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Medicaid Alert MA-2025-03
Act
by Sep 30, 2025
Effective date
Oct 1, 2025
Identified
Jun 20, 2026
Summary
New Jersey Medicaid is expanding the list of ICD-10-CM diagnosis codes that qualify for medical exception approval for outpatient dental services provided in a hospital operating room for beneficiaries with developmental disabilities and/or chronic medical conditions. This policy adds specific neurodevelopmental disorder codes (QA series) and clarifies which conditions meet the medical exception requirement. Prior authorization procedures and hospital reimbursement remain unchanged.
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What to do
by Sep 30, 2025 · 7 steps
01Billing team and dental providers must update prior authorization submission processes and billing system validation rules to recognize the complete expanded list of ICD-10-CM diagnosis codes that qualify for medical exception approval for operating room dental services.
02Update prior authorization submission templates to include the new QA series neurodevelopmental disorder codes (QA00101-QA00159, QA08) alongside existing qualifying diagnosis codes.
03Ensure billing system edits accept claims for outpatient hospital dental charges when paired with any of the listed ICD-10 codes.
04Train coding staff to accurately apply these diagnosis codes when submitting claims for NJ FamilyCare Fee-For-Service beneficiaries receiving dental treatment in an operating room.
05Providers and hospitals must document which qualifying diagnosis code(s) support the medical exception.
06Claims with service dates on or after October 1, 2025 submitted without a recognized qualifying diagnosis code will be denied.
07Coordinate with Gainwell Technologies Provider Services (1-800-776-6334) if system updates are needed.
Codes mentioned
E75E756F03F0391F06F068F07F079F09F48F489F53F60F609F70F71F72F73F78F79F84F849F88F90F909F91F919G10G25G259G31G319G40G409G71G719G72G729G73G737G80G809G93G939P04P049Q86Q90Q99R56R569S06S069X9F819I6783P154P158P159F89
Original notice
Medicaid Alert MA-2025-03
njmmis.com · Always check the source before changing claims.
Related changes
See all New Jersey Medicaid changes →Related policy hubs
New Jersey Medicaid policiesNJ policy changesDentistryPediatricsGeneral SurgeryPsychiatryCode E75Code E756Code F03Code F0391Code F06Code F068Code F07Code F079Code F09Code F48Code F489Code F53Code F60Code F609Code F70Code F71Code F72Code F73Code F78Code F79Code F84Code F849Code F88Code F90Code F909Code F91Code F919Code G10Code G25Code G259Code G31Code G319Code G40Code G409Code G71Code G719Code G72Code G729Code G73Code G737Code G80Code G809Code G93Code G939Code P04Code P049Code Q86Code Q90Code Q99Code R56Code R569Code S06Code S069X9Code F819Code I6783Code P154Code P158Code P159Code F89