MedicaidPrior AuthHigh impact
Newsletter Vol. 19, No. 01
New Jersey Medicaid·NJ · Dentistry·Provider Notice
Effective date
Jan 1, 2009
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid is eliminating the use of the '76' modifier (increased frequency) and 'EP' modifier (oral evaluations for children under 21) effective January 1, 2009. Providers must now obtain prior authorization for frequent diagnostic and preventive dental services, with written documentation of medical conditions required for approval.
Action Required
By January 1, 2009: Billing team must (1) Stop appending the EP modifier to periodic and comprehensive oral evaluation codes for patients under age 21; system should use date of birth to automatically identify age eligibility. (2) Stop using the 76 modifier for increased frequency of diagnostic and preventive services. (3) Implement prior authorization workflow for any diagnostic or preventive dental services required more frequently than standard frequency, particularly for patients with developmental disabilities, neurological impairment, or other medical disabilities. (4) Update billing system to require written clinical documentation on prior authorization forms documenting the specific medical condition/diagnosis and associated dental diagnosis before claims can be submitted. Contact Division of Medical Assistance & Health Services (609-588-7136) or Unisys Provider Services (1-800-776-6334) with questions. Claims submitted with the eliminated modifiers or without required prior authorization will be denied.