Current through Register Vol. 56, No. 18, September 16, 2024
(a) The Fiscal
Agency will process Medicaid claims daily and produce provider payments and
associated Remittance Advice (RA) statements once each week. The RA is the
provider's account statement and reflects the status of all Medicaid claims
currently entered into the Medicaid Management Information System. Provider
payments in the form of checks and electronic funds transfers will be released
following approval by the New Jersey Medicaid program. For charity care claims
pricing information, see N.J.A.C. 10:52-11, 12 and 13.
1. The Remittance Advice (RA) is the major
vehicle for communicating to the provider the status of all Medicaid claims
received by the fiscal agent. All of the provider's claims are processed and
supporting records are updated during each payment cycle. RA statements are
generated as a result of a payment cycle. All claims processed (entered into
the Medicaid Management Information System) fall into one of three
classifications: paid; in process; or denied.
i. A claim that is correctly completed for a
covered service provided to a Medicaid beneficiary by an approved provider will
be paid. The claim will appear on the RA Claims Status page, or pages, along
with all other claims for which a provider is being paid in that payment cycle.
If the amount differs from the billed charges, an explanation will appear on
the RA.
ii. In process claims or
processed but unpaid claims are those claims held for prepayment review by the
Division or by the Fiscal Agent. The review will result in a claim or group of
claims being paid, denied, or additional information being requested. If
additional information is required, a letter and/or a Claim Correction Form
(CCF) will be forwarded to the provider. (Additional billing information is
provided in the Fiscal Agent Billing Supplement following the second chapter of
each Provider Services Manual).
iii. Reasons for denial of a claim will be
provided on the RA in the form of an error/edit code.
(1) Messages explaining all codes reflected
on the Remittance Advice will be printed on a separate page.
(b) A unique
13 digit Internal Control Number (ICN) is assigned to each Medicaid claim
received by the Fiscal Agent. The ICN is reflected on the RA and can be used to
track the status of a claim. For more information about the ICN, see Fiscal
Agent Billing Supplement following the second chapter of each Provider Services
Manual.
(c) For each claim
processed in a payment cycle, the ICN, beneficiary name, dates of service and
other claim information is printed on the RA. On the line immediately below
this information, a code is printed representing a denial reason, and other
information that might be useful to the provider and payment reduction reasons,
if any. Messages explaining all codes found on the RA will be found on a
separate page following the status listing of all claims. For more information
about Remittance Advice see the Fiscal Agent Billing Supplement following the
second chapter of each Provider Services Manual.
(d) Claims may be paid beyond 12 months of
the date of receipt with Federal financial participation (FFP) in the following
situations:
1. When the claim invoice or
retroactive adjustment is paid to a provider reimbursed under a retrospective
payment system;
2. For a
Medicare/Medicaid claim or Medicare/NJ FamilyCare claim, timely filed, payment
may be made for services within six months after the program or provider
receives notice of the Medicare claim disposition for a timely filed
Medicare/Medicaid or Medicare/NJ FamilyCare claim;
3. For claims from providers under
investigation for fraud or abuse; or
4. For claims associated with administrative
or legal actions pursuant to a hearing action or agency corrective action
mandate, whether for an eligible individual or for all those eligibles affected
in a similar manner.
