New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES
Subchapter 8 - ENROLLEES
Section 10:74-8.7 - Protecting managed care enrollees against liability for payment

Universal Citation: NJ Admin Code 10:74-8.7

Current through Register Vol. 56, No. 18, September 16, 2024

(a) If a fee-for-service or managed care provider, whether or not a participant in a program administered in whole or in part by the Division of Medical Assistance and Health Services (DMAHS), renders a covered service to a beneficiary of a program administered in whole or in part by DMAHS, including, but not limited to, the WorkFirst NJ/General Assistance, Medicaid/ NJ FamilyCare program, the provider's sole recourse for payment, other than collection of any authorized cost-sharing and/or third-party liability, shall be either DMAHS or the MCO with which DMAHS contracts that serves the beneficiary. A provider shall not seek payment from, and shall not institute or cause the initiation of collection proceedings or litigation against, a beneficiary, a beneficiary's family member, any legal representative of the beneficiary or anyone else acting on the beneficiary's behalf unless (a)1 below, or (a)2 through and including 7 below, apply:

1. The beneficiary has been paid for the service by a health insurance company or other third party (as defined in 30:4D-3.m.), and the beneficiary has failed or refused to remit to the provider that portion of the third party's payment to which the provider is entitled by law; or

2. Either:
i. The service is not a covered service;

ii. The service is determined to be medically unnecessary before it is rendered; or

iii. The provider does not participate in the aforementioned programs either generally or for that service;

3. The beneficiary is informed in writing before the service is rendered that one or more of the conditions listed in (a)2 above exists and voluntarily agrees in writing before the service is rendered to pay for all or part of the provider's charges;

4. The service is not an emergency or related service covered by the provisions of 42 U.S.C. § 1396u-2(b)(2)(A)(i), 42 CFR 438.114, 30:4D-6i and/or 10:74-9.1;

5. The service is not a trauma service covered by the provisions of 11:24-6.3(a)3 i;

6. The protections afforded to beneficiaries under 42 U.S.C. § 1396u-2(b)(6), 42 CFR 438.106, 11:24-9.1(d)9 and/or 15.2(b)7ii do not apply; and

7. The provider has received no program payments from either DMAHS or the beneficiary's MCO for the service.

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