MedicaidAdministrativeHigh impact
Newsletter Vol. 18, No. 04
New Jersey Medicaid·NJ·Provider Notice
Effective date
May 1, 2008
We identified it
Jun 20, 2026
Summary
Horizon BCBSNJ has been awarded contract extensions through July 31, 2009 to perform DRG assignment and trauma/TPL claims audits on all New Jersey acute care hospitals. Hospitals must prepare specific documentation (medical records, UB-92, EOB information, liability information) for on-site audits, with 20% of Medicaid fee-for-service DRG claims and 100% of TPL claims subject to audit annually. Hospitals have 30 days to respond to preliminary audit findings or claims will be forwarded to the Division for adjustment/voiding.
Action Required
Immediately: All New Jersey acute care hospitals must establish audit preparation procedures. Billing and medical records teams must: (1) Designate staff to coordinate with BCBSNJ auditors; (2) Create processes to have pre-copied documentation ready at audit start (UB-92, Medicaid Remittance Advice, third-party EOB/EOMB information, liability information); (3) Establish workflow to retrieve and organize complete medical records for auditor identification; (4) Set internal deadline to review and respond to Preliminary Results forms within 30 days of receipt to avoid automatic claim forwarding to the Division for adjustment or voiding. Designate a point person to receive audit notification from BCBSNJ and coordinate scheduling.