of different drugs or provider services,
obtaining or attempting to obtain early refills of prescriptions in violation
of 10:51-1.19(a)5,
at more than one pharmacy, and forgery or alteration of prescriptions. A
determination that there has been misuse, abuse or overutilization of benefits
obtained by use of an HBID Card shall create a presumption that the beneficiary
listed on the HBID Card, or a person responsible for a minor listed on the HBID
Card, was responsible for such actions. If this presumption is successfully
rebutted by or on behalf of the Medicaid or NJ FamilyCare beneficiary, he or
she shall not be enrolled in the Special Status Program.
i. A beneficiary shall be permitted to change
the designated provider upon demonstration of good cause and the Division may
grant the request.
ii. The Division
may change the provider to which the beneficiary is restricted if a pattern of
continued misuse, abuse or overutilization by the beneficiary is evident, or if
it is determined that the provider has engaged in fraud or abuse, or if the
Division determines that such a change is in the best interest of the
beneficiary and/or the programs it administers in whole or part.
iii. The beneficiary may request a contested
case hearing in the following situations:
(1)
If the beneficiary objects to being included in the special status
program;
(2) If the beneficiary
requests a change and the request is denied;
(3) If the agency causes undue delay in
responding to the beneficiary's request for change.
2. The warning letter is issued to
Medicaid or NJ FamilyCare beneficiaries determined to have had their HBID Card
used by an unauthorized person or persons, or for an unauthorized purpose. The
purpose of the warning is to notify providers that the beneficiary's HBID Card
has been used by an unauthorized person or persons, or for an unauthorized
purpose. A message will be available on the REVS/MEVS/eMEVS system alerting the
provider to ask the Medicaid or NJ FamilyCare beneficiary for additional
identification or to take other appropriate action. A determination that an
HBID Card has been used by an unauthorized person or for an unauthorized
purpose shall create a presumption that the beneficiary listed on the HBID
Card, or a person responsible for a minor listed on the HBID Card, was
responsible for such actions. If this presumption is successfully rebutted by
the beneficiary, the beneficiary shall not be issued a warning
letter.
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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