N.J. Admin. Code § 10:167-7.2

Current through Register Vol. 57, No. 1, January 6, 2025

Section 10:167-7.2 - Recoveries for benefits incorrectly paid

(a) As provided in N.J.S.A. 30:4D-1 et seq., the Department may take all necessary action to recover the cost of benefits incorrectly paid on behalf of a beneficiary.

1. The term "incorrect payment" includes, but is not limited to:

i. Payment made on behalf of a beneficiary whose drug costs are wholly covered by another source;

ii. Payment made on behalf of a beneficiary who is no longer eligible, or has been incorrectly determined to be eligible to receive benefits;

iii. Payment made as a result of fraud perpetrated by a beneficiary, his or her authorized agent and/or provider; and

iv. An unanticipated payment that makes a recipient ineligible for benefits, in which case the provisions of N.J.S.A. 30:4D-21.4 shall apply.

(b) The Department shall take all reasonable measures to ascertain the legal liability of third parties to pay for prescription drugs arising out of injury, disease, or disability, where it is known that a third party is or may be liable to pay all or part of the drugs of a beneficiary. Payment on behalf of an eligible individual shall not be withheld because of the liability of third parties, if third party resources are not currently available to pay the individual's expenses. The Department shall recover from any such third party the full amount of payments made. Upon request of the Director, the Attorney General may enforce such right, institute legal proceedings against the third party who is or may be liable for the payment for drugs, or intervene in any proceedings, in the name of the Commissioner, or in the name of the injured person, his guardian, executor, administrator or other appropriate representative.

N.J. Admin. Code § 10:167-7.2

Amended by R.1993 d.368, effective 7/19/1993.
See: 24 N.J.R. 4329(a), 25 N.J.R. 3216(a).
Amended by R.1998 d.176, effective 4/6/1998.
See: 29 N.J.R. 5280(a), 30 N.J.R. 1314(b).
Amended by R.2009 d.16, effective 1/5/2009.
See: 40 N.J.R. 4479(a), 41 N.J.R. 221(a).