Claims Resolutions, Wrap Flex, Billing, and Eligibility FAQs

• What should I do if my claim was denied?
• What does it mean when the status of a prior authorization in CYBER shows as pending, accepted, or rejected?
• What should I do if the NJ FamilyCare/3560 number is not attached to the prior authorization?
• What should I do if the prior authorization is attached to an inactive NJ FamilyCare/3560 number?
• How do I request a prior authorization modification, and how long it will take?
• How can I obtain a retroactive authorization or service change?
• What should I do if the youth's NJ FamilyCare/3560 number does not appear in the Eligibility tab?
• How do I verify a youth's NJ FamilyCare/3560 number?
• What is the procedure to submit non-NJ FamilyCare claims for youth who are not enrolled with a Care Management Organization (CMO) or Mobile Response and Stabilization Services (MRSS)?
• Where can I print the service delivery encounter documentation (SDED) forms?
• Do I need to complete an electronic data interchange (EDI) request?
• What claims are paid out of PerformCare Wrap Flex funds?
• What is the 90-day rule for Wrap Flex claims submitted to PerformCare for reimbursement?
• How long do I have to resubmit my returned claim?
• If my claims are denied for late submission, how can I make an appeal?
• What claims are paid out of Substance Use (SU) Wrap Flex funds?
• What is the process for receiving a Wrap Flex payment?
• What should I do if I cannot locate a 3560 number in CYBER after the 3560 eligibility application has been approved?
• How can I obtain a 3560 number to cover an eligibility gap for youth newly referred to a CMO or MRSS?
• How can I be paid for outpatient services when the 3560 number is terminated?
• What is the process for requesting a missing days authorization?
• How many Biopsychosocial Assessments are billable per year?
• What is ICD-10?
• Are ICD-10 codes required in my claims?
• What is the 35605 number?
• What does the 35605 number cover?

What should I do if my claim was denied?

Submit your remittance advice (RA) with the following error code(s) to PerformCare Billing Unit for review. PerformCare will research and may be able to resolve the following rejection codes:

• 774 — PA not on file.
• 775 — PA record on file is not active.
• 779 — Medicaid PA number invalid.

Please contact the Service Desk at www.performcarenj.org/ServiceDesk or 1-877-652-7624. Provide the youth's CYBER ID and the prior authorization number in your request or have it available when you call.

All other error codes must be directed to the State Medicaid Fiscal Agent system first for resolution by calling 1-800-776-6334.

What does it mean when the status of a prior authorization in CYBER shows as pending, accepted, or rejected?

CYBER pending status means the prior authorization was transmitted to the State Medicaid Fiscal Agent system. It takes one to two business days for the system to process the prior authorization, which will then appear in CYBER as either "accepted" or "rejected."

CYBER accepted status means the prior authorization transmitted to the State Medicaid Fiscal Agent system has been accepted into the Medicaid PA file. Claims can be submitted against the prior authorization immediately.

CYBER rejected status means the prior authorization was transmitted to the State Medicaid Fiscal Agent system, which will appear in CYBER with a three-digit rejection code. This rejection code may indicate a potential discrepancy, such as dates on an issued prior authorization number overlapping with another existing prior authorization date span.

Please contact the Service Desk at www.performcarenj.org/ServiceDesk or 1-877-652-7624. Please provide the youth's CYBER ID number and the prior authorization number in your request or have them available when you call.

What should I do if the NJ FamilyCare/3560 number is not attached to the prior authorization?

First, check the eligibility tab to confirm the correct number is showing with the correct start and end dates to cover the prior authorization. Next, check the prior authorization to view the authorization status and authorization creation date. Please note that it takes seven to 10 business days for the NJ FamilyCare/3560 number to attach to the authorization. PerformCare transmits authorizations to the State Medicaid Fiscal Agent on Tuesdays and Thursdays.

If the authorization still has not been sent after 10 business days from the authorization creation date, please contact www.performcarenj.org/ServiceDesk.

What should I do if the prior authorization is attached to an inactive NJ FamilyCare/3560 number?

NJ FamilyCare/3560 benefit numbers (active and inactive) are cross-referenced in the State Medicaid Fiscal Agent system. Please submit your claims for payment using the active NJ FamilyCare/3560 number and contact PerformCare only if your claims are denied.

How do I request a prior authorization modification, and how long it will take?

The provider should submit their request to the entity that completed the plan of care for the youth and requested the service. However, if the requester of the service was PerformCare, please forward your request to www.performcarenj.org/ServiceDesk with the following information:

• Provider name and ID.
• Prior authorization number.
• What you are requesting to be modified (e.g., dates or unit amounts).
• Justification for this request.

How can I obtain a retroactive authorization or service change?

A retroactive authorization is any service request not previously submitted through the appropriate and approved treatment plan or assessment or with a start date more than seven business days earlier than the submitted date. If the youth is enrolled in a care management organization (CMO) or mobile response and stabilization services (MRSS) entity, then the provider should send their request to that care management entity.

If the youth was not enrolled with a CMO or MRSS, then the provider should submit the request to PerformCare at www.performcarenj.org/ServiceDesk for resolution. For any prior authorization that exceeds seven days, the requester must also provide an explanation for the lateness.

What should I do if the youth's NJ FamilyCare/3560 number does not appear in the Eligibility tab?

This means that when the youth was registered, the NJ FamilyCare/3560 number was not attached in the CYBER Management Information System (MIS). If you have the youth’s NJ FamilyCare/3560 number, you may contact the Service Desk at www.performcarenj.org/ServiceDesk or 1-877-652-7624. Please provide the youth's CYBER ID in your request or have it available when you call.

If you do not have the number when you contact us, PerformCare can still attempt to locate the NJ FamilyCare/3560 number by reviewing the youth's eligibility information using the youth's name and date of birth.

How do I verify a youth's NJ FamilyCare/3560 number?

Contact the State Medicaid Fiscal Agent Recipient Eligibility Verification System (REVS) at 1-800-676-6562. You should have available your seven-digit provider Medicaid ID number, the youth’s date of birth and Social Security number, and the dates of service.

What is the procedure to submit non-NJ FamilyCare claims for youth who are not enrolled with a Care Management Organization (CMO) or Mobile Response and Stabilization Services (MRSS)?

PerformCare will no longer process 1500 claim forms submitted on paper. To ensure prompt processing and payment of claims, please enter your claims through PerformCare CYBER Management Information System (MIS). You can find the instructional guide for entering claims into PerformCare CYBER MIS in the Provider Training section of the PerformCare website.

Only seasonal providers, such as summer camp and one-to-one aides, can send paper 1500 claim forms to PerformCare (specific billing instructions are sent via email to aforementioned providers).

Where can I print the service delivery encounter documentation (SDED) forms?

The SDED form is available through the Children's System of Care (CSOC) state website.

Do I need to complete an electronic data interchange (EDI) request?

Providers are only required to complete the EDI request if they purchase software that will be used for claims submission. Per the State Medicaid Fiscal Agent, the software company should inform the provider that they need an EDI authorization for submitting claims as part of their purchase. Providers cannot submit claims without this agreement with the State Medicaid Fiscal Agent in place. Please note that providers are not required to purchase software, as they can enter data directly through the New Jersey Medicaid Management Information System (NJMMIS).

What claims are paid out of PerformCare Wrap Flex funds?

Currently, PerformCare Wrap Flex funds are used to pay claims for youth who are not enrolled in a Care Management Organization (CMO) or Mobile Response and Stabilization Services (MRSS) entity. For youth who are not enrolled with a care management entity, PerformCare Wrap Flex pays for services such as a therapeutic needs assessment and some Substance Use (SU) treatments for any youth who does not have a NJ FamilyCare/3560 number. It also reimburses entities for non-therapeutic interventions, such as translation or summer camp.

What is the 90-day rule for Wrap Flex claims submitted to PerformCare for reimbursement?

All claim forms with service dates older than 90 days will be rejected by PerformCare.

How long do I have to resubmit my returned claim?

All claim forms returned to providers for error correction must be resubmitted to PerformCare within the original 90 days from the earliest service date on the form. Late resubmissions will be rejected.

If my claims are denied for late submission, how can I make an appeal?

Providers may submit a written appeal for denied claim(s) to PerformCare along with supporting documentation. Please upload into the PerformCare CYBER Management Information System (MIS) the written appeal in a letterhead format, along with an explanation in the Comment section of the electronic claim. PerformCare will review the appeal with supporting documentation and make a recommendation to the Children's System of Care (CSOC) for a final determination.

What claims are paid out of Substance Use (SU) Wrap Flex funds?

SU Wrap Flex funds are used to pay for enhancement and co-occurring services for youth who are not enrolled in an Out-of-Home (OOH) treatment facility.

What is the process for receiving a Wrap Flex payment?

To receive payment of Wrap Flex funded claims issued from the Department of the Treasury, providers must be established on the State of New Jersey Accounting System. If you are not registered with the State of New Jersey Accounting System (in lieu of the W-9 form), you must complete registration and obtain a vendor ID number on the New Jersey vendor website at https://www.njstart.gov/bso/.

For technical and customer support with njstart.gov, please call 1-609-341-3500.

PerformCare customarily processes these claims within 10 business days after submission by the provider. Approved Wrap Flex claims information and invoices are forwarded to the New Jersey Department of Children and Families (DCF) Office of Accounting for payment processing.

Please note that checks issued by the Department of the Treasury will have a check stub (remittance advice) that will list the authorization number, service date(s), dollar amount, and a phone number to contact DCF, should a provider have any questions about the payment.

Providers can search for payment information by registering through www.state.nj.us. Click on Register and follow the prompts. When completed, you can log in to the website with your login ID and password and the Vendor Payment Inquiry should appear on the My New Jersey homepage. Using your federal identification number, you are able to search for payments issued for a selected time period.

For questions regarding the DCF billing process, please contact the PerformCare Billing Unit at www.performcarenj.org/ServiceDesk.

What should I do if I cannot locate a 3560 number in CYBER after the 3560 eligibility application has been approved?

The 3560 number should appear in the CYBER eligibility tab within five to seven business days after the approval date on the 3560 application. If the number does not appear in the eligibility tab after seven business days, please contact PerformCare at www.performcarenj.org/ServiceDesk with the provider name and ID and the youth's CYBER ID number.

How can I obtain a 3560 number to cover an eligibility gap for youth newly referred to a CMO or MRSS?

PerformCare may issue a 3560 number to cover a gap of one to 30 days in eligibility at the beginning of the referral period to CMO or MRSS. The provider of the service should contact the CMO or MRSS to help the provider obtain this eligibility gap coverage. Any additional gaps in coverage require the CMO or MRSS entity to complete a new 3560 application.

How can I be paid for outpatient services when the 3560 number is terminated?

Outpatient services can only be billed against an active 3560 number. When outpatient services are approved as a part of the transition plan as the youth is closing to CMO or MRSS services, the care management entity (CME) must ensure that the plan is sustainable and that the payment source is defined.

If there is an approved authorization in CYBER Management Information System (MIS) for outpatient services and the youth transitions before that end date, the outpatient provider will only be able to bill on that authorization until the 3560 is closed, at which time the provider and family will need to identify a different payment source.

What is the process for requesting a missing days authorization?

A missing days authorization is one that covers up to a five-day period where a youth has left an Out-of-Home care program. The authorization allows the provider to keep a bed open for that same youth to return within the five-day period. Any Out-of-Home treatment provider can request a missing days authorization.

1. The program must enter a progress note in CYBER confirming the date the youth left the facility.
2. The facility may call the authorization request in to Member Services at 1-877-652-7624 or send the request via www.performcarenj.org/ServiceDesk. The facility should request the authorization on the day the youth returns or on the end of the fifth day after the youth leaves the facility, whichever is less. This allows PerformCare to create the missing days authorization with the correct number of days needed.
3. If the youth does not return to the program, the Out-of-Home treatment provider can discharge the youth after the end of the fifth day.
4. The program should communicate the authorization request to the billing staff so it may be billed appropriately. The missing days authorization service code is H2020HA.

How many Biopsychosocial Assessments are billable per year?

A maximum of two Biopsychosocial Assessments per beneficiary are billable per rolling period of 365 days.

What is ICD-10?

The International Classification of Disease, Tenth Edition (ICD-10), is a clinical cataloging system (diagnostic codes) that went into effect for the U.S. health care industry on October 1, 2015. The ICD-10 is a morbidity classification published by the United States for classifying diagnoses and reasons for visits in all health care settings.

These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10 Clinical Modification (ICD-10-CM): the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), the Centers for Medicare & Medicaid Services (CMS), and the National Center for Health Statistics (NCHS).

Are ICD-10 codes required in my claims?

Yes. Please note that ICD-10 is an updated version of the ICD-9 code sets.

What is the 35605 number?

35605 is an NJ FamilyCare (Medicaid) lookalike number to be used only by family support services (FSS) providers for respite services when submitting claims to the State Medicaid Fiscal Agent. You can identify the 35605 by the fifth digit, which will always be the number 5.

What does the 35605 number cover?

The 35605 number only covers respite services for youth (up to age 21) who are determined to be intellectually/developmentally disabled (I/DD) and accessing the Children’s System of Care (CSOC). Please note: The 35605 number does not include a medical package (e.g., hospital, physician, dental, vision, or prescriptions). Additionally, the 35605 number does not cover Wrap Flex services such as CMO, MRSS, Out-of-Home (OOH), or certain Substance Use (SU) treatment services.

PerformCare operates 24 hours a day, seven days a week, and 365 days a year. For billing inquiries, please submit a work order via www.performcarenj.org/ServiceDesk and it will be assigned and researched by a Billing and Claims associate.