MedicaidCoverageMedium impact
Medicaid Alert MA-2025-03
New Jersey Medicaid·NJ · Dentistry, Pediatrics, General Surgery +1 more·Eligibility
Effective date
Oct 1, 2025
We identified it
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.
Action Required
By September 30, 2025: Billing 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. Specifically: (1) Update prior authorization submission templates to include the new QA series neurodevelopmental disorder codes (QA00101-QA00159, QA08) alongside existing qualifying diagnosis codes; (2) Ensure billing system edits accept claims for outpatient hospital dental charges when paired with any of the listed ICD-10 codes; (3) Train 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. Providers and hospitals must document which qualifying diagnosis code(s) support the medical exception. Claims with service dates on or after October 1, 2025 submitted without a recognized qualifying diagnosis code will be denied. Coordinate with Gainwell Technologies Provider Services (1-800-776-6334) if system updates are needed.