Newsletter Vol. 25, No.11

REQUIREMENTS: - Immediately: Billing team must implement claims submission timeline compliance - all MLTSS claims must be submitted within 180 days of date of service; coordination of benefits (COB) claims must be submitted within 60 days from primary insurer's EOB or 180 days from service date, whichever is later. Update billing system to flag late submissions. - Immediately: Billing team must configure claims processing monitoring - establish tracking for 15-day processing requirement for MLTSS service claims and 30-day requirement for non-MLTSS service claims from MCO. Alert provider if payment not received within these windows. - Immediately: Medical billing staff must verify correct billing form usage - confirm use of CMS 1500 form (paper) or 837P (electronic) for assisted living facilities, HCBS service providers, and non-traditional providers (home improvement contractors, emergency response systems, meal delivery); use UB-04 form (paper) or 837I (electronic) for nursing facilities and skilled nursing facilities. - Immediately: Billing team must enforce balance billing prohibitions - do not attempt to bill MLTSS members, their families, or representatives for covered services, and do not initiate collection proceedings. Violations will result in regulatory penalties. - Before claims submission: Billing staff must verify MCO authorization processes with each managed care organization for nursing facilities, assisted living, community residential services, skilled nursing facilities, and home/community-based services. Reference individual MCO websites and provider manuals at http://www.state.nj.us/humanservices/dmahs/info/resources/hmo/ for specific prior authorization contact numbers and processes. - Before claims submission: Billing team must ensure prior authorization decisions are obtained within 14 calendar days for non-emergency services and denials/limitations are received in writing, per HCAPPA requirements. Document all authorization dates and reference numbers in claim submission. - Ongoing: Billing staff must coordinate benefits to ensure NJ FamilyCare is payer of last resort when members have other health or casualty insurers. Follow each MCO's coordination of benefits process before submitting claims. - Ongoing: Billing team must document all claim resubmissions with corrected information, prior notification/authorization verification, and bundled claim verification to reduce denials and delays in the 15/30-day processing timeline.