All Insurance Policy Changes (Page 853)

Continuing from page 852. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.

High impact
Newsletter Vol. 30, No.11
New Jersey Medicaid·Effective Mar 21, 2020
New Jersey temporarily modified billing and delivery of partial care and partial hospitalization services during the COVID-19 emergency. Telehealth services are now reimbursed at per diem rates using H0035GTUC (1 unit per day effective 5/15/20, previously 5 units per day). Prior authorization for these services is suspended, and services may be delivered individually or in groups via telecommunication devices. Face-to-face services continue using normal billing codes and hourly rates.
High impact
Newsletter Vol. 30, No.12
New Jersey Medicaid·Effective Mar 23, 2020
New Jersey Medicaid (NJ FamilyCare) now covers pediatric and adolescent well visits via telehealth for members under 21 years old due to COVID-19 emergency. These visits must include developmental screenings, behavioral screenings, health risk assessments, and anticipatory guidance components.
Low impact
Newsletter Vol. 30, No.13
New Jersey Medicaid·Effective Mar 1, 2020
This New Jersey Department of Human Services policy clarifies that COVID-19 CARES Act stimulus payments ($1,200 per adult) received by Medicaid-eligible residents in long-term care facilities must be handled as excluded income/resources for 12 months and cannot be retained by facilities. Facilities must promptly notify residents and make funds available for personal use, either directly or through personal needs accounts. This is informational guidance for LTC providers and does not directly impact medical billing workflows at healthcare practices.
Medium impact
Newsletter Vol. 30, No.14
New Jersey Medicaid·Effective Mar 21, 2020
New Jersey Medicaid now allows Presumptive Eligibility (PE) applications to be completed over the telephone and accepts PE applications for telehealth/telemedicine encounters during the COVID-19 emergency. PE applications must still be submitted within 5 calendar days of the healthcare service.
Medium impact
Newsletter Vol. 30, No.15
New Jersey Medicaid·Effective Dec 1, 2019
NJ FamilyCare now covers CenteringPregnancy group prenatal visits for CHI-credentialed sites. Billing teams must code individual E/M services (99212-99215) for each pregnant woman participant, plus add CPT 99078 TH for group education services. Providers receive an additional $7.00 per Medicaid beneficiary per group visit.
High impact
Newsletter Vol. 30, No.16
New Jersey Medicaid·Effective Aug 1, 2020
New Jersey Medicaid (NJFC) has discontinued the 'pay and chase' practice for prenatal, labor, delivery, postpartum care, and CHIP-eligible children's services. Effective August 1, 2020, claims for these services will be rejected (not denied) if a third party is identified as liable, and providers must bill the third party first before submitting balance claims to Medicaid. This shifts responsibility to providers to coordinate benefits upfront rather than Medicaid paying first and recovering later.
High impact
Newsletter Vol. 30, No.17
New Jersey Medicaid·Effective Jul 1, 2020
New Jersey Medicaid (NJFC) now covers Developmental, Individual Difference, Relationship-Based (DIR) therapy services for children under 21 diagnosed with Autism Spectrum Disorder (ICD-10 F84.0-F84.9). Billing teams must implement new CPT codes (96156EP-96171EP) with specific unit limits, verify provider credentials and DIR specialization training, and obtain prior authorization from MCOs or use single-case agreements for non-contracted providers.
High impact
Newsletter Vol. 30, No.18
New Jersey Medicaid·Effective Jul 1, 2020
All providers participating in NJ FamilyCare Medicaid MCO networks must complete either a full NJFC FFS enrollment application or a 21st Century Cures Act provider application with DXC Technology. Providers who choose to serve only MCO beneficiaries will be registered as 21st Century Cures providers and will not receive FFS payments or be listed in the FFS provider directory. Failure to comply may result in MCO contract termination.
Medium impact
Newsletter Vol. 30, No.19
New Jersey Medicaid·Effective Aug 1, 2020
New Jersey DDD/NJFC Medicaid now permits qualified temporary employment agencies to provide staffing for specific services (behavioral supports, day habilitation, therapy services, and individual/community-based supports) to approved providers. Temporary employment agencies must obtain their own NJFC Medicaid Provider ID and maintain vendor contracts with the primary provider. The primary provider remains responsible for billing and ensuring all temporary staff meet licensure, certification, and DDD/NJFC Medicaid requirements.
High impact
Medicaid Alert MA2020-05
New Jersey Medicaid·Effective Sep 20, 2020
New Jersey Medicaid is implementing enhanced NCPDP telecommunication standards for pharmacy claims effective September 20, 2020. Providers must now capture and validate the quantity prescribed (460-ET field), dispensing status (343-HD), fill numbers (403-D3), prescription written dates (414-DE), and refill authorizations (415-DF) on all prescriptions. Claims will be denied if these fields are missing, incorrect, or fail new edits for Schedule II drug partial fills and prescription expiration limits (30 days for controlled drugs, 365 days for non-controlled drugs).
High impact
Newsletter Vol. 30, No.20
New Jersey Medicaid·Effective Jan 1, 2021
New Jersey Medicaid requires all personal care services providers to comply with Electronic Visit Verification (EVV) mandates by January 1, 2021. Providers must complete a survey by October 23, 2020, selecting one of three EVV compliance options (free health plan tools, existing EVV system, or free HHAeXchange tools) to timestamp and electronically verify all in-home visits.
High impact
Newsletter Vol. 30, No.21
New Jersey Medicaid·Effective Jan 1, 2021
Effective January 1, 2021, NJ FamilyCare Medicaid will deny reimbursement for non-medically indicated early elective deliveries (scheduled cesarean sections or inductions before 39 weeks gestation without medical justification). All labor and delivery claims must include ICD-10-CM diagnosis codes indicating week of gestation (Z3A category). Claims reporting <39 weeks gestation without approved medical indication codes will be automatically denied.
High impact
Newsletter Vol. 30, No.22
New Jersey Medicaid·Effective Nov 1, 2020
New Jersey Medicaid is implementing the Office Based Addictions Treatment (OBAT) program effective November 1, 2020, requiring group practices to have an enrolled navigator to bill enhanced rates for substance use disorder treatment services. Practices with navigators receive higher reimbursement for intake/assessment (90792HF at $438.17) and E/M services (99201HF-99215HF at ~100% Medicare), plus navigator-specific codes (H0006HFHG, H0006HFSU, H0006HF). Individual providers without navigators may continue billing MAT services but only at base rates.
Low impact
Newsletter Vol. 30, No.23
New Jersey Medicaid·Effective Jan 1, 2021
⚠️ POLICY OUTDATED: This New Jersey Medicaid newsletter from 2020 has been superseded by Volume 31 No. 04 from February 2021 with revised billing codes. The original policy established doula service coverage under NJ FamilyCare Medicaid starting January 1, 2021, but current billing codes and procedures may differ from what's shown here.
Medium impact
Senior Services News Vol. 23, No. 01
New Jersey Medicaid·Effective Jan 1, 2021
New Jersey adjusted income eligibility limits for PAAD, Lifeline, HAAAD, and Senior Gold pharmacy assistance programs effective January 1, 2021, based on a 1.3% Social Security Cost of Living Adjustment. PAAD limits are now less than $28,769 (single) and less than $35,270 (married); Senior Gold limits are $28,769-$38,769 (single) and $35,270-$45,270 (married). Billing teams must verify patient eligibility against these new thresholds when processing pharmaceutical claims.
Medium impact
Newsletter Vol. 30, No.26
New Jersey Medicaid·Effective Jul 1, 2019
New Jersey Medicaid (NJ FamilyCare) now covers Peer Recovery Support Specialist (PRSS) services for outpatient substance use disorder treatment at independent clinics. Effective July 1, 2019, clinics can bill H0038 HF at $16.62 per 15 minutes for individual face-to-face peer services. Starting July 1, 2021, only certified peers can bill; peers must have 2+ years recovery experience and obtain NCPRS or NJ CPRS certification. Clinics must enroll peers via addendum and include peer NPI on claims.
Medium impact
Newsletter Vol. 30, No.25
New Jersey Medicaid·Identified Jun 20, 2026
A new payment methodology has been introduced for Substance Use Disorder (SUD) Long-Term Residential (LTR) Services. This change affects how billing and reimbursement will be processed for these specialized residential treatment services.
High impact
Newsletter Vol. 30, No.24
New Jersey Medicaid·Effective Jan 1, 2021
Effective January 1, 2021, New Jersey Medicaid (NJFC) requires prenatal care providers to complete and submit a First Visit Perinatal Risk Assessment Plus (PRA Plus) form to Family Health Initiatives before reimbursement will be processed. Claims for prenatal services will pend until the PRA form is received and verified; if not received within 30 days, claims will be denied with Error Code 1459.
High impact
Newsletter Vol. 31, No.01
New Jersey Medicaid·Effective Jan 1, 2021
New Jersey Medicaid is implementing Electronic Visit Verification (EVV) for Personal Care Services effective immediately. All Medicaid FFS and MCO providers billing for personal care must submit EVV-verified claims with phased compliance requirements: 20% verified visits in January 2021, escalating to 100% by July 1, 2021. Providers must complete mandatory training and meet minimum compliance thresholds or face consequences including non-assignment of new cases.
High impact
Newsletter Vol. 31, No.02
New Jersey Medicaid·Effective Jan 1, 2021
New Jersey Medicaid/NJ FamilyCare now reimburses pharmacies for administering SARS-CoV-2 vaccines at Medicare rates ($16.94 first dose, $28.39 second dose). Pharmacies must populate specific billing fields (420-DK with SCC codes "02" or "06", and 440-E5 with "MA") and report administration charges in the 438-E3 field. Claims without proper field population and the "MA" designation will be denied.
Medium impact
Newsletter Vol. 31, No.04
New Jersey Medicaid·Effective Jan 1, 2021
New Jersey Medicaid/NJ FamilyCare now covers doula services effective January 1, 2021. Doulas must enroll as individual Medicaid/FFS providers and can bill for prenatal, delivery, and postpartum support using six new HIPAA-compliant codes. Standard care includes 8 prenatal/postpartum visits plus 1 delivery; enhanced care (ages 19 and under) includes 12 visits plus 1 delivery. A clinician recommendation is required prior to initiating doula care.
High impact
Newsletter Vol. 31, No.03
New Jersey Medicaid·Effective Jan 1, 2021
New Jersey Medicaid/NJ FamilyCare will deny reimbursement for non-medically indicated early elective deliveries (EEDs) performed before 39 weeks of gestation effective January 1, 2021. Claims must include ICD-10-CM diagnosis codes indicating week of gestation (Z3A category). Claims without gestational age codes or showing <39 weeks without approved medical indication codes will be denied unless providers submit medical justification.
High impact
Newsletter Vol. 31, No.05
New Jersey Medicaid·Effective Apr 1, 2021
New Jersey Medicaid/NJ FamilyCare is conducting a mandatory five-year provider re-enrollment cycle beginning April 1, 2021. Providers must complete re-enrollment packets by their assigned deadline or face claim denials and termination of enrollment ID numbers. Institutional providers (as defined by CMS) must also submit a $599 application fee per service location.
Medium impact
Newsletter Vol. 31, No.06
New Jersey Medicaid·Effective Jan 11, 2021
New Jersey Medicaid/NJ FamilyCare now covers breastfeeding equipment for all eligible members during pregnancy and postpartum, effective January 11, 2021. Double electric breast pumps (E0603) require no prior authorization except hands-free models; manual pumps (E0602) and hospital-grade pumps (E0604) have specific coverage criteria. Breast pump supplies (A4281-A4286, K1005) are covered without prior authorization, while hands-free bras (A9900) require it. All equipment must be delivered within specified timeframes (24-72 hours depending on type) at no cost to members.
High impact
Newsletter Vol. 31, No.07
New Jersey Medicaid·Effective Apr 1, 2021
New Jersey Medicaid/NJ FamilyCare implemented significant restrictions on presumptive drug screening and definitive drug testing billing effective April 1, 2021. Multiple procedure codes were terminated, new HF (substance abuse program) modifiers were created with provider-type restrictions, and strict frequency/volume limits were imposed (max 1 encounter per date/10 per 30 days for presumptive; max 7 drug classes/2 encounters per 30 days for definitive). Claims will be denied if definitive testing follows negative presumptive results, if billed on same date as presumptive test, or if lacking prior presumptive test within 7 days.

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Newsletter Vol. 30, No.11

Newsletter Vol. 30, No.12

Newsletter Vol. 30, No.13

Newsletter Vol. 30, No.14

Newsletter Vol. 30, No.15

Newsletter Vol. 30, No.16

Newsletter Vol. 30, No.17

Newsletter Vol. 30, No.18

Newsletter Vol. 30, No.19

Medicaid Alert MA2020-05

Newsletter Vol. 30, No.20

Newsletter Vol. 30, No.21

Newsletter Vol. 30, No.22

Newsletter Vol. 30, No.23

Senior Services News Vol. 23, No. 01

Newsletter Vol. 30, No.26

Newsletter Vol. 30, No.25

Newsletter Vol. 30, No.24

Newsletter Vol. 31, No.01

Newsletter Vol. 31, No.02

Newsletter Vol. 31, No.04

Newsletter Vol. 31, No.03

Newsletter Vol. 31, No.05

Newsletter Vol. 31, No.06

Newsletter Vol. 31, No.07