MedicaidAdministrativeHigh impact
Newsletter Vol. 29, No.15
New Jersey Medicaid·NJ·Prior Authorization
Effective date
Oct 1, 2019
We identified it
Jun 20, 2026
Summary
Permedion has expanded its utilization review (UR) audit scope for NJ FamilyCare to now include Managed Care Organization (MCO) encounter records in addition to traditional fee-for-service inpatient claims. Hospitals must now submit medical records, UR certifications, billing documentation, and UB04 claim forms to Permedion within specified timeframes. Non-compliant or untimely submissions may result in claim recoupment.
Action Required
Immediately: (1) Billing team must establish a process to track and respond to Permedion's random sample medical records requests within Permedion's specified timeframes. (2) Ensure all UB04 claim forms submitted to MCOs are prepared in HIPAA 837(I) format and are available for submission to Permedion upon request. (3) Designate a point of contact for Permedion communications and adverse determination notifications. (4) Implement a system to track adverse determinations, appeals deadlines, and Fair Hearing deadlines. (5) If using outside billing vendors or medical record services, verify they are compliant with Permedion's UR audit response timelines. (6) Train billing and clinical staff on the appeal process: first level appeals must be submitted to Permedion, and upheld determinations can be appealed to DMAHS' Fair Hearing Unit. Failure to submit documentation timely or respond to audit requests will result in recoupment of subject claims/encounters. Contact Permedion at 609-632-1500 with questions.