MedicaidReimbursementMedium impact
Newsletter Vol. 19, No. 54
New Jersey Medicaid·NJ · Dentistry, General Surgery·Eligibility
Effective date
Nov 1, 2009
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid/NJ FamilyCare now reimburses operating room costs for outpatient hospital dental services provided to clients with developmental disabilities or traumatic brain injuries. Operating room charges must be billed using the hospital's Acute Care provider number (with ICD-9 surgical procedure codes), while dental services continue to be billed using the Dental provider number on the existing dental fee schedule.
Action Required
Immediately: Billing team must implement dual billing methodology for outpatient hospital dental procedures involving operating rooms for eligible NJ Medicaid/NJ FamilyCare clients (those with developmental disabilities or traumatic brain injuries). (1) Update billing system to allow operating room charges to be billed separately using the hospital's Acute Care provider number with corresponding ICD-9 surgical procedure codes in form locators 74/74A-E (or HI segment for electronic claims with HI01='BR' for primary codes and 'BQ' for secondary codes). (2) Ensure dental service charges continue billing under the Dental provider number using standard dental fee schedule. (3) Train billing staff to identify eligible clients by program status codes indicating developmental disabilities or traumatic brain injuries. (4) Verify cost-to-charge ratio calculation methodology is configured in billing system for Acute Care reimbursement. Failure to implement this change will result in operating room charges being denied for these high-need patients.