MedStats Billing delivers end-to-end revenue cycle management built for New Jersey practices. We hold carriers to the 30-day electronic and 40-day paper clean claim limits in N.J.A.C. 11:22-1.5, claim the 12% interest that attaches when they slip, block recoupments older than 18 months, price auto injury care to the PIP fee schedule, and bill all five NJ FamilyCare MCOs.
New Jersey gives providers the most structured escalation ladder in the region and then removes two of the biggest payer categories from it. Commercial and NJ FamilyCare claims run on a 30-day electronic and 40-day paper clock with 12% interest, a ten-business-day internal appeal and a formal arbitration route. Personal injury protection and workers’ compensation are expressly outside that regime and follow their own rules entirely, one with a published fee schedule and mandatory pre-certification, the other with no fee schedule at all. Knowing which ladder a claim is on is most of the job.
New Jersey Billing Specializations:
Prompt Payment of Claims (N.J.A.C. 11:22-1.5) — A carrier must remit payment of a clean claim within 30 calendar days when submitted electronically, or 40 calendar days by any other means, and must pay the uncontested portion of a claim while disputing the rest. Where information was missing, the same 30 or 40 days run from receipt of that information.
12% Statutory Interest — A health carrier that fails to pay a clean claim inside those limits must add simple interest at 12% per year to the claim amount at the time the overdue claim is paid. Dental plans carry 10%. Interest accrues from day 31 or day 41 as applicable.
Electronic Claim Protections — Payers must acknowledge receipt of an electronic claim within two working days, and where required data is missing must notify the provider electronically within seven days, specifying exactly what is needed. A payer that misses those notice requirements cannot treat the claim as unclean.
The 18-Month Recoupment Cap — Under HCAPPA a carrier may only seek reimbursement of an overpaid claim within 18 months of the first payment, except for fraud, a pattern of inappropriate billing, or coordination of benefits. Offsets outside that window are challengeable.
Prompt-Pay Appeals & Arbitration (N.J.A.C. 11:22-1.8) — A written internal clean-claim appeal must be answered by the carrier within ten business days, and an adverse determination opens an external alternative dispute resolution route, with DOBI complaints available where a carrier shows a pattern of late payment.
What Prompt Pay Does Not Cover — The regulation excludes Medicare, workers’ compensation, personal injury protection, automobile medical payment coverage, State Health Benefits, self-insured plans and federal employee plans. Those claims get their own tracking, because the 30-day clock and the 12% interest simply do not exist for them.
Auto PIP Fee Schedule & Decision Point Review — New Jersey caps auto injury reimbursement through the published PIP medical fee schedule and requires decision point review or pre-certification for identified treatments, with disputes going to designated PIP arbitration. Missing a decision point notice reduces payment on care that was otherwise compensable.
NJ FamilyCare Managed Care — Five MCOs hold NJ FamilyCare contracts: Aetna Better Health of New Jersey, Fidelis Care, Horizon NJ Health, UnitedHealthcare Community Plan and Wellpoint, formerly Amerigroup. Enrollment in NJMMIS does not enroll you with any MCO; each is a separate credentialing and submission relationship.
Workers’ Compensation Without a Fee Schedule — New Jersey publishes no workers’ compensation medical fee schedule, so reimbursement turns on what is reasonable and customary and unresolved bills go to the Division of Workers’ Compensation on a medical provider claim petition, subject to a two-year limitation.
Major New Jersey Payers — Horizon Blue Cross Blue Shield of New Jersey, Aetna, Cigna, AmeriHealth New Jersey, UnitedHealthcare, Clover Health and the five NJ FamilyCare MCOs.
Built to bring clarity, control and consistency to your New Jersey practice’s revenue cycle.
MedStats Billing manages the complete revenue cycle for New Jersey providers — from NJMMIS enrollment and MCO credentialing, through coding, claim scrubbing and submission, to prompt-pay appeals and arbitration, interest recovery, PIP decision point review compliance and medical provider claim petitions before the Division of Workers’ Compensation.
Certified CPT, ICD-10-CM, and HCPCS coding with pre-submission claim scrubbing built around each payer's edits, so claims pay on the first pass. We manage charge entry, claim submission, payment posting, and insurance follow-up.
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Enrollment with Medicaid managed care plans, Medicare via PECOS, and commercial payers — plus CAQH maintenance and re-credentialing deadline tracking, so your providers stay in-network and billable without gaps.
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Coverage confirmed before the visit — active policy status, deductibles, co-pays, plan type, and prior authorization requirements — so front-end denials are caught while there is still time to fix them.
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Aged claims worked by payer and denial reason, with appeals filed inside each plan's window. We monitor outstanding balances, manage rejections, and drive down days in A/R to protect cash flow.
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A detailed review of coding accuracy, documentation standards, and denial patterns that identifies revenue leakage and compliance exposure — before a payer audit finds it for you.
Explore serviceLocal SEO, Google Business Profile optimization, and reputation management built for medical practices — helping the patients already searching for your specialty find you first.
Explore serviceNew Jersey practices lose most of their recoverable revenue to the ladder they never climb and the regime they misidentify. These are the four we eliminate:
A written internal prompt-pay appeal obliges the carrier to issue a determination within ten business days, and an adverse decision opens external dispute resolution. Practices that re-bill instead of appealing forfeit both the deadline and the arbitration route the regulation gives them.
A health carrier that pays a clean claim outside the 30 or 40-day limit must add simple interest at 12% per year at the time of payment. Practices reconcile the principal and never check the interest line, which is the cheapest money in New Jersey to recover.
The prompt-pay regulation expressly excludes personal injury protection and automobile medical payment coverage. PIP runs on its own fee schedule with decision point review and pre-certification requirements and its own arbitration forum, so a practice that manages auto claims on the health-plan workflow loses both the notice requirements and the appeal route.
Under HCAPPA a carrier may seek reimbursement of an overpaid claim only within 18 months of the first payment on that claim, except for fraud, a documented pattern of inappropriate billing, or coordination of benefits. Offsets outside that window arrive quietly inside a remittance and are usually just absorbed.
A carrier must pay a clean claim within 30 calendar days of receipt when submitted electronically, or within 40 calendar days when submitted by other means, and must pay the uncontested portion while disputing the rest. Overdue clean claims carry simple interest at 12% per year for health carriers and 10% for dental plans, added when the claim is paid.
New Jersey gives providers a defined escalation path: a written internal clean-claim appeal answered within ten business days, external alternative dispute resolution on an adverse determination, and complaints to the Department of Banking and Insurance where a carrier shows a pattern of non-compliance. Carrier recoupment of overpayments is limited to 18 months from first payment outside defined exceptions.
Auto injury reimbursement is capped by the published PIP medical fee schedule and conditioned on decision point review or pre-certification for identified treatments, with disputes resolved in PIP arbitration rather than through the health prompt-pay route. Workers’ compensation has no medical fee schedule at all: reimbursement turns on reasonable and customary charges, and unresolved bills go to the Division on a medical provider claim petition.
Five MCOs hold NJ FamilyCare contracts: Aetna Better Health of New Jersey, Fidelis Care, Horizon NJ Health, UnitedHealthcare Community Plan and Wellpoint, formerly Amerigroup New Jersey. Each manages its own network, credentialing and reimbursement rules, and enrollment with New Jersey Medicaid through NJMMIS does not enrol a practice with any of them.
MedStats Billing provides tailored billing solutions for a wide range of medical specialties, ensuring accurate coding, fewer denials, and faster reimbursementsto maximizes your revenue potential.
MedStats Billing handles NJMMIS enrollment, MCO credentialing, 30 and 40-day clock tracking, prompt-pay appeals and arbitration, PIP compliance and workers’ compensation claim petitions across New Jersey, giving practices end-to-end RCM support in a state with four separate payment regimes running at once.
Claims are scrubbed against NJ FamilyCare MCO and commercial carrier edits before submission to drive clean first-pass reimbursement.
Every claim is routed to the regime that actually governs it — commercial and FamilyCare prompt pay, auto PIP with decision point review, or workers’ compensation — before it is submitted or appealed.
We track the 30 and 40-day clocks on every clean claim and pursue the 12% interest New Jersey attaches to overdue payment, rather than reconciling the principal alone.
Working knowledge of Horizon Blue Cross Blue Shield of New Jersey, AmeriHealth New Jersey, Aetna, Cigna, UnitedHealthcare, Clover Health and all five NJ FamilyCare MCOs.
Whether you practise in Newark, Jersey City, Paterson, Trenton or Cherry Hill, our workflows adjust seamlessly as your group grows across the state.
HIPAA-compliant data handling and controlled access protect patient health information and billing records at every stage.
We integrate smoothly with widely used EHR platforms to ensure accurate data flow from documentation to claim submission. This reduces manual errors, speeds processing, and supports cleaner reimbursements.
We work alongside leading systems including:
Schedule a complimentary billing assessment with MedStats Billing to uncover hidden revenue loss, review the recoupments carriers have taken outside the 18-month window, and quantify the 12% interest your practice is owed on overdue clean claims.
Under N.J.A.C. 11:22-1.5 a carrier must remit payment of a clean claim within 30 calendar days of receipt where the claim was submitted electronically, or within 40 calendar days where it was submitted by any other means. Where a claim was disputed or denied for missing information, the same 30 or 40 days run from receipt of that information, and the uncontested portion must be paid in the meantime.
A health carrier that fails to pay a clean claim within the regulatory time limits must include simple interest on the claim amount at 12% per year, added at the time the overdue claim is paid. Dental plan organizations and dental service corporations pay 10%. Interest accrues from day 31 for electronic claims and day 41 for paper claims, measured from receipt of all information needed to process the claim.
The prompt-pay regulations do not apply to Medicare, workers’ compensation, personal injury protection, automobile medical payment insurance, State Health Benefits, self-insurance, CHAMPUS or federal employee plans. That exclusion matters operationally: auto and work injury claims have no 30-day clock and no 12% interest, and they must be worked through their own notice, fee schedule and dispute rules.
Auto injury care is reimbursed under the PIP medical fee schedule and is conditioned on the insurer’s decision point review or pre-certification requirements for identified treatments and diagnostic tests. Failing to submit a decision point or pre-certification request when required reduces the payable amount even where the treatment itself was appropriate, and disputes are heard in PIP arbitration rather than through the health prompt-pay appeal route.
New Jersey does not publish a workers’ compensation medical fee schedule, so reimbursement is measured against reasonable and customary charges rather than a fixed maximum. Where an employer or carrier will not pay, the provider pursues a medical provider claim petition before the Division of Workers’ Compensation, which is subject to a two-year limitation, so the bill must be tracked from the date of service rather than revisited later.
Five managed care organizations hold NJ FamilyCare contracts: Aetna Better Health of New Jersey, Fidelis Care, Horizon NJ Health, UnitedHealthcare Community Plan and Wellpoint, formerly Amerigroup New Jersey. Each maintains its own provider network, credentialing process and reimbursement rules, and being enrolled with New Jersey Medicaid does not create access to any MCO’s members.
We serve practices and healthcare facilities statewide, including Newark, Jersey City, Paterson, Elizabeth, Edison, Woodbridge, Toms River, Hamilton, Trenton, Clifton, Camden, Cherry Hill, Atlantic City and Princeton.
