MedicaidReimbursementHigh impact
Newsletter Vol. 28, No.20
New Jersey Medicaid·NJ · Emergency Medicine·Provider Notice
Effective date
Nov 1, 2018
We identified it
Jun 20, 2026
Summary
New Jersey hospitals must reduce reimbursement for non-emergent emergency room visits to a flat $140.00 triage fee effective November 1, 2018. Claims are evaluated based on the first three diagnosis codes and procedure codes (99281-99285); if all meet low-acuity criteria, the $140 fee applies instead of full reimbursement. Specific exceptions exist for pregnant women, children ≤6 years, seniors ≥65 years, and cases with emergency certification.
Action Required
By November 1, 2018: Billing team must update billing system logic to identify non-emergent emergency room claims with revenue code 45X and procedure codes 99281-99285. Implement automated system rules to: (1) check if all first three diagnosis codes match the provided low-acuity diagnosis code list (pages 3-5 of policy); (2) for procedure codes 99283-99284-99285, verify if any of the first three diagnosis codes contain emergency indicator 'Y'; (3) if low-acuity criteria are met with no emergency indicator, process revenue code 45X line at $140.00 flat fee and deny remaining claim lines; (4) if emergency indicator present OR procedure codes are 99281-99282, reimburse at hospital cost-to-charge ratio. Update system to automatically flag claims for four exceptions: condition code B3 (pregnant), patient age ≤6 years, patient age ≥65 years, or certification of emergency form attachment—these bypass the $140 cap. Train billing staff to prepare appeal documentation (corrected claim, remittance advice, supporting documentation) for inappropriate triage denials. Direct appeals to DMAHS, PO Box 712, Trenton, NJ 08628, Mail Code 44 Triage Appeal. Failure to implement these changes will result in systematic underpayment of non-emergent ED claims.