Updated Guidance on Exclusion Screening for New Jersey’s Medicaid Providers and Plans

Posted by Joe Stefansky on February 15, 2023 in Industry News, New Jersey,

In January of 2023, New Jersey issued new guidance regarding those databases that healthcare entities (including providers and managed care organizations) participating in NJ’s Medicaid program must query monthly to verify that any current or prospective employees, contractors or subcontractors are not excluded, unlicensed or uncertified. Excluded individuals or entities are those identified by New Jersey  or the federal government as not being allowed to participate in New Jersey’s  or federally-funded health benefit programs, such as Medicaid, NJ FamilyCare, or Pharmaceutical Assistance to the Aged and Disabled (PAAD).

Health care organizations who participate in Medicaid and meet certain monetary thresholds are subject to the federal 2005 Deficit Reduction Act and are required to annually certify to their compliance with the DRA.  Those DRA requirements include assuring that excluded or otherwise ineligible individuals do not participate in federal health care programs. While the requirements of the DRA are not subject to state modification, each state has some discretion regarding how Medicaid providers and plans certify their compliance, as well as which state databases must be checked monthly. In New Jersey, subject entities are required to submit a DRA certification form annually.  For more information about the DRA and this requirement, please check Streamline Verify’s  linked recent article.

Prior to this 2023 update, the last guidance document regarding the DRA requirements was issued in 2016. However, in 2022, New Jersey updated the Certification Form required by health care entities subject to the DRA in order to certify compliance with the exclusion requirements set forth therein. Unfortunately, the 2016 guidance and the updated 2022 form were not entirely consistent regarding the databases that had to be queried, creating  some ambiguity for providers who  in good faith were completing certification form as required.

Under the January 2023 guidance, New Jersey has clarified that the following databases must be queried monthly by providers and MCOs who participate in the state’s Medicaid program:

This list is now consistent with the updated Certification Form which New Jersey Medicaid plans and entities subject to the DRA are required to complete to certify compliance. The form specifically requires confirmation that each of these data sources is queried.  

About Joe Stefansky

About Joe Stefansky

Joe Stefansky has a keen sense of business opportunities in complex problems, using technology to transform difficulty into efficiency. The CEO and founder of Streamline Verify specializes in solving compliance, legal and administrative issues through intuitively designed software that reduces costs and saves time.

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