MedicaidBilling CodesHigh impact
Newsletter Vol. 30, No.06
New Jersey Medicaid·NJ · Psychiatry, Pediatrics, General Practice·Provider Notice
Effective date
Apr 1, 2020
We identified it
Jun 20, 2026
Summary
Effective April 1, 2020, New Jersey Medicaid (NJ FamilyCare) expanded coverage to include Applied Behavior Analysis (ABA) services for children under 21 diagnosed with Autism Spectrum Disorder. Billing teams must transition from PerformCare codes to new HIPAA-compliant HCPCS codes (97151-97158, 0362T, 0373T) and determine whether each child is enrolled in managed care (MCO) or fee-for-service (FFS) to route claims correctly. Providers must obtain prior authorization from the appropriate MCO or continue billing DXC Technology for FFS cases.
Action Required
By March 31, 2020: Billing team must complete the following: (1) Update billing system to recognize and process HCPCS codes 97151-97158 and CPT codes 0362T and 0373T for ABA services; (2) Configure system to flag ABA claims for ICD-10 diagnoses F84.0-F84.9 (Autism Spectrum Disorder); (3) Implement logic to route claims based on Medicaid enrollment status—if child is MCO-enrolled, route to the specific MCO with prior authorization requirement; if child is pending MCO enrollment or FFS-only, route to DXC Technology under NJ FamilyCare FFS benefit. (4) Update provider encounter forms and intake workflows to identify MCO enrollment status and document which provider type (BCBA-D, BCBA, BCaBA, or RBT) is delivering services. (5) Establish process for providers to contact MCOs requesting single case provider agreements if not already contracted. (6) Discontinue use of PerformCare billing codes effective April 1, 2020 for Medicaid-eligible children; continue PerformCare billing only for non-Medicaid children with identification numbers starting with '3560.' Billing team must verify child Medicaid status on every claim to prevent denials. Failure to route claims to correct payer or obtain MCO prior authorization will result in claim denials and service interruptions.