MedicaidCoverageMedium impact
Newsletter Vol. 25, No.04
New Jersey Medicaid·NJ · Psychiatry, General Practice·Provider Notice
Effective date
Jun 1, 2015
We identified it
Jun 20, 2026
Summary
NJ FamilyCare (NJFC) expanded coverage to include inpatient hospital and certain inpatient-related professional services for incarcerated individuals (State inmates SPC '98' and County inmates SPC '99'). Billing teams must verify eligibility using MEVS, eMEVS, or REVS before providing services, as these beneficiaries have limited benefit packages restricted to inpatient acute care only. Claims for inmates without Medicaid eligibility are processed through the State's Fiscal Agent (Molina) using SBI numbers or through County Adjusters; outpatient and community-based services must be billed separately.
Action Required
Immediately: Billing team must update eligibility verification procedures to identify Special Program Codes (SPC) '98' (State inmates) and '99' (County inmates) in MEVS, eMEVS, or REVS responses before authorizing any NJFC-covered services. Confirm that only inpatient hospital and inpatient-related professional services (physician, nurse midwife, APN) are covered for these populations. Implement workflow to: (1) Route inmate claims with Medicaid eligibility to Medicaid Recipient ID with place of service '3'; (2) Route inmate claims without Medicaid eligibility to Molina using SBI number or to appropriate County Adjuster based on inmate type; (3) Reject or redirect all outpatient, dental, podiatric, and ophthalmological claims for community-based services to County Adjuster or DOC. Train front-line staff to catch ineligible service types before claim submission. Failure to verify and route claims correctly will result in denials. Reference County Adjuster contact list provided in policy for billing routing.