N.J. Admin. Code § 10:167B-5.5

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

Section 10:167B-5.5 - Agency controls

(a) The Department has the responsibility for reviewing a statistically valid representative sample of Senior Gold cases to assure beneficiary eligibility. A quality control review of sample cases selected on a random basis includes:

1. Analysis of the beneficiary's case record, including the application which is maintained by the PAAD Bureau;

2. An interview with the beneficiary or the beneficiary's representative(s) to review eligibility for Senior Gold and availability of third party resources; and

3. Verification of eligibility factors and third party liability information through collateral contacts.

(b) The Department, in conjunction with the Division of Medical Assistance and Health Services, has the responsibility for monitoring providers participating in the Program, verifying that claims submitted to the Program by such providers are in compliance with Program regulations, and investigating beneficiaries in matters involving potential fraud and/or abuse.

(c) The Department shall, as appropriate, recover benefits incorrectly paid on behalf of a beneficiary.

N.J. Admin. Code § 10:167B-5.5