New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 59 - MEDICAL SUPPLIER MANUAL
Subchapter 1 - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT
Section 10:59-1.9 - Dual Medicare/Medicaid/NJ FamilyCare coverage
Current through Register Vol. 56, No. 18, September 16, 2024
(a) When a Medicaid/NJ FamilyCare beneficiary also has Medicare coverage, the Medicaid/NJ FamilyCare program requires that Medicare benefits be used first and to the fullest extent. Responsibility for payment by the New Jersey Medicaid/NJ FamilyCare program shall be limited to the unsatisfied deductible and/or coinsurance to the extent that the combined Medicare/Medicaid/NJ FamilyCare payment does not exceed the Medicaid/NJ FamilyCare maximum allowable.
(b) In those instances where Medicare policy disallows reimbursement for an item/service under certain circumstances, for example, a special wheelchair for a NF resident, the provider shall obtain prior authorization from the Medicaid/NJ FamilyCare--Plan A program and submit a hard copy claim to the Medicaid/NJ FamilyCare--Plan A program with an Explanation of Benefits from Medicare attached.
(c) Medicare/Medicaid/NJ FamilyCare claims shall be filed timely, in accordance with N.J.A.C. 10:49-7.2.
(d) When a beneficiary is eligible for Medicare/Medicaid/NJ FamilyCare coverage, a Medicare/Medicaid/NJ FamilyCare claim will cross over from the Medicare DMERC Region A to the Medicaid/NJ FamilyCare fiscal agent. There are instances, however, where claims will not cross over from Medicare to Medicaid/NJ FamilyCare, for example, claims denied by Medicare or claims where the Medicaid/NJ FamilyCare fiscal agent is unable to match pertinent identifying data (see N.J.A.C. 10:49-7.2(d)3 for further instructions).
(e) There are situations in which Medicare coverage differs significantly from coverage considered medically necessary by the Medicaid/NJ FamilyCare program. In these situations, the provider may request PA from the Medicaid/NJ FamilyCare program prior to requesting Medicare payment.
(f) For dually eligible beneficiaries, Medicaid/NJ FamilyCare coverage shall be based on Medicare policy as it relates to rental and/or purchase of supplies and DME except as described at (e) above.
