MedicaidCoverageHigh impact
Newsletter Vol. 12, No. 20
New Jersey Medicaid·NJ · Pharmacy, Oncology, Endocrinology +1 more·Pharmacy
Effective date
Apr 15, 2002
We identified it
Jun 20, 2026
Summary
Effective April 15, 2002, New Jersey Medicaid will limit coverage of Medicare-covered prescription drugs and diabetic supplies for dual-eligible beneficiaries. These claims must now be submitted to Medicare first as medical supply claims by pharmacies enrolled as Medicare-approved DME providers, then crossover to Medicaid for deductible/coinsurance payment. Pharmacies without Medicare DME approval will have claims denied by Medicaid.
Action Required
By April 15, 2002: (1) Billing team must verify pharmacy enrollment status as Medicare-approved medical supply/DME provider in DMAHS system. (2) For all Medicare-eligible Medicaid beneficiaries receiving the listed drugs (oral cancer drugs, diabetic supplies, anti-emetics, immunosuppressives, nebulizer solutions), route claims to Medicare first on HCFA 1500 form or electronic equivalent using Medicare-approved HCPCS procedure codes. (3) Ensure Medicare claims are submitted with assignment accepted and will crossover to Medicaid through DMERC electronic process. (4) If pharmacy is NOT Medicare DME-enrolled, do not submit these claims through Medicaid POS—claims will be auto-denied. (5) If Medicare denies for medical necessity or unmet deductible, obtain Medicare Explanation of Benefits (EOB) before resubmitting directly to Medicaid POS system with Other Coverage Code value of '3' and retain Medicare EOB documentation for audit purposes. (6) Before billing Medicaid for any amount, verify beneficiary does not have commercial Medigap coverage that must be billed first. Consequences: Claims submitted to Medicaid POS without Medicare approval will be denied; inappropriate use of Other Coverage Code '3' may trigger claim recoupment by State of New Jersey.