MedicaidCoverageHigh impact
Newsletter Vol. 33, No.18
New Jersey Medicaid·NJ · Geriatrics, Palliative Care·Provider Notice
Effective date
Dec 1, 2023
We identified it
Jun 20, 2026
Summary
NJ FamilyCare is implementing stricter discharge planning requirements for nursing facility members whose prior authorizations are ending due to failure to meet nursing facility level of care. Facilities must now provide proper notice, conduct 30-day discharge planning with MCO collaboration, and follow formal involuntary discharge procedures. Billing teams must ensure claims are not submitted after authorization expiration and that proper appeal processes are followed before payment ceases.
Action Required
Immediately: Billing team must implement the following operational changes: (1) Update claim submission procedures to STOP accepting and processing claims for NJ FamilyCare managed care nursing facility services after the member's authorization end date has been communicated by the MCO; (2) Verify that all nursing facility discharge notifications are received and documented before final claim submission; (3) Flag any claims for members whose authorizations have ended without documented discharge planning completion; (4) Ensure all appeals submitted by members result in authorization extensions until fair hearing conclusion, and track these extended authorization periods in billing system; (5) Track the 30-day discharge planning extension period granted by MCOs and do NOT bill beyond this extended period unless new authorization is issued. Consequences: Claims submitted after authorization expiration without proper discharge planning documentation will be denied. Improper discharge without 24-hour notification to members may trigger compliance violations under N.J.A.C. 8:39 and 8:85, potentially affecting provider credentialing and future reimbursement.