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Essential Information for
New Jersey FamilyCare Providers
Geralyn D. Molinari
Director, Managed Provider Relations Unit
Office of Managed Health Care
NJ Department of Human Services
Division of Medical Assistance and Health Services
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• Overview of New Jersey Medicaid/NJ FamilyCare
• Confirmation of Member Eligibility
• Provider Relations Overview- DMAHS /OMHC
• Balance Billing
• Authorization and Claims Processing
• Continuity of Care
• Utilization Appeals
• Provider /Stakeholder Resources
Presentation Topics
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• Medicaid is a joint Federal and State program that
helps pay medical costs if individuals have limited
income and resources or meet other requirements.
• Medicaid is a voluntary program. If you want to
participate, you must know, accept and abide by
the rules and regulations
• New Jersey Medicaid is referred to as NJ FamilyCare
in member and provider communication
What is Medicaid?
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The New Jersey Department of Human Services, DMAHS, has
a contract with the following Managed Care Organizations:
– Aetna Better Health of New Jersey
– Amerigroup New Jersey, Inc.
– Horizon NJ Health
– UnitedHealthcare Community Plan
– WellCare Health Plans of NJ, Inc.
New Jersey Medicaid
Managed Care Contracts
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Administration & Oversight
The Medicaid program in New Jersey is administered and/or overseen by
Department of
Law & Public
Safety
Department of
Treasury
Department of
Human
Services
Office of the
State
Comptroller
Medicaid
Fraud Control
Unit
(MFCU)
Division of
Medical
Assistance
and Health
Services
(DMAHS)
Medicaid
Fraud Division
(MFD)
Office of the
Insurance
Fraud
Prosecutor
Division of
Criminal
Justice
Managed Care
Organizations
(MCO)
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CONFIRMATION OF MEMBERS
NJ FAMILYCARE ELIGIBILITY
Provider’s Requirement to
Confirm NJ FamilyCare Eligibility
• Providers must confirm NJ FamilyCare Eligibility each
month to ensure that member is currently enrolled
• Provider must confirm that member is enrolled in
Health Plan and that they have an active
authorization
• If Member has changed MCO, provider must
contact existing Health Plan regarding authorization
update
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Medicaid Eligibility Verification System (MEVS)
E-Mevs
• Medicaid Eligibility Verification System (MEVS) is an electronic
system used to verify recipient Medicaid eligibility. This
electronic verification process will provide date specific
eligibility which will help reduce claim denials related to
eligibility. It can help to eliminate Medicaid fraud.
• NJ Providers access eMEVS through “Login” on the NJMMIS
website www.njmmis.com
• In order to login, individual must have a secure username and
password
• Users ids and passwords are requested through Provider
Registration link on the NJMMIS navigational bar on main
screen.
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Users access eMEVS by
selecting Login
Enter your secure
Username and
Password
Balance Billing
A provider shall not seek payment from, and shall not
institute or cause the initiation of collection proceedings or
litigation against a beneficiary, a beneficiary's family
member, any legal representative of the beneficiary, or
anyone else acting on the beneficiary's behalf unless service
does not meet criteria referenced in NJAC 10:74-8.7(a).
Balance Billing details are also outlined in NJ Family Care
Newsletter:
Volume 23 No. 15 September 2013
Limitations Regarding the Billing of NJ Family Care (NJFC) Beneficiaries
All Medicaid/NJ Family Care newsletters posted on http://www.njmmis.com
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• creating an annual provider manual and preparing
updates as necessary;
• offering provider education and outreach, and
• provide a call center for claims troubleshooting for
providers
• establish process for claims and utilization appeals
• assign Provider representative or contact to address
Provider contract
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Managed Care Organization
Provider Relations Unit Requirements
Prior Authorization Parameters
Prior authorization decisions for non-emergency
services shall be made within 14 calendar days
Prior authorization denials and limitations must be
provided in writing in accordance with the Health
Claims Authorization Processing and Payment
Act, P.L. 2005, c.352.
Source: Health Claims Authorization Processing
and Payment Act, P.L. 2005, c.352.
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New Member
No Existing Plan of Care
Member Transitions to MCO with
existing Plan of Care for LTCE
MCO must prior-authorize service
MCO must honor continuity of care
parameter of contract
Provider must be in Network with
MCO and/or have a single case
agreement to serve member
MCO and Provider must set up SCA
or join network. Approved services
as per existing plan will be
reimbursed until new plan of care
established
Prior Authorization Guidelines for
NJ Family Care Services
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Managed Care Organization
Claim Submission Requirements
• Capture and adjudicate all claims submitted by
providers
• Support NJs NJ Family Care’s encounter data
reporting requirements
• Comply with "Health Claims Authorization,
Processing and Payment Act“ (HCAPPA) for all
Medical Services
• Ensure Coordination of Benefits (exhaust all other
sources of payment before NJ Family Care pays)
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Claim Processing Compliance with
Federal and State Laws and Regulations
• 1. The Provider/Subcontractor shall submit claims
within 180 calendar days from the date of service.
• 2. The Provider/Subcontractor shall submit
corrected claims within 365 days from the date of
service.
• 3. The Provider and Subcontractor shall submit
Coordination of Benefits (COB) claims within 60 days
from the date of primary insurer’s Explanation of
Benefits (EOB) or 180 days from the dates of service,
whichever is later.
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Claim Dispute
Adjudicate--the point in the claims/encounter
processing at which a final decision is reached to
pay or deny a claim, or accept or deny an
encounter.
Contested Claim--a claim that is denied because
the claim is an ineligible claim, the claim
submission is incomplete, the coding or other
required information to be submitted is incorrect,
the amount claimed is in dispute, or the claim
requires special treatment.
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Continuity of Care
Definition: The plan of care for an enrollee that should assure
progress without unreasonable interruption
• The Contractor shall ensure continuity of care and full
access to primary, behavioral, specialty, MLTSS and
ancillary care as required under this contract and access
to full administrative programs and support services offered
by the Contractor for all its lines of business and/or
otherwise required under this Contract.
Source: Article 2.B of the July 2017 NJ FamilyCare Managed
Care Contract
Continuity of Care
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Utilization Appeals
UM Appeal Process: Definitions
UM Appeal: An appeal of an adverse Utilization
Management determination, initiated by the Member
(or a provider acting on behalf of a Member with the
Member’s written consent)
Utilization Management Determination: A decision
made by a Managed Care Organization (MCO) to
deny, reduce, suspend or terminate a service based
on medical necessity
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IURO
(External Appeal)
Time Frame
Medicaid Fair
Hearing
Continuation of Benefits
NJ FamilyCare A and
ABP Members
Yes* Yes Member and/or Provider
on behalf of member must
request within appeal
timelines
Appeal Process for NJFC
B, C, and D Members
Yes Not Available Member and /or Provider
on Behalf of member must
request within appeal
timelines
(Select services are not eligible for IURO: Adult Family Care, Assisted Living Program, Assisted Living
Services, Caregiver Participant Training, Chore Services, Community Transition Services, Home
Based Supportive Care, Home Delivered Meals, PCA, Respite, Social Day Care, Structured Day
Program )
Utilization Appeals Guidelines for
NJ Family Care Services
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Resources for Providers and
Stakeholders
Mobile Friendly & Browser Independent
Link to Website with Enrollment informtion
http://www.njfamilycare.org/analytics/home.html
http://www.njfamilycare.org
DMAHS Office of Managed Health Care (OMHC)
Provider Relations Inquiry Process
Provider and/or Member contact DMAHS:
• Provider must submit claim detail to DMAHS:
Providers must submit detail indicating that Medicaid
guidelines were followed and MCO was contacted
prior to outreach to OMHC
– check eligibility
– request prior authorization,
– timely claim submission
– Submission of appeal timely
Member: Submits copy of balance bill
DMAHS will contact the MCO
Submit to [email protected]
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DMAHS Office of Managed Health Care (OMHC)
Provider Relations Inquiry Process
• OMHC completes inquiry upon receipt of detail indicating
that MCO contract guidelines were followed
• OMHC will review and follow-up with MCO on behalf of
the Provider if initial response does not meet contract
guidelines. All inquiries sent to MCO are logged into a
SharePoint database
Example: Claim inquiries are closed upon receipt of claim
number and amount and /or letter to Provider.
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MCO Provider Relations Reporting
• MCO Contracted Quarterly Report (Table 3C)
includes all inquires submitted to MCO on behalf of
Provider by the Office of Managed Health Care
(OMHC)
• DMAHS prepares a Quarterly Provider Inquires Report
(Feb 15th, May 15th, Aug 15
th
and Nov 15
th
)
• Quarterly Report documents all reported inquiries
and identify inquiries that remain open beyond a
designated quarterly period
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• Based on trends across plans and /or service types
– Develop Provider Education
– Develop policy guidance
– Develop contract changes / updates
– Present MCO Notices of Deficiencies or
Corrective Action Plans if necessary
DMAHS Follow-up
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• NJ FamilyCare Health Plans Currently Under Contract
and Providing Medicaid Managed Care Services in
New Jersey
https://www.state.nj.us/humanservices/dmahs/clients/m
edicaid/hmo/index.html
• Member Relations- Access Member Manual
• Provider Relations -Provider Quick Reference Guide
NJ FamilyCare MCO Resources
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Access
• MLTSS Resources
http://www.state.nj.us/humanservices/dmahs/home/mltss_resources.html
• Behavioral Health Resources
https://www.state.nj.us/humanservices/dmahs/news/ebhb.html
• Form to submit inquiry is located by clicking on highlight
• DMAHS Provider Relations Inquiry Information
• Provider Relations Inquiry Request form – single case
• Provider Relations Inquiry Request form – multiple cases
Email detail via secure email to mahs.provider-[email protected]
Separate emails should be sent for individual MCOs.
Multiple cases must include excel summary of information.
State Resource for Managed Care Providers:
Office of Managed Health Care (OMHC)
Managed Provider Relations Unit
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Questions
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