MedicaidCoverageHigh impact
Newsletter Vol. 13, No. 59
New Jersey Medicaid·NJ · Pharmacy·Eligibility
Effective date
Sep 1, 2003
We identified it
Jun 20, 2026
Summary
Effective September 1, 2003, all pharmaceutical services prescribed for Aged, Blind and Disabled (ABD) beneficiaries enrolled in New Jersey Medicaid managed care are now eligible for reimbursement through Medicaid fee-for-service (FFS) rather than through their HMO. Pharmacy claims for these beneficiaries must be submitted to Unisys through the state's point-of-sale system. ABD beneficiaries are identified by specific values (10, 15, 20, 25, 50, 55) in positions 3-4 of their Beneficiary Eligibility Identification number.
Action Required
By September 1, 2003: Billing team must implement the following changes: (1) Identify ABD beneficiaries enrolled in managed care using their Beneficiary Eligibility Identification numbers (look for values 10, 15, 20, 25, 50, or 55 in positions 3-4); (2) Update billing software to route ALL pharmaceutical claims for these identified ABD beneficiaries to Unisys through the state's point-of-sale (POS) claims processing system instead of submitting to the HMO; (3) Remove HMO pharmaceutical claim submission rules for ABD beneficiaries; (4) Train pharmacy and billing staff on the new identification and routing procedures. Pharmacy providers must update their claim submission protocols. Failure to route claims correctly will result in denials and delayed reimbursement. Contact Unisys Provider Services at (800) 776-6334 or the Office of Utilization Management at (609) 588-2718 with questions.