MedicaidAdministrativeHigh impact
Newsletter Vol. 17, No. 12
New Jersey Medicaid·NJ · General Surgery, Plastic Surgery, Cardiothoracic Surgery +10 more·Provider Notice
Effective date
Jun 30, 2007
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid is implementing McKesson ClaimCheck® Solution, an automated claims auditing software that will systematically identify and adjust billing errors, code manipulations, and overpayments across 14 categories of claim edits (rebundling, mutually exclusive procedures, duplicates, modifiers, age/gender restrictions, etc.). All NJFC/Medicaid FFS claims will be subject to these automated audits effective before June 30, 2007.
Action Required
Before June 30, 2007: Billing team must review and update claim submission practices to ensure compliance with ClaimCheck® edits across all 14 audit categories. Specific actions required: (1) Audit current billing patterns for rebundling errors, mutually exclusive code pairs, and duplicate procedures on same date of service; (2) Review all modifier usage to ensure appropriate reporting; (3) Verify age and gender restrictions are applied correctly to procedures; (4) Eliminate coding of pre-operative and post-operative visits with primary surgical procedures; (5) Ensure E&M codes are not billed when substantial diagnostic/therapeutic procedures occur on same date; (6) Verify all procedure codes are current (remove obsolete/experimental/unlisted codes); (7) Update billing software edits and staff training on these 14 categories. Contact Unisys/McKesson for detailed edit specifications. Failure to comply will result in automatic claim denials and adjustments by the state system.