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Newsletter Vol. 13, No. 25
Act
by Apr 15, 2003
Effective date
Apr 15, 2003
Identified
Jun 20, 2026
Summary
New Jersey Medicaid eliminates prior authorization requirements for specific orthotics and shoe HCPCS codes (L3001-L3090, L3201-L3223) when billed with approved diagnosis codes, but implements automatic system-level utilization limits (4 units/year for orthotics, 2 units/year for shoes) and mandatory post-payment review with diagnosis code validation. Invalid diagnosis codes will result in claim denials (Error Code 251) that cannot be overridden through prior authorization, with potential recoupment for incorrect reporting.
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What to do
by Apr 15, 2003 · 5 steps
01Billing team must remove prior authorization requirements from billing system for HCPCS codes L3001-L3090 and L3201-L3223 ONLY when paired with approved diagnosis codes (343.0-343.9, 707.0-707.9, 711.0-712.9, 715.0-722.9, 724.0-728.9, 730.0-737.9, 754.2-754.79, 755.0-755.39, 755.6-755.69, 756.1-756.19, 756.8-756.89, 892.0-897.7).
02Update NJMMIS billing rules to enforce automatic utilization limits: 4 units/12 months for L3001-L3003, L3010, L3020, L3030, L3040, L3050, L3060, L3070, L3080, L3090; 2 units/12 months for L3201-L3207, L3215-L3217, L3219, L3221-L3222; 4 units/12 months for L3218, L3223, X4890-X4892.
03Providers must validate diagnosis codes before submission—claims with inappropriate diagnosis codes will be denied with Error Code 251 and cannot be appealed through prior authorization.
04Prepare for post-payment medical record audits.
05Inform providers that incorrect diagnosis code reporting may trigger payment recoupment and audit actions.
If missed: Failure to comply will result in automatic claim denials and potential financial penalties.
Codes mentioned
L3001L3002L3003L3010L3020L3030L3040L3050L3060L3070L3080L3090L3201L3202L3203L3204L3205L3206L3207L3215L3216L3217L3218L3219L3221L3222L3223X4890X4891X4892
Original notice
Newsletter Vol. 13, No. 25
njmmis.com · Always check the source before changing claims.
Related changes
See all New Jersey Medicaid changes →Related policy hubs
New Jersey Medicaid policiesNJ policy changesPodiatryOrthopedicsGeneral SurgeryPhysical TherapyCode L3001Code L3002Code L3003Code L3010Code L3020Code L3030Code L3040Code L3050Code L3060Code L3070Code L3080Code L3090Code L3201Code L3202Code L3203Code L3204Code L3205Code L3206Code L3207Code L3215Code L3216Code L3217Code L3218Code L3219Code L3221Code L3222Code L3223Code X4890Code X4891Code X4892