MedicaidCoverageHigh impact
Newsletter Vol. 30, No.21
New Jersey Medicaid·NJ · OB-GYN·Provider Notice
Effective date
Jan 1, 2021
We identified it
Jun 20, 2026
Summary
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.
Action Required
By December 31, 2020: Billing team must update all systems and provider workflows to require ICD-10-CM Z3A diagnosis codes (week of gestation) on ALL labor and delivery claims for NJ FamilyCare Medicaid patients. Providers and medical coders must be trained that claims without Z3A codes will be denied. System must auto-deny claims with <39 weeks gestation unless one of the following medical indication codes is present: O10, O11, O12, O13, O14, O15, O16, O24, O30, O31, O33, O35, O36, O42, O43, O44, O45, O71, or R03. Establish process for providers to submit appeals with DXC Technology Medicaid Claim Inquiry/Response Form (FD-998) and supporting medical documentation to request reconsideration for medical necessity. Update encounter templates and clinical documentation requirements for OB/GYN and midwifery providers to capture gestational age at delivery and medical indications. Failure to include required Z3A codes will result in automatic claim denials.