MedicaidPrior AuthHigh impact
Newsletter Vol. 6, No. 29
New Jersey Medicaid·NJ · General Surgery, OB-GYN, Neurosurgery +2 more·Provider Notice
Effective date
Jun 1, 1996
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid requires Second Surgical Opinions (SSO) for specific elective procedures before surgery is performed, unless the procedure is urgent/emergent or no appropriate provider is geographically accessible. Claims for covered procedures must include Form FD-263 (SSO Referral Form) or physician attestation of urgent/emergent status. This applies to hysterectomy, spinal fusion, laminectomy, hernia repair, and tonsillectomy/adenoidectomy procedures with specific ICD-9 code exceptions.
Action Required
Immediately: Billing team must implement Second Surgical Opinion (SSO) requirements for all New Jersey Medicaid claims for covered procedures (hysterectomy, spinal fusion, laminectomy, hernia repair, tonsillectomy/adenoidectomy). SPECIFIC ACTIONS: (1) Update billing system to flag claims with affected ICD-9 codes for SSO verification before submission; (2) Require providers to obtain SSO from approved providers via hotline 1-800-676-6562 and attach completed Form FD-263 to all claims for these procedures (except urgent/emergent cases); (3) For urgent/emergent cases, require operating physician to attach written statement attesting to urgent/emergent nature to claim; (4) For geographic waivers, require documentation of Form FD-263 geographic waiver from SSO Hotline; (5) Submit all covered procedure claims as hard copy with FD-263 form attached; (6) Do NOT require SSO for: spinal fusion or laminectomy patients age 18 or under with scoliosis diagnosis, or tonsillectomy/adenoidectomy procedures with service dates on or after February 5, 1996. CONSEQUENCES: Claims submitted without required SSO documentation or Form FD-263 will be denied by New Jersey Medicaid. Ensure providers and front desk staff are trained on SSO requirements and hotline contact procedures.