On appeal from the Department of Human Services, Division of Medical Assistance and Health Services, OAL Docket No. HMA 11048-03 and OAL Docket No. HMA 09856-02.
NOT FOR PUBLICATION WITHOUT THE APPROVAL OF THE APPELLATE DIVISION
Submitted December 5, 2007
Before Judges Parker and Lyons.
Petitioner, Bergen Regional Medical Center (Hospital), appeals from a final decision by the Director of the Division of Medical Assistance and Health Services (DMAHS) denying petitioner's claims for Medicaid-reimbursable services it rendered to five patients. The Administrative Law Judge (ALJ) who initially heard the consolidated petitions found in favor of the Hospital and ordered that the agency process the claims. On April 26, 2006, however, the Director reversed the ALJ's decision, concluding that the Hospital was remiss in its billing practices.
On appeal, the Hospital argues that (1) it pursued the claims in a diligent and timely manner; (2) the agency misapplied the regulation addressing Medicare/Medicaid crossover claims; and (3) the Hospital's ongoing communications with the agency satisfied the regulatory requirement that claimants "follow up" in order to correct errors in submitted claims.
The highly technical nature of the claims involved in the administration of Medicaid benefits places this matter squarely within the agency's expertise. After carefully considering the record in light of petitioner's arguments, however, we are persuaded that the Director erred with respect to one of the five petitions at issue, the Hospital's claim on behalf of Margaret Blahut. The record indicates that the Blahut claim was presented within the time prescribed by the regulation and was denied primarily because the Medicaid fiscal agent prematurely purged the claim from its system. For that reason, we reverse the Director's decision on the Blahut claim. We affirm the Director's denial of the remaining four claims, however, substantially for the reasons stated in the Director's decision rendered on April 26, 2006.
Medicaid is jointly funded by the State and Federal governments and is available to individuals who meet the financial eligibility criteria. 42 U.S.C.A. § 1396; N.J.S.A. 30:4D-2. Medicare, on the other hand, is funded solely by the federal government and applies only to the elderly and disabled.
42 U.S.C.A. § 1395c. Medicare has two parts: Part A, which covers care from institutional providers; and Part B, which covers certain inpatient, physician and laboratory services. 42 U.S.C.A. § 1395k.
Elderly or disabled individuals with poor financial resources may be covered by both Medicare and Medicaid. Claims made to both Medicare and Medicaid are commonly referred to as "crossover claims." When a crossover claim is submitted on behalf of a beneficiary, Medicare has the obligation of first payment because Medicaid is designed to be the payer of last resort. 42 U.S.C.A. 1396a(a); N.J.S.A. 30:4D-2; N.J.A.C. 10:49-7.3(b).
Claims for Medicaid benefits made by a hospital must be submitted to Unisys Corporation*fn1 (Unisys) within one year from the date of the patient's discharge. N.J.A.C. 10:49-7.2(b).*fn2 "It is the responsibility of the provider to ensure that each Medicaid claim submitted by that provider is received by the New Jersey Medicaid program's Fiscal Agent within the time periods indicated in this section." N.J.A.C. 10:49-7.2(a)(2). "The New Jersey Medicaid program shall not reimburse for a claim received outside the prescribed time periods. This policy also applies to inquiries concerning a claim or claim related information received outside the prescribed time periods." N.J.A.C. 10:49-7.2(a)(2)(i).
The procedure for submitting crossover claims is set forth in N.J.A.C. 10:49-7.2(d):
The time requirements for submitting a combination Medicare/Medicaid or Medicare/NJ KidCare claim are as follows . . . .
1. A combination Medicare/Medicaid claim is defined as a request for payment from the New Jersey Medicaid program for a medical service provided ...