MedicaidPrior AuthMedium impact
Medicaid Alert - MA-2002-09
New Jersey Medicaid·NJ · Psychiatry·Prior Authorization
Effective date
Oct 1, 2002
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid revised the completion instructions for form FD-07A (Request for Prior Authorization Supplemental Information) for mental health services. All Medicaid/NJ FamilyCare-approved mental health providers must now follow specific field completion requirements for the top section of FD-07A forms, including exact copying of PA numbers, provider information, beneficiary information matching eligibility cards, and contact person details. PACT providers are excepted and use alternate documentation.
Action Required
Immediately: All mental health providers rendering services to Medicaid/NJ FamilyCare beneficiaries (child or adult) must update their prior authorization submission procedures. Billing/clinical staff must: (1) Ensure form FD-07 is completed first and obtain the PA# from that form; (2) Copy the PA# EXACTLY as it appears onto the FD-07A upper right corner; (3) In Provider Information section, enter provider name exactly as registered with Medicaid/NJ FamilyCare, complete billing address, and seven-digit provider number; (4) In Beneficiary Information section, enter beneficiary name EXACTLY as it appears on their Medicaid/NJ FamilyCare eligibility ID card and the 12-digit eligibility ID number EXACTLY as shown on that card; (5) In Contact Person section, enter name and telephone number of a licensed clinical professional who can answer Division questions about clinical information; (6) Complete fields 9a (Brief Clinical History), 10a (Present Clinical Status), 11a (Diagnosis/ICD-9-CM code and medications), 17 (Treatment Plan and Goals), and 18 (Additional Clinical Information); (7) Leave field 19 blank as it is for DMAHS use only; (8) File FD-07 and FD-07A together. Exception: PACT providers must complete FD-07 with DMHS PACT Referral and Intake Outcome form and submit directly to Statewide PACT Coordinator. Update all internal templates, checklists, and staff training materials to reflect exact matching requirements for beneficiary and provider information to prevent claim delays or denials. Contact Office of Utilization Management, Mental Health Services Unit at (609) 588-2726 with questions.