MedicaidCoverageMedium impact
Newsletter Vol. 28, No.11
New Jersey Medicaid·NJ · Gastroenterology, Infectious Disease, Internal Medicine·Medical Policy
Effective date
Jul 1, 2018
We identified it
Jun 20, 2026
Summary
Effective July 1, 2018, New Jersey FamilyCare expanded hepatitis C treatment coverage to all Metavir fibrosis stages (F0-F4), eliminating previous restrictions to F3-F4 only. All hepatitis C treatment now requires prior authorization, confirmation of detectable HCV RNA within 90 days, genotype identification, and prescription by a hepatologist, gastroenterologist, infectious disease specialist, or liver transplant specialist.
Action Required
By July 1, 2018: Billing team must implement prior authorization requirement for all hepatitis C treatments in the NJ FamilyCare billing system. Update encounter forms and provider education materials to clarify that treatment is now covered for Metavir scores F0-F4 (previously F3-F4 only). Ensure all claims include documentation of: (1) detectable HCV RNA levels within past 90 days, (2) identified HCV genotype, (3) Metavir fibrosis stage or objective fibrosis documentation, and (4) prescribing provider specialty (hepatologist, gastroenterologist, infectious disease specialist, or liver transplant specialist). Claims missing prior authorization or required documentation will be denied. Coordinate with providers to obtain prior authorization before service dates.