MedicaidAdministrativeHigh impact
Newsletter Vol. 20, No.20
New Jersey Medicaid·NJ · General Surgery, Pediatrics·Provider Notice
Effective date
Oct 4, 2010
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid is implementing UB-04 specific claim processing rules effective October 4, 2010, replacing legacy UB-92 processing logic. Billing teams must update systems to handle new UB-04 field requirements including expanded physician identifiers (NPI and Medicaid Provider Numbers), up to 11 condition codes, 8 occurrence codes, and 4 occurrence span codes, plus new validation rules for admission source, diagnosis codes, and birth designations.
Action Required
REQUIREMENTS: By October 4, 2010 (effective date): Billing team and IT staff must update UB-04 claim processing in the billing system to enforce new validation rules including: (1) Accept up to 11 condition codes instead of 5, and reject codes A7, A8, 47, 82, 83, 84, 85 on UB-04 submissions; (2) Accept up to 8 occurrence codes instead of 4, and reject codes 60, 61, 70, 71, 74, 79, M3, M4; (3) Accept up to 4 occurrence span codes and enforce Occurrence Span Code 74 for non-facility days instead of Occurrence Codes 60/61; (4) Validate Source of Admission field based on Type of Admission value (reject value 3 for non-newborn admissions); (5) Validate Admit Diagnosis codes for inpatient claims; (6) Accept up to 3 Patient Reason for Visit codes on outpatient claims and up to 3 External Cause of Injury codes (note: HIPAA claims limited to 1 each); (7) Update forms and training materials to reflect proper use of new condition codes M2, M3, M4 for multiple births. Hospitals must forward requirements to billing staff; Home Health Providers must implement changes; HMO encounter claims are not affected. Failure to implement new processing logic will result in claim rejections and processing delays. Retain this newsletter for reference during future claim audits and system updates.