MedicaidCoverageHigh impact
Newsletter Vol. 10, No. 47
New Jersey Medicaid·NJ · Pharmacy·Provider Notice
Effective date
Sep 1, 2000
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid, GA, and NJ KidCare now require pharmacies to submit pharmaceutical claims to other insurance carriers BEFORE submitting to the state programs, and to report all third-party payments on claims. Claims with service dates on or after September 1, 2000 that have third-party coverage on file will be denied unless third-party payment amounts are reported using NCPDP field 431 (Other Payer Amount) or MC-6 form fields. Non-participating pharmacies must obtain prior authorization from First Health Services when serving beneficiaries in non-participating networks.
Action Required
By September 1, 2000: Pharmacy billing team must implement the following changes: (1) Update billing software to require submission of claims to primary/third-party insurance BEFORE submitting to NJ Medicaid, GA, or NJ KidCare; (2) Configure systems to report third-party payment amounts in NCPDP Field 431 (Other Payer Amount) on all POS claims or in the 'Other Insurance' field on MC-6 paper claim forms; (3) Train pharmacy staff to report appropriate 'Other Coverage Code' values (0-4) based on claim circumstances; (4) Implement error code monitoring for codes 886, 892, 893, 894, 895, 896; (5) For non-participating pharmacies: establish process to request prior authorization from First Health Services (1-877-266-3589) and report PA number with value '5' in NCPDP Field 416 for claims more than 5 miles from beneficiary residence. Failure to report third-party payments will result in automatic claim denials. Contact Unisys Provider Services at 1-800-776-6334 for MC-6 forms and technical support.