Back
to top
Untitled Document

Information on
Novel Coronavirus

Have questions about COVID-19?
The NJ Poison Control Center and 211 have partnered with the State to provide information to the public on COVID-19:
Call: 2-1-1 for general information (24/7) or 1-800-962-1253 for medical information (24/7); Text: NJCOVID to 898-211
Visit covid19.nj.gov or nj.gov/health for additional information

Special Education Medicaid Initiative (SEMI) and Medicaid Administrative Claiming (MAC)

Special Education Medicaid Initiative (SEMI)

SEMI LEA Rates

Department of the Treasury - Fiscal and Resources
SEMI Interim Billing Bundled Rates - Local Education Agencies
Procedure Code Description of Service Group A Rate Group B Rate Group C Rate
Y9433 Evaluation (per eval) $1,788.55 $1,788.55 $1,788.55
Y9438 Medical Transportation (Round Trip) $29.31 $29.31 $29.31
Y9434 In-District (per diem) $30.99 $61.98 $92.97
Y9435 Out-of-District (per diem) $30.99 $61.98 $92.97

Local Education Agencies are assigned a group by the State. Group assignment is based on multiple factors, including, but not limited to, particiption rate, historical data and expenditures. Newly participating LEAs are automatically assigned to Group B.

Look up my LEA’s Interim Billing Rate

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: Friday, 02/21/20