N.J. Admin. Code § 10:51-2.21

Current through Register Vol. 56, No. 11, June 3, 2024

Section 10:51-2.21 - Claims submission

(a) Based on the level of service provided by an approved pharmacy to a nursing facility, a provider may choose to:

1. Submit a properly completed hard copy pharmacy claim form approved by the New Jersey Division of Medical Assistance and Health Services (DMAHS).

2. Submit an electronic media claim (EMC) by modem, diskette, or magnetic tape in an approved electronic format that complies with the National Council Prescription Drug Program (NCPDP) standards Version 5.1 and Version 1.1, incorporated herein by reference, as amended and supplemented. The Council's address is 4201 North 24th Street, Suite 365, Phoenix, Arizona 85016.

i. In order for a pharmacy provider to be eligible to submit an EMC claim to the Medicaid NJ FamilyCare programs, a pharmacy provider or vendor of EMC services shall complete the "New Jersey Medicaid Provider Electronic Billing Agreement."

ii. The completed agreement shall be submitted to the fiscal agent and approved by the Division.

iii. The pharmacy provider or vendor of EMC services shall submit electronic media claims under an approved submitter identification number and comply with EMC requirements contained in the EMC Manual, Appendix E, incorporated herein by reference.

iv. For the purposes of this subchapter, all electronically submitted claims, including POS claims, shall commonly be referred to as EMC claims.

3. Enter into an agreement with a point-of-sale (POS) intermediary or directly provide a similar telecommunication network approved by DMAHS to submit claims to the fiscal agent for adjudication. POS claims require an approved electronic format which complies with the National Council Prescription Drug Program standards, Version 5.1 and 1.1 as amended and supplemented, incorporated herein by reference. The Council's address is 4201 North 24th Street, Suite 365, Phoenix, Arizona 85016.

i. The approved POS intermediary or provider established network shall enter into an agreement with the State of New Jersey to provide on-line telecommunication services, including transmission of pharmacy claim detail data, access to the fiscal agent's POS computer and return of adjudicated claim data to the provider.

(b) A properly completed claim form or a properly formatted electronic media claim (EMC) may be submitted to the fiscal agent, or transmitted by an approved POS intermediary or provider established telecommunication network to the fiscal agent for claims adjudication.

1. A single claim form shall be completed manually or by computer or an EMC claim shall be transmitted in the approved EMC format for each Medicaid or NJ FamilyCare prescription dispensed. See Appendix D, Fiscal Agent Billing Supplement, for instructions concerning the completion and submission of the specified claim form, and Appendix E, regarding the proper EMC claim format;

2. All claim forms and EMC claims must contain the National Drug Code (NDC) of the actual drug dispensed. The 11-digit NDC has three components. The first five digits are the manufacturer's labeler code, the next four digits are the product code and the final two digits are the package size code. For claim submission, leading zeros shall be included in all fields. For example, 00003-0234-01.

i. The dispenser shall always report the actual labeler code and drug product code of the drug dispensed. The package size code reported may differ from the actual stock package size code reported on the claim.

3. All Medicaid or NJ FamilyCare fee-for-service pharmacy claims submitted to the fiscal agent for payment consideration shall be adjudicated based on the outcome of established POS and PDUR edits, regardless of the mode of claim submission.

N.J. Admin. Code § 10:51-2.21

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