MedicaidBilling CodesHigh impact
Newsletter Vol. 11, No. 60
New Jersey Medicaid·NJ·Coding
Effective date
Jul 1, 2001
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid/NJ FamilyCare has issued a directive prohibiting balance billing of Medicaid beneficiaries for covered services, effective immediately. Providers may only bill beneficiaries under three specific exceptions: (1) when beneficiary waives Medicaid and pays privately, (2) for non-covered services with prior notification, or (3) for services determined not medically necessary by the program before rendering. Providers must obtain signed waivers before service delivery in all exception cases.
Action Required
Immediately: Billing team must implement the following changes: (1) Stop all balance billing practices for Medicaid/NJ FamilyCare beneficiaries unless one of three exceptions applies; (2) Develop and implement signed waiver forms for front desk/provider staff to use BEFORE services are rendered in exception cases; (3) Train all billing, clinical, and front desk staff on the three allowable billing exceptions and the requirement for pre-service waivers; (4) Update billing system to flag Medicaid/NJ FamilyCare and NJ Care 2000+ HMO claims to prevent balance billing; (5) For disputed payment amounts, instruct billing team to appeal directly to New Jersey Medicaid Program or Fiscal Agent (Unisys: 1-800-776-6334) rather than billing beneficiaries; (6) For HMO-enrolled beneficiaries, establish process to contact HMO for reimbursement disputes instead of patient billing. Failure to comply will result in regulatory violations and potential loss of Medicaid participation.