MedicaidReimbursementHigh impact
Newsletter Vol. 26, No. 05
New Jersey Medicaid·NJ · Psychiatry·Coding
Effective date
Jul 1, 2016
We identified it
Jun 20, 2026
Summary
New Jersey implements enhanced reimbursement rates for behavioral health services effective July 1, 2016, with rates set at 100% of Medicare rates. Providers must bill Medicaid/NJFC FFS first for eligible consumers, use specific service code/modifier combinations, and comply with new bundled rates for Medication Assisted Treatment (MAT) in Opioid Treatment Programs (OTPs). Prior authorization requirements apply for certain SUD services and outpatient services exceeding $6,000 annual spend per member.
Action Required
By July 1, 2016: (1) Billing team must update fee schedules in billing system to reflect new rates in Table 1 for all mental health and SUD services. (2) Implement modifier requirements: use modifiers 22, 26, SA, SA/26, 52, or UC for mental health services; use HF or HF/26 for SUD clinic services. (3) Update claim submission workflow to bill Medicaid/NJFC FFS FIRST for consumers aged 21 or under and 65 or older for short-term residential and detox services in IMDs. (4) Establish prior authorization process through Interim Management Entity (IME) for SUD services requiring pre-approval. (5) Configure system to cap annual outpatient spend at $6,000 per member per year per provider before requiring prior authorization. (6) Ensure all DMHAS-approved providers are enrolled/re-enrolled in Medicaid/NJFC FFS program via www.njmmis.com. (7) Train billing staff on new bundled MAT rates for OTPs covering medication dispensing, drug costs, counseling, case management, and medication monitoring. Failure to comply will result in claim denials and improper reimbursement.