CommercialBilling CodesHigh impact
Newsletter Vol. 3, No. 12
New Jersey Medicaid·NJ · Optometry, Ophthalmology·Coding
Effective date
Apr 1, 2024
We identified it
Jun 20, 2026
Summary
Garden State Health Plan now requires a specific modifier to be appended to ALL procedure codes, lenses, frames, and dispensing fees when billing for a second pair of glasses in lieu of bifocals. Failure to use this modifier will result in claim denials for duplicate or excess service. Prior authorization remains mandatory before dispensing the second pair.
Action Required
Immediately: Billing team must update all claim submission processes to require the designated modifier on EVERY procedure code associated with the second pair of glasses (including lenses, frames, and dispensing fees). Providers must ensure prior authorization is obtained BEFORE dispensing. Update billing system rules to automatically append the modifier to second pair claims or implement mandatory verification step. Train all billing and front desk staff on the modifier requirement. When resubmitting previously denied claims for second pair of glasses, attach the original remittance advice showing the claim was submitted within the one-year timely filing window and was denied; send documentation to Paramax Unisys, CN, Trenton NJ, Attention Timely Filing Unit. NOTE: Do NOT use this modifier for replacement glasses. Claims submitted without the modifier for second pair billing will be denied as duplicates or excess services.