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Newsletter Vol. 22, No.18
Act
immediately
Effective date
Nov 1, 2012
Identified
Jun 20, 2026
Summary
New Jersey Medicaid/FamilyCare now allows operating room reimbursement for outpatient dental services provided to clients with developmental disabilities and chronic medical conditions through a medical exemption process. Dentists must request prior authorization using procedure code D9999 with specific documentation from treating physicians and clinical justification. Hospitals must include ICD-9-CM diagnosis codes from the Division's approved medical exception list on claims to qualify for OR cost reimbursement.
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What to do
immediately · 7 steps
01Dentist/Clinic staff must establish new prior authorization process for dental OR visits using CPD code D9999 instead of standard office visit codes.
02Prior auth requests must include: physician documentation on letterhead listing specific medical conditions with ICD-9-CM diagnosis codes, dentist documentation on clinic letterhead explaining why office/clinic setting is not feasible and why other sedation levels won't work, planned treatment and 12-month dental history.
03Billing team must update claim submission procedures to attach prior authorization number to all dental OR claims.
04Hospital billing staff must ensure all OR claims for dental services include ICD-9-CM codes from the Division's Medical Exception list (codes 290.2, 293.8, 293.9, 299, 301.3, 308.0, 310, 312.9, 314, 315.5, 315.8, 315.9, 317, 318, 319, 331.8, 330, 333.4, 333.5, 343, 345, 348.3, 359, 758, 759.83, 760.7, 767.9, 780.3, 850-854).
05For previously denied OR dental claims, resubmit with complete documentation attached to original denial form (FD-360) with reconsideration request.
06Failure to obtain prior authorization or use approved ICD codes will result in claim denials.
07For questions: Dentists contact Bureau of Dental Services (609-588-7136); Hospitals contact Hospital Reimbursement Unit (1-609-588-2668).
Codes mentioned
D9420D9999
Original notice
Newsletter Vol. 22, No.18
njmmis.com · Always check the source before changing claims.