MedicaidCoverageHigh impact
Newsletter Vol. 31, No.12
New Jersey Medicaid·NJ · Psychiatry, Family Medicine, OB-GYN +1 more·Medical Policy
Effective date
May 10, 2021
We identified it
Jun 20, 2026
Summary
Effective May 10, 2021, New Jersey Medicaid/NJ FamilyCare expanded age verification procedures for claims processing. The Division now uses procedure code modifiers and program policy criteria in addition to clinical ClaimCheck® software to determine beneficiary age eligibility. Billing teams must apply the correct age-range modifier to claims based on the service type to ensure proper payment processing and avoid claim denials.
Action Required
By May 10, 2021: Billing team must implement age verification procedures for all NJ Medicaid/FamilyCare claims. REQUIREMENTS: (1) Map all service types provided by the practice to the appropriate modifier from the policy reference table (EP, FP, HA, HC, HF, HG, HI, HK, HM, HN, HE, HU, HV, TJ, TH, TR, TV, U1-U5, U9, UA, UB, UD, AA, Newborn, Infant, Child). (2) Update billing system/claim submission software to automatically append correct age-range modifiers to applicable procedure codes based on beneficiary age at time of service. (3) Create validation rules in billing system to reject or flag claims where beneficiary age falls outside the covered age range for the assigned modifier. (4) Train all billing and claims staff on the modifier requirements and age ranges. (5) Audit claims submitted between May 10, 2021 forward to ensure correct modifiers are applied. Failure to apply correct modifiers will result in claim denials for age ineligibility. Special note: H0045 claims require modifier HA and TV together (age 0-21) or TV with modifier 22 (age 0-21).