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MD Revenue Group is based in Jersey City. New Jersey is where we started, and most of our staff and clients are still here. That matters, because New Jersey does not bill like the rest of the country. Medicaid runs through five separate managed care plans instead of one. Horizon Blue Cross Blue Shield covers a bigger slice of the commercial market than any single insurer does in most states. And the state has one of the country's more aggressive out-of-network billing laws, one that most national RCM vendors never bother to learn in any real detail.
National RCM playbooks assume every state works the same way. New Jersey doesn't, and the practices that lose the most revenue are the ones billed like it does.
NJ FamilyCare enrolls its members into one of five managed care organizations: Horizon NJ Health, Aetna Better Health, Fidelis Care, Wellpoint, and UnitedHealthcare Community Plan. Each one sets its own prior-authorization rules and its own appeal process. A claim that clears Horizon NJ Health without a hitch can bounce at Aetna Better Health for a missing authorization the first plan never required. We build a separate workflow for each of the five.
New Jersey's Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act (P.L. 2018, c.32) bars balance-billing patients past their in-network cost-sharing for emergency care and inadvertent out-of-network visits. Disputed claims go through mandatory good-faith negotiation, and if that fails, binding arbitration. A lot of practices treat an out-of-network emergency claim as a write-off. It's a claim with a legal path to full or near-full reimbursement, and that path has deadlines. Miss one and the arbitration option is gone for good.
New Jersey's telehealth payment parity requirement, which forced insurers to reimburse telehealth visits at the same rate as in-person ones, expired on July 1, 2026. Practices that leaned on telehealth for routine follow-ups now have a payer-by-payer question to answer: does this plan still pay parity rates voluntarily, or did it quietly drop to a lower telehealth fee schedule the day the law lapsed? We're already seeing the first answers come back from claims filed this month, and they aren't consistent across payers.
Hackensack Meridian Health and RWJBarnabas Health between them touch a huge share of North and Central Jersey referrals. Atlantic Health System, Virtua Health, Inspira Health, and Cooper University Health Care carry similar weight in their own regions. Credentialing a provider across two or three of these systems, plus Horizon and the five FamilyCare plans, is an ongoing enrollment workload, not a one-time task, and it's bigger than most in-house billing staff were ever sized to handle.
NJ FamilyCare's five managed care organizations each run separate prior-auth thresholds, timely-filing windows, and appeal procedures. A denial code that means one thing at Fidelis Care can mean something else entirely at UnitedHealthcare Community Plan. Without a plan-by-plan playbook, claims stall in the gap between what your front desk assumes and what the specific plan actually requires.
P.L. 2018, c.32 gives providers a real shot at full reimbursement on disputed out-of-network emergency claims, but only if the good-faith negotiation and arbitration filings go in on time. Practices that treat these claims like ordinary denials, and sit on them, forfeit a remedy the law built specifically for this situation.
New Jersey's telehealth pay-parity mandate lapsed this month. Some carriers are holding rates steady on their own; others have already moved to a lower telehealth fee schedule. Practices billing telehealth volume need a payer-by-payer read on where reimbursement actually landed, not an assumption based on last year's rate.
Horizon NJ Health rejects the claim outright. Retroactive referral tokens aren’t permitted for specialty codes, so the practice absorbs the full claim value.
Eligibility checks run before check-in, so booking is blocked until the primary care referral token is linked, not after the claim is already denied.
Fidelis Care enforces a strict 90-day filing window. Claims submitted late by an in-house team are written off with no recourse.
Claims are audited, batched, and transmitted within 24 hours of clinical note lock, with an internal alert at day 15 if a note is still unlocked.
Under P.L. 2018, c.32, balance-billing is barred. The payer pays a low commercial rate, and most billing teams write off the gap.
The 30-day good-faith negotiation window is calendared automatically. If negotiation fails, binding arbitration is filed on day 31 to recover full value.
A free audit checks your last 90 days of claims against the New Jersey-specific issues above.
Medicaid: NJ FamilyCare, administered through five contracted managed care organizations
Medicare Administrative Contractor: Novitas Solutions (Medicare Administrative Contractor, Jurisdiction L, covering NJ, PA, DE, MD, and DC)
In effect since August 2018. It bars balance-billing patients beyond their in-network cost-sharing for emergency and inadvertent out-of-network care, and routes reimbursement disputes into mandatory good-faith negotiation followed by binding arbitration if that fails. We track filing windows on these claims the same way we track any other deadline. Miss the window and the arbitration remedy disappears, along with the upper hand it gave you.
New Jersey does not route Medicaid through a single MCO the way some states do. Enrollees land with one of five separate plans, each running its own prior-authorization rules, timely-filing windows, and appeal path. A workflow tuned for one plan does not carry over to the next without real adjustment.
New Jersey required health plans to reimburse telehealth visits at in-person rates. That mandate expired this month. Some carriers are still paying parity rates voluntarily; others have shifted to separate, lower telehealth fee schedules. Practices with meaningful telehealth volume need this checked payer by payer, not assumed.
Book a 15-minute call and we'll walk through exactly how your specific payer mix would be handled.
Every fact on this page, from the Medicaid structure to the regulatory notes, was researched specifically for New Jersey, not copied from a 50-state boilerplate.
AAPC-certified coders handle your claims directly, with a named point of contact instead of a rotating support queue.
We run your existing vendor in parallel while we credential and rebuild your claim rules, so nothing lapses during the switch.
Claims submission, scrubbing, and collections built around the specific quirks of NJ FamilyCare's five-plan structure, not a generic national template stretched to fit New Jersey.
Learn moreFull-cycle RCM from eligibility verification through payment posting, with workflows tuned to Horizon's market share and the payer mix specific to your county.
Learn moreProvider enrollment across Horizon BCBSNJ, all five NJ FamilyCare MCOs, and the major hospital-affiliated networks your referrals actually come from.
Learn moreA free audit that checks specifically for missed out-of-network arbitration eligibility and telehealth parity underpayment, the two leakage points we see most in New Jersey practices right now.
Learn moreFront-desk and administrative support that scales with a growing New Jersey practice without adding office space or new hires.
Learn moreBenchmarks your claims data against current NJ payer-specific denial patterns, including the post-parity telehealth shift, to find revenue you are not currently collecting.
Learn moreLocal visibility support built for a dense, multi-county market where patients are choosing between three or four practices within a 10-minute drive.
Learn moreTalk to our team about your specific specialty, payer mix, and current billing setup.
We analyze your last 90 days of claims for denial patterns, underpayments, and coding gaps specific to your state and specialty.
A written plan targeting the specific leakage points the audit found, not a generic onboarding checklist.
Your existing vendor keeps running while we credential and build claim rules in parallel, proven on real claims first.
Real-time reporting on collections, denials, and A/R velocity, so you see the recovery as it happens, not at quarter-end.
If we don't find money you're leaving on the table, you don't pay a dime.
No commitment. No sales pressure. Just answers.
