MedicaidAdministrativeHigh impact
Newsletter Vol. 24, No.09
New Jersey Medicaid·NJ · Family Medicine, Internal Medicine, General Practice +1 more·Provider Notice
Effective date
Jul 1, 2014
We identified it
Jun 20, 2026
Summary
New Jersey confirms FQHC wraparound reimbursement procedures requiring all Medicaid encounters to be processed through HMOs first before DMAHS payment, with a formal 15-day appeal process for denied claims. FQHCs must submit detailed claim-level data and cannot include pended, duplicate, or incorrectly denied claims in wraparound reports.
Action Required
Immediately: FQHCs must ensure all Medicaid encounters are first submitted to assigned HMO plans before reporting to DMAHS for wraparound reimbursement. Do not submit pended claims, duplicate encounters, or HMO-denied claims due to incorrect/missing data in quarterly reports. Submit complete supporting claim data in required format with all wraparound reports. If challenging HMO denials, initiate appeal within 15 days of receiving encounter file from DMAHS with complete supporting documentation.