MedicaidAdministrativeHigh impact
Newsletter Vol. 5, No. 53
New Jersey Medicaid·NJ·Coding
Effective date
Oct 8, 1995
We identified it
Jun 20, 2026
Summary
This policy establishes new billing procedures for Personal Care Assistant (PCA) services under Medicaid, defining the calendar work week as Sunday 12:00 a.m. to Saturday 11:59 p.m., prohibiting overlap of work weeks on claims, and imposing an 8-hour daily limit for mental health PCA clients (with a 25-hour weekly cap). Claims exceeding 40 hours/week for regular Medicaid or 25 hours/week for mental health will be denied entirely.
Action Required
By October 8, 1995: Billing team must implement the following changes: (1) Update billing software to enforce the calendar work week definition (Sunday 12:00 a.m. to Saturday 11:59 p.m.) and prevent overlap of work weeks on HCFA 1500 claim forms; (2) Configure system to split dates of service across two claim lines when PCA services span multiple calendar weeks; (3) Implement automated edits to deny entire claims exceeding 40 hours in a calendar work week for regular Medicaid PCA or 25 hours for mental health PCA; (4) Effective immediately, add validation rule to deny mental health PCA claims with more than 8 hours billed in a single day; (5) Ensure all claims are submitted on the correct HCFA 1500 form version (per Newsletter Vol. 5 No. 39, July 1995); (6) Train billing staff and providers on the new work week parameters and split-line billing requirements. Failure to comply will result in claim denials for the entire week's services.