MedicaidCoverageHigh impact
Newsletter Vol. 31, No.03
New Jersey Medicaid·NJ · OB-GYN·Provider Notice
Effective date
Jan 1, 2021
We identified it
Jun 20, 2026
Summary
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.
Action Required
By January 1, 2021 (retroactive): Billing team must implement the following: (1) Update billing system to REQUIRE ICD-10-CM diagnosis code Z3A (week of gestation) on all labor and delivery claims submitted to NJ Medicaid/NJ FamilyCare. Claims without this code will be automatically denied. (2) Configure system to DENY payment for claims reporting gestational age <39 weeks UNLESS at least one of the listed medical indication diagnosis codes (O10-O99325 or R3) is present. (3) Providers (obstetricians, midwives, hospitals, clinics) must document medical indication in clinical records for all deliveries before 39 weeks. (4) For any denied claims, providers must submit the Gainwell Technologies Medicaid Claim Inquiry/Response Form (FD-998) with hard-copy claim and supporting medical documentation to request reconsideration for payment based on medical necessity. (5) Share ACOG and March of Dimes educational materials with patients regarding risks of early elective delivery. Consequences: All non-compliant labor and delivery claims will be denied by Medicaid/NJ FamilyCare.