Current through Register Vol. 56, No. 18, September 16, 2024
(a) A Medicaid
claim is defined as a request for payment from the New Jersey Medicaid program
for a Medicaid reimbursable service provided to a Medicaid recipient.
1. A Medicaid claim or any other provider
claim submitted for payment from or through the Division of Medical Assistance
and Health Services shall be submitted by means of an approved method of
automated data exchange unless an attachment to the claim is required, in which
case the claim for payment instead shall be submitted using an approved hard
copy claim form.
2. It is the
responsibility of each provider to ensure that each Medicaid/NJ FamilyCare-Plan
A claim submitted by that provider is received by the New Jersey Medicaid/NJ
FamilyCare program's Fiscal Agent within the time periods indicated in this
section. Providers shall reconcile their claims submission records with the
Remittance Advice they receive from the Division's Fiscal Agent in order to
verify that the Division's Fiscal Agent has received their claims. Providers
shall resubmit any claims for reimbursement, which the provider determines have
been submitted previously, but which do not appear on the Remittance Advice.
i. The New Jersey Medicaid program shall not
reimburse for a claim received outside the prescribed time periods. This policy
also applies to inquiries concerning a claim or claim related information
received outside the prescribed time periods.
ii. For retroactive eligibility cases, a
claim associated with a retroactive eligibility application will be considered
as received on the date of receipt of the application at the appropriate
eligibility determination agency on behalf of the applicant. For information
about retroactive eligibility, see
10:49-2.9.
(b) "Prospective" medical bill(s)
are bills submitted to the Retroactive Eligibility Unit with an Application for
Retroactive Medicaid Eligibility (FD-74) on the assumption that they were
incurred during the retroactive eligibility period but were actually incurred
during the month of application for Medicaid or later. These bills were
incurred during a time period when Medicaid eligibility already existed or
should have existed (except that the individual experienced a delayed
determination of Medicaid eligibility).
(c) Under the circumstances in (c)1 through 3
below, the Division of Medical Assistance and Health Services' Retroactive
Medicaid Eligibility Unit will generate letters to providers whose bills were
included with an Application for Retroactive Medicaid Eligibility, allowing the
one-year timely submission requirements to be bypassed.
1. These "prospective" claims must not have
already been submitted to the Fiscal Agent within one-year of the date that
services were rendered;
2. The
Application for Retroactive Medicaid Eligibility that these "prospective" bills
are associated with must have been received at the Retroactive Eligibility Unit
within 60 days of the date of the above mentioned letter (with the original
letter attached); and
3. In order
for payment to be made, these claims must remain outstanding and any collection
action against the Medicaid beneficiary must be withdrawn.
(d) An institutional claim is a claim
submitted by a hospital; home health agency; nursing facility; intermediate
care facility/mental retardation (ICF/MR); residential treatment center; or
governmental psychiatric hospital. The time requirements for submitting an
institutional claim is as follows:
1. For
claims submitted by home health agencies and hospitals (excluding governmental
psychiatric hospitals), a claim for payment of a service provided to any
Medicaid beneficiary shall be received by the New Jersey Medicaid Fiscal Agent
within:
i. One year of the date of discharge
on an inpatient hospital claim;
ii.
One year of the date of service entered on an outpatient hospital claim or home
health claim;
iii. One year of the
earliest date of service entered on an outpatient hospital claim or home health
claim, if the claim carries more than one date of service; or
iv. For Early and Periodic Screening,
Diagnosis and Treatment (EPSDT) including pediatric HealthStart services,
claims must be submitted to the Fiscal Agent within 30 days of the provision of
services.
2. For claims
submitted by a nursing facility; an intermediate care facility for the mentally
retarded; a residential treatment center; or a governmental psychiatric
hospital, a claim for payment for services shall be received by the fiscal
agent no later than one year after the "from date of service" as indicated on
the claim.
(e) A
non-institutional claim is a claim submitted by all providers except a
hospital, home health agency, nursing facility, intermediate care
facility/mental retardation (ICF/MR), residential treatment center, or
governmental psychiatric hospital. The time requirements for submitting a
non-institutional claim are as follows:
1. A
claim for payment of a non-institutional service provided to any Medicaid
beneficiary shall be received by the New Jersey Medicaid Fiscal Agent within:
i. One year of the date of service;
ii. One year of the earliest date of service
entered on the claim if the claim carries more than one date of
service;
iii. One year (365 days)
of the dispensing date on a pharmacy claim; or
iv. For Early and Periodic Screening,
Diagnosis and Treatment (EPSDT) including pediatric HealthStart services,
claims must be submitted to the Fiscal Agent within 30 days of the provision of
services.
(f)
The time requirements for submitting a combination Medicare/Medicaid or
Medicare/NJ FamilyCare claim are as follows (Under Federal regulations this
applies only to Medicare/Medicaid or Medicare/NJ FamilyCare claims and does not
extend to claims involving any other third party insurance.):
1. A combination Medicare/Medicaid claim is
defined as a request for payment from the New Jersey Medicaid program for a
medical service provided to any Medicare/Medicaid beneficiary.
i. The claim shall contain the Medicaid
Eligibility Identification Number, the Medicare three digit carrier/payor code,
and the Medicare HIC Number.
2. A combination Medicare/Medicaid claim
shall be received by the Medicare Intermediary/Carrier within the applicable
Medicaid timely submission period (see (d) and (e) above) to be considered for
further payment by the New Jersey Medicaid program.
i. The provider shall continue to have one
year from the date of service for a claim to be received by the Medicaid Fiscal
Agent. A claim received by the Medicaid Fiscal Agent after Medicare
adjudication and within one year from the date of service shall be considered
timely submitted.
ii. For
combination Medicare/Medicaid claims received by the Medicare
Intermediary/Carrier within the applicable Medicaid timely submission period
and where Medicare adjudication occurs beyond the one year of the date of
service, the provider shall submit a claim to be received by the Medicaid
Fiscal Agent within 90 days of the date of the Medicare adjudication.
iii. For Medicare/Medicaid claims where the
Medicare adjudication occurs within one year from the date of service, but less
than 90 days remain within the timely filing period, the provider shall submit
the claim to be received by Medicaid within the one year timely filing period
or 90 days, whichever is later.
iv.
A combination Medicare/Medicaid claim received outside the applicable Medicaid
timely submission period shall not be reimbursed by the New Jersey Medicaid
program.
3. In most
cases, when a beneficiary is eligible for both Medicare and Medicaid, or
Medicare and NJ FamilyCare, a Medicare/Medicaid approved claim will crossover
from the Medicare Carrier/Intermediary to the program's Fiscal Agent. The
provider is requested to allow 45 days from Medicare adjudication for the
Medicaid or NJ FamilyCare program to receive and process crossover claims.
Failure to allow the 45 days for the transition from Medicare to Medicaid or NJ
FamilyCare will result in claim denials due to duplicate claim errors. There
are instances, however, where claims will not cross over from Medicare. In
those instances, or when a Medicare/Medicaid or Medicare/NJ FamilyCare
crossover is not reflected on the provider's Medicaid Remittance Advice within
45 days of the Medicare Explanation of Benefits (EOB), the provider shall
follow the billing instructions in the Fiscal Agent Billing Supplement
following the second chapter of the provider services manual.
(g) If additional information is
required in order to process a Medicaid claim, the provider shall supply the
information as soon as possible but not more than 30 days after the end of the
timely submission period.
(h)
Regarding a Medicaid claim submitted timely that has been adjudicated and
denied, a provider may resubmit the claim within one year of the date of
service or 30 days of the date of adjudication as indicated in the Remittance
Advice Statement, whichever is later.
(i) If it appears that an individual is
eligible for Supplemental Security Income (SSI), the Medicaid provider or a
designee should, but is not required to, assist the patient in completing and
submitting an application for SSI. The application for SSI shall be submitted
to the Social Security Administration (SSA) so that it is received by the SSA
within the time requirements for claim submission contained in (a) through (h)
above. For institutional and non-institutional claims for services provided to
an individual who was not found to be eligible for Medicaid as of the date of
service and who thereafter is determined to be eligible for SSI (for that date
of service) by the SSA, and, therefore, also eligible for Medicaid (for that
date of service), the following requirements shall apply:
1. If the individual's application for SSI is
received by the SSA within the time requirements for claim submission contained
in (a) through (h) above, the Medicaid provider or a designee shall file a
claim for services rendered to the individual so that it is received by the
State's fiscal agent within the later of the following:
i. The applicable time requirements for claim
submission contained in (a) through (h) above;
ii. Six months from the date of the SSI
eligibility determination; or
iii.
Six months from the date that the SSI/Medicaid eligibility data appears on the
New Jersey Medicaid Management Information System.
