MedicaidPrior AuthMedium impact
Newsletter Vol. 25, No.14
New Jersey Medicaid·NJ · Dentistry, Oral & Maxillofacial Surgery, Pediatrics +3 more·Eligibility
Effective date
Oct 1, 2015
We identified it
Jun 20, 2026
Summary
New Jersey FamilyCare updates ICD-10-CM diagnosis codes required for prior authorization and reimbursement of outpatient hospital dental services provided in operating rooms to beneficiaries with developmental disabilities and/or chronic medical conditions. Hospitals must report specific revenue codes (OP 360 or OP 512) and qualifying ICD-10-CM diagnosis codes on claims with service dates on or after October 1, 2015. Prior authorization requires CDT code D9999, medical documentation, clinical justification, and treatment summary.
Action Required
By October 1, 2015 (or immediately for current claims): (1) Billing team and dental providers must update systems to require prior authorization for all outpatient hospital dental services using CDT code D9999 on MC-10 forms. (2) Providers must submit medical documentation on office letterhead including: beneficiary's medical condition and ICD-10-CM diagnosis code from the approved list, clinical justification explaining why office/clinic setting is not viable and why alternative sedation is not an option, and planned treatment details with 12-month dental history. (3) Hospital billing must report only Revenue Code OP 360 or OP 512 for operating room charges and include one or more qualifying ICD-10-CM diagnosis codes from the attached list. (4) Update billing software to enforce correct revenue codes and diagnosis codes based on service date (ICD-10 for October 1, 2015 forward; ICD-9 for dates prior to October 1, 2015). (5) Train billing staff that claims missing correct revenue codes or invalid diagnosis codes will be denied with Error Code 1310. (6) For claims prior to October 1, 2015, continue using ICD-9-CM codes from Medicaid Newsletter Volume 22, No. 18 and disregard the November 2012 version of this newsletter.