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New Jersey MedicaidTraditional Medicare · Administrative · Pharmacy · NJHigh impact

Senior Services News Vol. 29, No. 01

Act
by Mar 15, 2026
Effective date
Mar 15, 2026
Identified
Jun 20, 2026

Summary

New Jersey PAAD/Senior Gold pharmacy claims will be denied starting March 15, 2026 if Medicare Part D patient responsibility amounts exceed the $2,100 annual out-of-pocket maximum or LIS copayment limits ($5.10 generic, $12.65 brand). Pharmacies must ensure proper secondary billing to avoid new error codes 2358 and 2359.

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What to do

by Mar 15, 2026 · 3 steps
01Pharmacy billing teams must update claims processing systems to ensure NCPDP Field 352-NQ 'Other Payer-Patient Responsibility Amounts' never exceed $2,100 annually for Medicare Part D or $5.10/$12.65 for LIS beneficiaries when billing PAAD/Senior Gold as secondary.
02Configure system to track cumulative out-of-pocket amounts and prevent submission of claims that would trigger error codes 2358 or 2359.
03Verify proper billing sequence: 1) Medicare Part D primary, 2) PAAD/SG secondary, 3) Medicare Prescription Payment Plan if applicable.

Original notice

Senior Services News Vol. 29, No. 01
njmmis.com · Always check the source before changing claims.
View original ↗

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