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N.J.A.C. 10:90-13.2 This file includes all Regulations adopted and published through the New Jersey Register, Vol. 56 No. 24, December 16, 2024

NJ - New Jersey Administrative Code > TITLE 10. HUMAN SERVICES > CHAPTER 90. WORK FIRST NEW JERSEY PROGRAM > SUBCHAPTER 13. MEDICAL SERVICES FOR WFNJ SINGLE ADULTS AND COUPLES WITHOUT DEPENDENT CHILDREN

§ 10:90-13.2 Payment of medical service claims for WFNJ/GA recipients residing in a nursing facility

(a) Claims resulting from medical services provided to WFNJ/GA recipients residing in a nursing facility, on or after February 1, 1997, shall be processed and paid by the New Jersey Division of Medical Assistance and Health Services (DMAHS) through its fiscal agent, in accordance with the rules appropriate for the services rendered (see N.J.A.C. 10:49). Payment of claims submitted to the fiscal agent for medical services covered under the WFNJ/GA program shall be based upon the Medicaid reimbursement methodology for the respective services. Those medical services identified at (a)2 below shall not be considered eligible for payment by the fiscal agent for WFNJ/GA program purposes. 1. Medical service claims with service dates on or after February 1, 1997 shall be submitted directly to the fiscal agent by the medical provider/vendor for payment processing. The original claim must be received by the fiscal agent within the time frame of one year from the date the service was rendered or the product was provided. If the original claim is not received by the fiscal agent within the one year time frame the claim shall not be processed for payment. i. The provider/vendor shall direct all concerns relating to the payment or processing of WFNJ/GA medical service claims to the fiscal agent. (1) A provider/vendor may, however, contact the agency in which the WFNJ/GA recipient is receiving assistance to ascertain information concerning WFNJ/GA policies, coverage of services and/or eligibility. ii. Medical service claims, except for prescription claims, with service dates prior to February 1, 1997 shall be processed by the county/municipality. Such claims, however, must be received by the county/municipality within a time frame of six months from the date the service was rendered in order for that claim to be considered eligible for payment processing. 2. The following services are not considered eligible medical services for WFNJ/GA program purposes and shall not be processed for payment by the fiscal agent: