N.J. Admin. Code § 10:74-12.7

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:74-12.7 - Situations where no payment will be made

(a) The contractor shall not be responsible and shall not be paid when DMAHS has previously notified the contractor by mail specifying enrollee-months for which DMAHS is not responsible.

(b) If an enrollee is deceased and appears on the beneficiary file as active, the contractor shall promptly notify DMAHS. DMAHS will recover through offset all capitation payments made after the date of death.

(c) Newborn babies shall be the responsibility of the plan that covered the mother on the date of birth and for a minimum of 60 days after the birth, through the period ending at the end of the month in which the 60th day falls, unless the baby is determined eligible beyond that point. Any baby who is hospitalized during the first 60 days after the birth shall be the contractor's responsibility until discharge. Any baby who is readmitted to a hospital within 48 hours of discharge for the same diagnosis (other than "liveborn infant") shall also remain the contractor's responsibility. The contractor shall be responsible to notify DMAHS when a newborn has not been accreted to its enrollment roster after 12 weeks from the date of birth. DMAHS shall take action with the appropriate county board of social services to have the infant accreted to the eligibility file and subsequently to the enrollment roster following the notification. The mother's MCO is responsible for the hospital stay and subsequent services for the newborn following delivery.

(d) Newborn infants born to NJ FamilyCare-Plan B, C, and D mothers shall be the responsibility of the contractor that covered the mother on the date of birth for a minimum of 60 days after the birth through the period ending at the end of the month in which the 60th day falls unless the child is determined eligible beyond this time period. The managed care entity shall notify DMAHS of the birth immediately in order to assure payment for this period.

N.J. Admin. Code § 10:74-12.7

Recodified from N.J.A.C. 10:74-12.8 and amended by R.2000 d.370, effective 9/18/2000 (operative October 1, 2000).
See: 32 New Jersey Register 1352(a), 32 New Jersey Register 3426(a).
Rewrote (c); and added (d). Former N.J.A.C. 10:74-12.7, Services provided in excess of limits, recodified to N.J.A.C. 10:74-12.6.
Amended by R.2006 d.17, effective 1/3/2006.
See: 37 New Jersey Register 2787(a), 38 New Jersey Register 294(d).
Rewrote (c); in (d), substituted "FamilyCare" for "KidCare".