MedicaidAdministrativeMedium impact
Newsletter Vol. 3, No. 31
New Jersey Medicaid·NJ·Prior Authorization
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid affirms that Utilization Review Organizations (UROs) must continue performing utilization review functions for inpatient hospital services provided to Medicaid recipients under the DRG reimbursement methodology. Utilization review costs are included in the DRG hospital reimbursement rate as an indirect cost component. All New Jersey hospitals reimbursed under DRG must cooperate with UROs in conducting these required reviews.
Action Required
Billing and Finance departments at New Jersey DRG-reimbursed hospitals must: (1) Ensure full cooperation with assigned Utilization Review Organizations for all Medicaid inpatient services; (2) Verify that utilization review processes are integrated into admission and care management workflows; (3) Confirm that URO contact information and review procedures are communicated to clinical and billing staff; (4) Maintain documentation of all utilization review submissions and denials/approvals. Contact the Division of Medical Assistance and Health Services (Deborah Bradley, Executive Director, Office of Medical Affairs and Provider Relations) for clarification on URO assignments or review requirements. Failure to cooperate with URO reviews may result in claim denials or payment delays for Medicaid inpatient services.