MedicaidCoverageHigh impact
Newsletter Vol. 28, No.04
New Jersey Medicaid·NJ · Psychiatry·Medical Policy
Effective date
Jul 1, 2018
We identified it
Jun 20, 2026
Summary
Effective July 1, 2018, New Jersey FamilyCare (NJFC) managed care organizations (MCOs) now assume responsibility for ALL acute care hospital admissions regardless of diagnosis or age for enrolled beneficiaries, including psychiatric hospitalizations. Additionally, behavioral health and substance use disorder (SUD) services are expanded and shifted from fee-for-service to MCO coverage for MLTSS, FIDE-SNP, and DDD members. Billing teams must route acute inpatient claims to MCOs rather than fee-for-service and update prior authorization workflows for behavioral health services.
Action Required
By June 30, 2018: Billing team must implement the following changes: (1) Update billing system routing rules to direct ALL acute care hospital admission claims (inpatient medical detox, inpatient psychiatric services, psychiatric hospital stays, partial hospital services) to the appropriate MCO for NJFC managed care enrolled members, effective for service dates on or after 7/1/18. (2) Remove age restrictions for psychiatric hospital admissions (IMD exclusion no longer applies for managed care members). (3) Configure system to route the following services to MCO for MLTSS, FIDE-SNP, and DDD members: hospital-based SUD services, outpatient SUD services, IOP, SUD partial care, SUD residential services, ambulatory withdrawal management, and medication-assisted treatment. (4) Continue routing these services to fee-for-service: Targeted Case Management (TCM) via Justice Involved Services, CSOC, ICMS, PATH; Programs in Assertive Community Treatment (PACT); Behavioral Health Homes (BHH); and Community Support Services (CSS). (5) Update prior authorization requirements in system based on MCO vs. FFS designations. (6) Train billing and coding staff on new MCO vs. FFS routing rules. (7) For psychiatric admissions prior to 7/1/18, continue routing to FFS through discharge; only admissions on or after 7/1/18 route to MCO. Failure to route claims correctly will result in denials and delayed payments.