MedicaidCoverageMedium impact
Newsletter Vol. 9, No. 48
New Jersey Medicaid·NJ · Pediatrics, Geriatrics, Physical Therapy +1 more·Provider Notice
Effective date
Jul 1, 1999
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid is expanding Private Duty Nursing (PDN) coverage under three waivers (ABC, ACCAP, MW III) to include services outside the home when a beneficiary must leave home to obtain a Medicaid-reimbursable medical service (e.g., physician office visit). Previously, PDN was limited to in-home settings only. A case manager must request MDO approval for out-of-home PDN accompaniment, and nurses cannot operate vehicles or engage in non-medical activities.
Action Required
Immediately: Billing and case management teams must update internal protocols to allow PDN service requests outside the home for ABC, ACCAP, and MW III waiver beneficiaries when medically necessary. Prior to processing out-of-home PDN claims, verify that: (1) the beneficiary is enrolled in one of the three approved waivers, (2) the out-of-home service is for a Medicaid-reimbursable medical treatment (not social events), and (3) MDO prior approval documentation is attached to the claim. Update claim submission procedures to route out-of-home PDN requests through the Medicaid District Office (MDO) for approval before billing. Ensure billing staff understand that out-of-home PDN is subject to individual waiver service cost caps and that nurses cannot bill for non-medical activities or vehicle operation. Contact the Bureau of Home and Community Services (609-588-2620) for clarification on specific approval procedures.