New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 52 - HOSPITAL SERVICES MANUAL
Subchapter 12 - CHARITY CARE COMPONENT OF THE DISPROPORTIONATE SHARE HOSPITAL SUBSIDIES
Section 10:52-12.1 - Definitions

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise:

"Adjudication" means the processing of all submitted claims accepted by the Fiscal Agent during a monthly adjudication cycle, with the outcome being the claim is priced, denied, or processed as a void or adjustment of a previous claim. Voids and adjustments are also either priced or denied.

1. Claims included in files that are rejected during preprocessing are not adjudicated because the claims never enter the system for pricing.

2. Adjudicated claims are reported monthly to the hospital or the hospital's designated agent on the Remittance Advice.

"Adjudication cycle date" is the date on which claims are accepted for pricing by the Fiscal Agent and are adjudicated.

"Clean charity care claim" means a charity care claim that is received by the Fiscal Agent and accepted by the Fiscal Agent in accordance with electronic media procedures and is adjudicated and priced no later than two years after the date of patient discharge (inpatient) or date of service (outpatient). Claims that are denied are not clean claims. A clean charity care claim includes:

1. The name and provider number assigned by the Department of Health to each licensed hospital;

2. The name and, if available, Social Security number of the charity care eligible recipient of the services;

3. The diagnosis(es);

4. The date of service for outpatient services or dates of admission and discharge for inpatient services;

5. The services rendered and the charge for the service; and

6. The data required by the Fiscal Agent in accordance with the Fiscal Agent Billing Supplement, provided that the requirement is not in conflict with the provisions of the New Jersey Administrative Code.

"Pricing cycle" means the Fiscal Agent's charity care claims submission schedule, as described in 10:52-12.2(c).

"Remittance Advice (RA)" means the hospital's account statement of activity for the most recent monthly adjudication cycle which reflects the status of all charity care claims, tracked according to a unique Internal Control Number (ICN), adjudicated by the Fiscal Agent during that cycle.

"Submission cut-off date" means the date by which claims shall be received by the Fiscal Agent to assure processing for and possible adjudication in the pricing cycle.