N.J. Admin. Code § 10:51-1.24 - Claim submission

(a) An approved pharmacy 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 which complies with the National Council Prescription Drug Program (NCPDP) standards Version 5.1 and Version 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. In order for a pharmacy provider to be eligible to submit an EMC claim to the Medicaid or 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 of Medical Assistance and Health Services.

iii. The pharmacy provider or vendor or 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; or

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 electronic format approved by the Division which complies with the National Council Prescription Drug Program standards, Version 5.1 and Version 1.1, as amended and supplemented, incorporated herein by reference. The Council's address is 4201 North 24th Street, Suite 365, Phoenix, Arizona 85016.

(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 shall 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.

Notes

N.J. Admin. Code § 10:51-1.24

Repeal and New Rule, R.1995 d.104, effective 2/21/1995.
See: 26 New Jersey Register 4136(a), 27 New Jersey Register 684(a).
Formerly "EMC Incentive Program".
Amended by R.1996 d.146, effective 3/18/1996 (operative April 1, 1996).
See: 27 New Jersey Register 4566(a), 28 New Jersey Register 1526(a).
Recodified from N.J.A.C. 10:51-1.23 by R.1998 d.154, effective 2/27/1998 (operative March 1, 1998; to expire August 31, 1998).
See: 30 New Jersey Register 1060(a).
Former N.J.A.C. 10:51-1.24, Point-of-sale (POS) claims adjudication system, recodified to N.J.A.C. 10:51-1.25.
Adopted concurrent proposal, R.1998 d.487, effective 8/28/1998.
See: 30 New Jersey Register 1060(a), 30 New Jersey Register 3519(a).
Readopted the provisions of R.1998 d.154 without change.
Amended by R.1998 d.488, effective 9/21/1998.
See: 30 New Jersey Register 2169(b), 30 New Jersey Register 3538(a).
In (a)2i and (b)1 inserted references to NJ KidCare; and in (b)3, inserted a reference to NJ KidCare fee-for-service.
Amended by R.2004 d.26, effective 1/20/2004.
See: 35 New Jersey Register 3788(a), 36 New Jersey Register 558(a).
In (a), rewrote the introductory paragraph of 2, in 3, inserted "approved by the Division" following "electronic format" and substituted "Version 5.1 and Version 1.1" for "Version 3.2" following "standards,"; substituted references to NJ FamilyCare for references to NJ KidCare throughout.