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Governor Phil Murphy • Lt. Governor Tahesha Way

New Jersey School-Based Health Services

Special Education Medicaid Initiative (SEMI)
SEMI LEA Interim Reimbursement Rates

Groups Direct Medical Service , Evaluation, or Transportation Gross Claim Rate Federal Share
50%		 State Share
32.5%		 School Share
17.5%
All 1 $20.00 $10.00 $6.50 $3.50
  2 $40.00 $20.00 $13.00 $7.00
  3 $60.00 $30.00 $19.50 $10.50
  4 $80.00 $40.00 $26.00 $14.00
  5 $100.00 $50.00 $32.50 $17.50
  6 $120.00 $60.00 $39.00 $21.00
  7 $140.00 $70.00 $45.50 $24.50
  8 $160.00 $80.00 $52.00 $28.00
  9 $180.00 $90.00 $58.50 $31.50
  10 $200.00 $100.00 $65.00 $35.00
SEMI Documentation
Accountability Regulation

In accordance with New Jersey Statutes Annotated 18A:55-3 school districts are required to maximize their participation in the Special Education Medicaid Initiative (SEMI). The newly adopted Accountability Regulations specified in New Jersey Administrative Code (N.J.A.C. 6A:2A-5.3). include programmatic guidelines and standards for local school districts to maximize participation in SEMI.

Memos:
Percentage Shares
Effective for all services rendered July 1, 2006 and forward, the district share for SEMI and MAC is 35% of net revenue.
Agency Responsibilities

  • Researches and resolves fiscal issues for LEAs
  • Provides assistance with SEMI and Medicaid Administrative Claiming (MAC) payments
  • Facilitates signing of Memorandum of Understanding (MOU) for SEMI/MAC program by all parties
  • Provides policy guidance
  • Maintains SEMI/MAC public website
  • Serves as Contract Manager on behalf of the State of New Jersey

  • Provides policy and guidance
  • Coordinates the process and maintains documentation (LEA Statement of Assurances and Approved Board Minutes) for Board of Education approval for participation by LEA
  • Facilitates pre-enrollment process by the LEA for participation in the SEMI program

  • Conducts Medicaid provider enrollment, including issuing Electronic Data Interchange (EDI) Agreement to LEAs for their signature
  • Issues Medicaid provider numbers to LEAs
  • Provides Medicaid technical assistance
  • Communicates requirements of program specifics to ensure that Federal Medicaid regulations are followed
  • Processes and adjudicates claims
  • Provides policy guidance

  • Conducts Office of Education evaluations
  • Provides Medicaid technical assistance and transportation to DCF Campuses
  • Appoints a SEMI Coordinator to coordinate with PCG in fulfilling the operational responsibilities for SEMI
  • Verifies that student health-related services submitted to PCG for Medicaid claiming are included in the student’s IEP which is valid for the dates of service
  • Verifies that service providers have the appropriate qualifications or credentials for Medicaid billing

  • Pre-enrolls with the Department of Education to certify LEA status by submitting board approval and assurances for program implementation related to participation in SEMI program
  • Completes the Medicaid Provider Application package to enroll as a Medicaid provider with the Medicaid program and receives a unique seven-digit Medicaid provider number which will be used for billing purposes
    • Obtains assistance, as needed, from the Medicaid office to complete the various forms included in the application package
  • Designates PCG as the LEA’s Medicaid billing agent by completing the State of New Jersey Submitter/Provider Relationship EDI and Electronic Remittance Advice (ERA) agreements
  • Appoints a SEMI Coordinator to coordinate with PCG in fulfilling the LEA’s operational responsibilities for SEMI
  • Verifies that student health-related services submitted to PCG for Medicaid claiming are included in the student’s IEP which is valid for the dates of service
  • Verifies that service providers have the appropriate qualifications or credentials for Medicaid billing
  • Verifies that signed written positive parental consent to bill Medicaid has been obtained prior to submitting service records to PCG for Medicaid billing
  • Verifies that transportation services billed to Medicaid are: (1) for transportation on specialized vehicles; (2) included in the student’s IEP; (3) for a student who received another Medicaid covered service on the day for which round-trip transportation is billed; and (4) for a student who actually used the transportation service
  • Monitors service documentation compliance by related service providers and conducts necessary follow-up
  • Complies with New Jersey DOE’s Fiscal Accountability Regulations and record retention responsibilities

  • Receives and processes Billing Agreements (Electronic Data Interchange) from newly Medicaid enrolled LEAs
  • Provides a toll-free Help Desk telephone hotline and email address to provide technical assistance to LEAs regarding SEMI service documentation issues
  • Manages and hosts EdPlan™ for LEA’s electronic service documentation and compliance for the fee-for-service program component of the State’s program
    • Conducts Medicaid eligibility verification activities for New Jersey students
    • Provides initial user names and passwords for LEA providers documenting services within EdPlan
    • Provides training to providers for service documentation using EdPlan (see Appendix A)
  • Maintains and hosts PCG Claiming System in supporting various MAC and Cost Settlement program requirements
    • Provides initial user names and passwords for SEMI administrators at LEA
    • Provides training to administrators for reporting and certifying data
  • Prepares and submits claims for FFS Medicaid reimbursement, MAC, and Cost Settlement, based on LEA service and compliance documentation, consistent with Medicaid billing requirements
  • Supports the State in administering aspects of on-going Medicaid legal and regulatory compliance monitoring and facilitates best-practice sharing across districts
  • Complies with all responsibilities outlined in the State Contract


Last Updated: Tuesday, 09/24/24