Newsletter Vol. 33, No.10

REQUIREMENTS: - By May 11, 2023: Billing team must reinstate prior authorization requirements for all Medicaid/NJ FamilyCare fee-for-service claims. Update billing software to block claims without prior auth documentation and configure system to reject pre-existing authorizations that were extended through the PHE without new authorization requests. - By May 11, 2023: Long-term care and facility billing staff must verify PASRR Level I and Level II assessments are completed PRIOR to admission for all nursing facility, ICF/IDD, PRTF, and hospital NF admissions. Update admission checklists and billing intake forms to require PASRR documentation before processing claims. - By May 11, 2023: Verify all alternative setting placements (unlicensed facilities used for emergency evacuations) are transitioned back to licensed facilities. Do not bill for services rendered in unlicensed settings after this date; claims will be denied. - By May 11, 2023: HCBS billing and claims staff must require written, signed consent from beneficiaries and providers on all HCBS Person-Centered Service Plans before billing services. Update EMR/billing system to flag unsigned plans and prevent claim submission. - By May 11, 2023: Level of Care determinations and redeterminations must return to standard timelines (initial determination before service start; annual redetermination within 12-month period). Billing staff must verify assessments are completed on schedule before authorizing services. - By May 11, 2023: Billing and care coordination teams must identify all beneficiaries currently receiving personal care services (PCS) from legally responsible or family member caregivers. Notify these beneficiaries (per MCO guidance) and transition claims to compliant, non-family PCS providers. Do not bill for family-member-provided PCS after this date. - By May 11, 2023: Pharmacy billing staff must discontinue auto-dispensing of 90-day medication supplies and early refills for maintenance medications. Revert to original prescription quantities and schedules. Reinstate all signature requirements for pharmacy orders in billing system. - Immediately: Obtain and review NJ Medicaid Alert MA-2023-04 (Pharmacy) for additional compliance requirements and update pharmacy billing procedures accordingly. - May 11, 2023 onward: Reject and rework any claims that bypass reinstated prior authorization requirements. Educate clinical and administrative staff that the PHE flexibilities have expired and standard Medicaid rules are in effect.