MedicaidReimbursementMedium impact
Newsletter Vol. 15, No. 09
New Jersey Medicaid·NJ · Pharmacy, Nephrology·Coding
Effective date
Jul 1, 2005
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid is transitioning all provider manuals, newsletters, and billing supplements from paper to electronic distribution effective immediately (August 2005). Providers must access these materials from the DMAHS website or Unisys website unless they submit a paper request form. Additionally, reimbursement for practitioner-administered drugs (Level II HCPCS codes) is being reduced to AWP less 12.5% or acquisition cost (whichever is lower), effective July 1, 2005, and new EPO billing procedures apply to hospital-based ESRD providers using revenue codes 634/635 with HCPCS code Q4055.
Action Required
REQUIREMENTS:
1. IMMEDIATE (August 2005): Billing team must transition to accessing provider manuals, newsletters, and billing supplements electronically from www.state.nj.us/humanservices/dmahs/manuals.html or www.njmmis.com instead of paper copies, unless a paper request form (page 4 of this newsletter) is submitted to DMAHS.
2. By July 1, 2005 (or immediately for service dates after this date): Update billing system reimbursement calculations for all practitioner-administered drugs (Level II HCPCS codes) to reimburse at AWP less 12.5% or practitioner's acquisition cost, whichever is lower. This replaces the former policy of lower of AWP or acquisition cost.
3. For hospital-based ESRD providers effective March 7, 2005 (for service dates on or after September 1, 2004): Implement new EPO billing procedures requiring Revenue Codes 634 (administration of less than 10,000 units) and 635 (administration of 10,000 or more units) on UB-92 claims, report HCPCS code Q4055 in Field 44, report actual EPO units per 1000 in Field 46, and set reimbursement at $12.26 per 1000 units.
4. Pharmacy team must update systems to enforce 85% days supply threshold before refills (increased from 75%) for all prescriptions effective July 1, 2005.
5. Implement new error code monitoring to prevent beneficiaries from receiving methadone from substance abuse treatment centers while simultaneously receiving narcotic prescriptions from pharmacies, effective July 1, 2005.
Failure to update reimbursement calculations will result in overpayment and potential clawbacks. Failure to implement new EPO procedures will cause hospital-based ESRD claims to be denied.