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Frequently Asked Questions
  1. What is TPL?
    TPL stands for Third Party Liability which exists when there is private insurance for someone on Medicaid.
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  2. Why is TPL important?
    TPL assures the per Federal and State Medicaid guidelines, Medicaid is the payor of last resort.
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  3. What happens if my private insurance terminates?
    When someone signs up for Medicaid, or NJ Family Care, they sign an application stating that they will update any insurance information that changes. If insurance changes or terminates, Medicaid needs a "Certificate of Creditable Coverage", from your insurer, in order to update the TPL in the Medicaid System. This is the same whether it is a change or a termination.
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  4. Why are my claims not being paid (provider question)?
    The most likely scenario, is that you have omitted TPL information or TPL payment from your claim to Medicaid/Unisys.
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  5. Is it wrong for my NJM service provider to offer or give me money and/or various items such as gifts, coupons, vouchers, trips, etc?
    Yes.  An offer of money or any other items or services of value by a Medicaid provider is a violation of the Federal Anti-Kickback Statute Social Security Act 42 U.S.C. § 1320(a) and 7(b).
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  6. Am I responsible to pay money to my doctor or pharmacist for the services they provide to me?
    No.  A New Jersey Medicaid beneficiary is not required to pay any additional fee or co-payment to service providers such as a physician, dentist, or pharmacy.  However, drug prescription co-payments are required for State funded only programs such as P.A.A.D. and Senior Gold.  P.A.A.D. requires a $6.00 co-pay for generic drugs and a $7.00 co-pay for brand name drugs.  Senior Gold requires a co-pay of $15.00 plus half of the remaining cost of the drug.
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  7. How can I report Medicaid fraud and abuse to the Medicaid Fraud Division?
    You may either call our Fraud Hotline directly at 1.888.937.2835, submit a form online by clicking on the "File a Complaint" button above or send us an email to njmedicaidfraud@omig.state.nj.us.
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  8. If I report an incident, can I remain anonymous?
    Yes.
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  9. What happens to my case once I file a report?
    Your case will be assigned to an investigator.  As long as you provide adequate contact information, the investigator may reach out to you for additional information.
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  10. Is everything I say kept confidential?
    If you would prefer, we will keep your information confidential.  Please note, though, that allegations of patient abuse will be referred to the proper authorities.
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  11. Will I be told of the outcome of my case?
    If the result is public knowledge and not confidential, you will be notified of the outcome.
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  12. What happens if you cannot help me?
    We will refer you to the proper agency if we cannot work on your case.
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  13. How long does an investigation take?
    It depends on the depth of the investigation, but some cases can be resolved within 90 days.
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