N.J. Admin. Code § 10:167C-1.25

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

Section 10:167C-1.25 - Point-of-sale (POS) claims adjudication system

(a) Senior Gold pharmacy claims may be submitted through a point-of-sale (POS) system and adjudicated by the State's fiscal agent on-line and in real-time. The POS system is an alternative to other methods of claim submission, including magnetic tape, diskette and paper claims. The pharmacist would be required to enter pharmacy claim detail data into a computer or POS device and transmit this data to the fiscal agent over a dedicated telephone line. Regardless of the method of claim submission, all claims will go through all New Jersey Medicaid Management Information System (NJMMIS) claims processing edits and the claims will be processed to determine their payment disposition (for example, paid or denied).

(b) In order for a Senior Gold approved pharmacy provider, in accordance with N.J.A.C. 10:167C-1.3, to submit pharmacy claims through a POS system, the provider shall enter into an agreement with a POS intermediary or shall directly provide a similar telecommunications network approved by the New Jersey Division of Medical Assistance and Health Services (Division).

1. In order to become an approved POS intermediary or provider established network, a firm shall notify the Division at the following address:

Division of Medical Assistance and Health Services

Office of Information Systems

PO Box 712-Mail Code #4

Trenton, New Jersey 08625-0712

Telephone: (609) 588-2802

2. The Division shall send the interested party a summary of the program and instructions on how to submit an application.

3. The Division shall consider the following in evaluating an application:

i. The applicant's general approach and plans to meet the requirements of the POS project;

ii. The applicant's detailed approach and plans to meet the requirements of the POS project;

iii. The applicant's documented qualifications, expertise, and experience on similar projects;

iv. The applicant's proposed staff's documented qualifications, expertise, and experience on similar projects; and

v. The applicant's adherence to the requirements of CMS.

(c) A POS participating pharmacy or intermediary must supply the computer hardware or POS device and required software to generate electronic media claims (EMC) in a format consistent with POS standards adopted by the Program.

(d) A POS participating pharmacy or intermediary shall supply modem capability required to properly transmit claim detail data to the approved POS intermediary or to participate in the provider established telecommunication network.

(e) All Senior Gold pharmacy providers choosing to submit claims through the POS system shall submit claims in the approved electronic format, and transmit these claims online for adjudication by the fiscal agent's POS computer system.

1. Pharmacy services provided to nursing facility and residential care residents utilizing 24-hour unit-dose or modified unit-dose drug delivery systems are precluded from the POS system.

(f) Claim data requirements for electronic media claims (EMC) generated by POS participating pharmacies include:

1. The first five alpha characters of the last name and the first three alpha characters of the Senior Gold beneficiary's first name;

2. The 12 digit Senior Gold identification number;

3. The date of birth, if applicable;

4. The date of service or dispense date;

5. The pharmacy prescription number;

6. The actual 11 digit National Drug Code (NDC) of the drug dispensed;

7. The metric quantity dispensed;

8. The days supply;

9. The prescriber's Medicaid provider service number;

10. The third party payment, if applicable;

11. The provider's usual and customary charge; and

12. The pharmacy provider number.

(g) Additional supplementary data requirements, which are claim specific, include:

1. The medical certification indicator;

2. The nursing facility residency indicator;

3. The compound drug indicator;

4. The other insurance indicator, if applicable; and

5. The carrier code(s), if applicable.

(h) A POS participating pharmacy or intermediary shall be required to implement software changes requested by the Division within 60 days of notification of such a request to ensure the generation of electronic claims acceptable to the Program.

(i) Pharmacy software must have the capability to display on-line adjudicated claim data returned to the pharmacy by the fiscal agent, including:

1. Payment disposition;

2. Error code messages; and

3. Claim pricing data, including drug cost reimbursement, dispensing fee and applicable co-payment amounts.

(j) Pharmacy software must provide the pharmacy with the capability of claim reversal and resubmission, if required.

1. A pharmacy may initiate a claim reversal of a previously submitted pharmacy claim for a period of 12 months from the initial date of claim service.

2. Pharmacies are required to initiate claim reversals for those services in which a claim was generated and adjudicated to payment by the fiscal agent's POS computer and the service was not subsequently provided to a Senior Gold beneficiary.

3. All prescriptions adjudicated to payment by the fiscal agent's computer shall be subsequently dispensed and their receipt by Senior Gold beneficiaries properly documented on a Senior Gold approved certification statement/signature log. (See N.J.A.C. 10:49-9.8 and 9.9.) During a public health emergency, a Senior Gold beneficiary is not required to provide a signature at the time a prescription is dispensed or delivered. The pharmacist must document in the patient's profile the date the beneficiary received the prescription.

N.J. Admin. Code § 10:167C-1.25

Amended by R.2007 d.134, effective 5/7/2007.
See: 38 N.J.R. 5295(a), 39 N.J.R. 1711(a).

Modified by Executive Order No. 103(2020) 52 N.J.R. 1253(a), effective 5/6/2020