SBHS and MAC Flow Process Documentation

This document presents process flow diagrams for two New Jersey school-based health services programs: the School-Based Health Services (SBHS) flow and the Medicaid Administrative Claiming (MAC) flow, dated June 3, 2025. The SBHS flow outlines the contractor's responsibilities in managing Medicaid billing for school health services across New Jersey districts. The process begins with district users logging into an online portal to update student records, which the system verifies against the Medicaid eligibility list. Once student lists match, services are assigned and the contractor collects data from the online portal on a minimum monthly basis. The contractor then imports Medicaid-eligible data into the billing system, creates HIPAA-compliant claim files for all districts, performs quality assurance validation on a sample dataset, and submits monthly claims to the New Jersey Medicaid Management Information System (NJ MMIS). The contractor reconciles submitted claims against remittance advice and provides reports to both the state and individual districts. Data corrections are made as needed when validation fails.

The MAC flow describes a quarterly process for claiming reimbursement based on staff effort and financial participation. The contractor identifies the staff pool of clinicians and administrative staff along with the school calendar, then formulates the quantity of Required Medicaid Time Survey (RMTS) questionnaires according to federal guidelines. The system distributes RMTS surveys electronically, and the contractor performs quality assurance for response completeness. In parallel, local education agencies (LEAs) enter and certify financial data for program participants. The contractor calculates claims using RMTS data, quarterly financial information, and management and unrestricted indirect cost rates. Both the RMTS process and financial claim process occur quarterly, with data validation occurring before claim submission.