MedicaidAdministrativeMedium impact
Newsletter Vol. 7, No. 17
New Jersey Medicaid·NJ · Pharmacy·Reimbursement
Effective date
Jul 25, 1996
We identified it
Jun 20, 2026
Summary
This policy clarifies that pharmacy claims adjudicated as 'payable' by New Jersey's Point of Sale (POS)/Prospective Drug Utilization Review (PDUR) system are NOT guaranteed for reimbursement. The State may conduct further review for fraud and abuse concerns, potentially denying claims even if they initially received a positive payment response. Pharmacies must understand that POS/PDUR approval is preliminary, not final payment authorization.
Action Required
Billing and pharmacy teams must update staff training and internal communications to clarify that Point of Sale (POS)/Prospective Drug Utilization Review (PDUR) payment responses for New Jersey Medicaid, General Assistance (GA), Cystic Fibrosis Drug (CFD), AIDS Drug Distribution (ADDP), and Pharmaceutical Assistance to the Aged and Disabled (PAAD) programs do not guarantee final payment. Implement internal controls to monitor for follow-up claim denials post-adjudication. Do not treat POS/PDUR approval as final authorization. Establish a process to track and investigate any claims denied after initial 'payable' status to identify patterns related to fraud/abuse concerns. Contact Unisys Provider Services (1-800-776-6334) or the Chief of Pharmaceutical Services (609-588-2724) with questions regarding claim status.