MedicaidCoverageHigh impact
Newsletter Vol. 10, No. 54
New Jersey Medicaid·NJ · Pharmacy, Endocrinology, Oncology +1 more·Pharmacy
Effective date
Sep 1, 2000
We identified it
Jun 20, 2026
Summary
Effective September 1, 2000, New Jersey Medicaid and NJ KidCare FFS programs will only reimburse Medicare-covered prescription drugs and diabetic materials when supplied by pharmacies enrolled as Medicare-approved medical supply providers. Non-participating pharmacies must submit these claims as crossover claims through Medicare first, or request prior authorization if no alternative provider exists within 5 miles. Claims submitted by non-Medicare-approved pharmacies will be denied.
Action Required
By September 1, 2000: Billing team must verify that all contracted pharmacies and medical supply providers are enrolled as Medicare-approved DME providers before processing claims for Medicare-covered drugs and diabetic materials for dual-eligible beneficiaries. Update billing system to route all Medicare-covered drug claims initially to Medicare using HCFA 1500 forms with Medicare-approved HCPCS codes, with claims crossing over to Medicaid/NJ KidCare for deductible/coinsurance only. For pharmacies without Medicare approval, implement prior authorization requirement through First Health Services (1-877-266-3589) and report PA code "5" in NCPDP Field 416. Train billing staff to deny payment for non-Medicare-approved provider claims except when prior authorization is obtained for geographic exceptions (no alternative provider within 5 miles). Update claim submission workflows to process these claims as crossover claims through DMERC. Failure to comply will result in claim denials and loss of Medicaid/NJ KidCare reimbursement.