N.J. Admin. Code § 10:51-2.22

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

Section 10:51-2.22 - Point-of-sale (POS) claims adjudication system

(a) Pharmacies providing traditional pharmacy services, as described in 10:51-2.7, to nursing facilities 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 10:51-2.3, 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 Health Care Financing Administration.

(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 nursing facility residency indicator;

5. The date of service or dispense date;

6. The pharmacy prescription number;

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

8. The metric quantity dispensed;

9. The days supply;

10. The prescriber's provider service number;

11. The third party payment, if applicable;

12. The provider's usual and customary charge;

13. The pharmacy provider number; and

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

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

1. The medical certification indicator;

2. The other insurance indicator, if applicable;

3. The compound drug indicator; and

4. 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 ensue 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 messages; 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 the 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.

(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.

N.J. Admin. Code § 10:51-2.22

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