Reimbursement
Physicians, other health care professionals, ancillaries and hospitals should submit bills promptly after services are rendered.
Billing & Reimbursements
Effective November 21, 2019, health care professionals and facilities will be required to use an X12 837 electronic transaction to submit bills in accordance with New Jersey’s Department of Labor and Workforce Development Rule N.J.A.C.12:235-1.9 New Jersey’s Department of Labor and Workforce Development Rule N.J.A.C.12:235-1.9 opens a dialog window. Failure to comply with this rule may result in denied bills.
HCS is the administrator for the State of New Jersey employees’ workers’ compensation program. Bills for State of New Jersey claimants must be submitted to HCS. Hospitals and ancillary providers must submit supporting medical documentation using a managed file transfer (MFT).
All other claimants’ bills must be submitted to the claimants’ insurer or the Third Party Administrator (TPA).
Reimbursement Guidelines
Workers’ compensation bills are processed according to the terms and conditions in the contract. Reimbursement of billed services may be issued by the claimant’s insurer or the TPA. Reimbursement of billed services for State of New Jersey claimants is issued by HCS.
Hospitals and providers may call HCS at 1-800-985-7777 for reimbursement status of previously submitted bills.
For PIP claims, HCS processes bills received from participating hospitals and ancillary providers according to the terms and conditions in the Hospital or Ancillary Provider Agreement and the State of New Jersey PIP Regulations.
The PIP insurers’ limit of liability for any medical expense benefit shall be the amounts identified in the New Jersey PIP Fee Schedule (N.J.A.C. 11:3-29).
Reimbursement for billed services is issued by the PIP insurer. Untimely reimbursement of PIP bills may be subject to interest payments.
For more information about the New Jersey PIP regulations or to access the New Jersey PIP Fee Schedule, read PIP Information for Health Care Providers PIP Information for Health Care Providers opens a dialog window.
Refunds & Overpayments
In cases where an overpayment has been made, hospitals and providers are expected to issue a refund of the overpayment within 90 days of notification of the amount owed. HCS will only seek reimbursement of a bill overpayment from the hospital or provider within 18 months from the date the bill was paid.
To obtain information about electronic billing, please contact the EDI Service Desk toll-free at 1-888-334-9242. Representatives are available weekdays from 7 a.m. to 6 p.m.