MedicaidCoverageHigh impact
Newsletter Vol. 26, No. 13
New Jersey Medicaid·NJ · Psychiatry·Provider Notice
Effective date
Sep 1, 2016
We identified it
Jun 20, 2026
Summary
Effective September 1, 2016, NJ FamilyCare (NJFC) fee-for-service will deny payment for specific substance use disorder (SUD) treatment service combinations billed on the same date of service by the same provider. Additionally, psychiatric evaluation codes 90791 HF and 90792 HF are limited to a maximum of two encounters per 365-day period. Providers must use correct modifiers (HF, HF/26, SA, SA/26, UC, 26, 52) to identify service type and place of service, or claims will be denied.
Action Required
By September 1, 2016: Billing team must update billing system with all 25 same-day service conflict rules to automatically deny or flag claims when conflicting service codes appear on the same claim date. Implement frequency limitation rules to deny any claims exceeding 2 encounters of CPT 90791 HF or 90792 HF in a rolling 365-day period per provider. Update claim submission procedures to require providers to append correct modifiers (HF, HF/26, SA, SA/26, UC, 26, 52) based on service type and place of service; configure system to deny with error code 1007 if place of service modifier is inconsistent with reported place of service. Create internal documentation mapping all 25 conflicts for billing staff and provider education. Contact IME (Rutgers University Behavioral Health Care) at 1-800-776-6334 with any questions. Failure to implement these rules will result in automatic claim denials by NJFC.