MedicaidAdministrativeHigh impact
Newsletter Vol. 19, No. 02
New Jersey Medicaid·NJ · Dentistry·Provider Notice
Effective date
Jun 1, 2009
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid is transitioning to the 2006 ADA form for dental claims processing, effective Summer 2009. Providers must use the ADA form as the statement of actual services for payment requests, while the prior authorization process continues using the existing NJ Medicaid Prior Authorization and Dental Claim form. The state will no longer provide the ADA form; providers must obtain it independently.
Action Required
By Summer 2009: Billing team must transition all dental claims submission processes to use the 2006 ADA form for payment requests to New Jersey Medicaid. (1) Obtain the 2006 ADA form independently as DMAHS will no longer provide it. (2) For services requiring prior authorization: continue submitting diagnostics with the two-part NJ Medicaid Prior Authorization and Dental Claim form, then submit the completed ADA form for payment (do not use the returned state dental claim form for billing). (3) For services not requiring prior authorization: submit the ADA form directly to the fiscal agent (Unisys). (4) Review the Revised Fiscal Agent Billing Supplement on www.njmmis.com under "Billing Supplements" for New Jersey-specific requirements. (5) Update internal billing procedures to comply with NJ-specific formatting rules: enter place of service as single digit in Block 38 (not checkboxes); submit services provided at different locations on separate forms; use three-digit NJ carrier code in Block 11 for third-party insurance; note page numbers in Block 35 for multi-page submissions; format procedure code modifiers with five-digit CDT code in section 29 and underscored modifier in section 30. Contact DMAHS at 609-588-7136 or Unisys at 1-800-776-6334 for clarification. Failure to use the ADA form for payment requests will result in claim rejection.