N.J. Admin. Code § 10:51-1.25

Current through Register Vol. 56, No. 24, December 18, 2024

Section 10:51-1.25 - Point-of-sale (POS) claims adjudication system

(a) Medicaid or NJ FamilyCare fee-for-service pharmacy claims may be submitted through a 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).

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.

(b) In order for a Medicaid or NJ FamilyCare approved pharmacy provider, in accordance with N.J.A.C. 10:51-1.3, 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.

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

Mail Code #4

PO Box 712

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 the Centers for Medicare and Medicaid Services.

(c) A POS-participating pharmacy or intermediary shall 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 Division.

(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 Medicaid and NJ FamilyCare pharmacy providers choosing to submit claims through the POS system, shall submit claims in the approved electronic format, and transmit these claims on-line for adjudication by the fiscal agent's POS computer 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 Medicaid or NJ FamilyCare beneficiary's first name;

2. The 12-digit Medicaid or NJ FamilyCare 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 or NJ FamilyCare 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 Medicaid, NJ FamilyCare or WFNJ/GA prior authorization number, if applicable;

4. The compound drug indicator;

5. The other insurance indicator, if applicable; and

6. 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 Division.

(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 message; and

3. Claim pricing data, including drug cost reimbursement, dispensing fee and applicable copayment 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 Medicaid or NJ FamilyCare fee-for-service beneficiary.

3. All prescriptions adjudicated to payment by the fiscal agent's computer shall be subsequently dispensed and their receipt by Medicaid or NJ FamilyCare fee-for-service beneficiaries properly documented on an NJ FamilyCare approved certification statement/signature log. (See N.J.A.C. 10:49-9.6). During a public health emergency, an NJ FamilyCare 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.

(k) Pharmacies are required to interact with prescribers and/or beneficiaries at POS to resolve matters related to on-line messages resulting from claim adjudication by the fiscal agent.

(l) The following shall apply for coverage of prescriptions when provided to Medicaid or NJ FamilyCare or Work First New Jersey/General Assistance (WFNJ/GA) beneficiaries during an interruption in POS service:

1. Pharmacists shall confirm Medicaid or NJ FamilyCare eligibility by reviewing the respective eligibility card/letter, or by contacting the Recipient Eligibility Verification System (REVS) at 1-800-676-6562. If eligibility cannot be confirmed, pharmacists should follow the "good faith" guidelines as described in N.J.A.C. 10:49-2.10.

2. All claims for original prescriptions shall be payable for up to a 34-day supply initially. Upon refill, a 34-day supply or 100 dosage units, whichever is greater, shall be payable, if authorized by a prescriber.

3. Prior authorization (PA) requirements shall not apply to pharmacy services provided during a sustained interruption in POS service, except that prior authorization shall be required for those drugs identified by the New Jersey Drug Utilization Review Board as causing severe drug-drug interactions, if the interacting drugs are dispensed by the same pharmacy.

4. Pharmacies shall be responsible for, and shall not be reimbursed for, early refills and duplicate prescriptions dispensed by their own pharmacy. In the event that early refills or duplicate prescriptions submitted by the same pharmacy during a sustained interruption are paid, the Division of Medical Assistance and Health Services will institute recovery procedures subsequent to the restoration of service.

i. "Sustained interruption" means the period of time that POS service has been interrupted during which the Division of Medical Assistance and Health Services has notified pharmacies by fax and/or email of a sustained interruption in the POS system.

5. The Division of Medical Assistance and Health Services will reimburse pharmacies for early prescription refills and duplicate prescriptions provided by another pharmacy during a sustained interruption in POS service.

6. After POS service is restored, pharmacies should submit claims which could not be processed during the interruption in POS service during off-peak hours. This will allow all pharmacies to receive timely responses to routine claims submitted immediately after service has been restored.

N.J. Admin. Code § 10:51-1.25

Amended by 48 N.J.R. 2785(a), effective 12/19/2016

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