MedicaidAdministrativeHigh impact
Newsletter Vol. 20, No.21
New Jersey Medicaid·NJ·Prior Authorization
Effective date
Nov 1, 2010
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid is transitioning utilization review, DRG validation, and quality of care audit responsibilities from multiple contractors (NJPR, HQSI, BCBSNJ) to Permedion (HMS subsidiary) effective November 1, 2010. Hospitals must now provide complete medical records, UB04 forms, remittance advice, EOB information, liability information, and utilization review certification to Permedion auditors within specified timeframes or face claim recoupment.
Action Required
By October 31, 2010: Billing and compliance teams must (1) update internal audit response procedures to direct all utilization review requests to Permedion instead of NJPR, HQSI, or BCBSNJ; (2) establish documentation protocols ensuring complete medical records, UB04 forms, Medicaid remittance advice, third-party EOBs, liability information, and utilization review certification (for delegated hospitals) are readily available for Permedion auditors; (3) implement strict deadline tracking for Permedion's document requests with zero-extension policy to prevent claim recoupment; (4) notify all hospital departments that add-on payments previously received from NJPR and HQSI audit functions will cease effective October 31, 2010; (5) contact Hospital Reimbursement Services at 609-588-2668 for clarification on delegated vs. non-delegated hospital status assignment. Failure to respond to audit requests within specified timeframes will result in recoupment of subject claims.