Current through Register Vol. 56, No. 18, September 16, 2024
(a) This subchapter sets forth the requirements of the New Jersey State Department of Health that the provider shall adhere to when submitting a charity care claim.
(b) A charity care claim shall be submitted in accordance with the electronic media claims (EMC) manual, which is part of the Fiscal Agent Billing Supplement (see (d) below), by an approved method of electronic automated data exchange. In order for a charity care claim to be priced, it must be a clean charity care claim.
(c) The State of New Jersey uses a Fiscal Agent for the pricing of charity care claims.
1. The Department of Health will advise hospitals in December of each year of the Fiscal Agent's pricing cycle and submission cut-off dates for the following calendar year. Charity care claims shall be adjudicated monthly by the Fiscal Agent.
2. Hospitals shall submit claims at least monthly to the Fiscal Agent. Claims submitted after the submission cut-off date shall not be guaranteed to be processed for the upcoming monthly cycle. Hospitals shall be solely responsible for meeting submission cut-off deadlines.
3. Hospitals shall be solely responsible for submission of clean charity care claims in an electronic format that can be processed by the Fiscal Agent.
4. Hospitals shall be solely responsible for verifying receipt and acceptance or rejection by the Fiscal Agent of all submitted claims files.
5. The Fiscal Agent shall reject partially or in its entirety an electronic claims file containing any technical defect(s) that prevent electronic processing. The Fiscal Agent shall advise the hospital or its designated agent in writing, within 10 days of the attempted processing, that the file could not be processed. The notice shall document the reason(s) for the failure to process the electronic claims file. If the hospital designates an agent to submit its charity care claims to the Fiscal Agent, all notices from the Fiscal Agent to the hospital's designated agent shall constitute notice to the hospital.
6. The Fiscal Agent shall deny for pricing all claims that do not meet the criteria for clean charity care claims.
7. The Fiscal Agent shall provide the hospital a charity care claim remittance advice once a month, unless the hospital has failed to submit any claims capable of adjudication during the adjudication cycle. The charity care claim remittance advice shall constitute the hospital's account statement for all charity care claims adjudicated by the Fiscal Agent during the most recent adjudication cycle. The charity care claim remittance advice shall identify codes for claims on the remittance advice, both priced and unpriced. If the hospital designates an agent to submit its charity care claims to the Fiscal Agent, all notices from the Fiscal Agent to the hospital's designated agent shall constitute notice to the hospital.
8. A unique internal control number (ICN) is assigned to each charity care claim that is adjudicated by the fiscal agent. The ICN is reflected on the remittance advice. The ICN can be used to track the status of a claim.
9. All charity care claims adjudicated by the Fiscal Agent are classified as either priced or denied claims. Void and adjustment claims may also be either priced or denied.
i. Priced claims shall be processed in accordance with this subchapter. A charity care claim that is a clean charity care claim for a covered service provided to an eligible charity care recipient by an approved hospital will be priced. The status of the claim shall appear on the claim status page, or pages, of the remittance advice, along with the status of all other claims which are being priced in that cycle.
ii. Denied claims shall be processed in accordance with this subchapter. Reasons for denial of a charity care claim shall be provided on the remittance advice in the form of a code. The hospital shall have the opportunity to resubmit a denied charity care claim in a subsequent cycle, within two years of the date of service (outpatient) or date of discharge (inpatient).
iii. Void and adjustment claims will be processed and adjudicated in accordance with this subchapter. Void and negative adjustment (reduction in payment) claims may be submitted at any time. Adjustments resulting in an increased payment amount shall be submitted within two years of date of service (outpatient) or date of discharge (inpatient).
(d) In addition to information in this section about submitting claims for pricing of outpatient and inpatient charity care claims, a Fiscal Agent Billing Supplement (FAB) and an Electronic Claims Manual are included as Appendices A and B to this chapter, incorporated herein by reference. The FAB includes information regarding the following:
1. The proper completion and submission of claim forms;
2. The procedure to follow when claims are denied and returned to the provider by the Fiscal Agent during the adjudication process;
3. Third party liability verification;
4. EMC submission;
5. Remittance Advice statements for pricing of claims and adjustments of Medicare;
6. The procedure to follow when a claim is priced in error (void);
7. The procedure for inquiries about claims;
8. The procedure for ordering forms;
9. Provider services; and
10. Item by item instructions for completing the claim form and other forms.
(e) The Fiscal Agent Billing Supplement is not published in the New Jersey Administrative Code but is referenced as an Appendix to this chapter and is not a legal description of the charity care program rules. Should there be any conflict between the Fiscal Agent Billing Supplement and the applicable laws or rules governing the charity care program, the charity care rules contained in this chapter and in N.J.A.C. 10:49 shall take precedence.
