MedicaidPrior AuthHigh impact
Newsletter Vol. 2, No. 28
New Jersey Medicaid·NJ · General Surgery, OB-GYN, ENT (Ear, Nose & Throat) +1 more·Provider Notice
We identified it
Jun 20, 2026
Summary
This policy establishes a Second Surgical Opinion (SSO) program requirement for certain elective surgical procedures at acute care general hospitals. SSO is now mandatory for hysterectomy, spinal fusion, laminectomy, hernia repair (age 18+), and tonsillectomy/adenoidectomy (age 18+), with specific exemptions for pediatric scoliosis cases and urgent/emergent situations. Hospitals must obtain the Medicaid Second Opinion Referral Form (FD) and attach it to claims for reimbursement.
Action Required
IMMEDIATE: Billing team must implement the following: (1) Update billing system and claim submission workflows to require attachment of completed Medicaid Second Opinion Referral Form (FD) for all claims involving hysterectomy (elective), spinal fusion, laminectomy, hernia repair (bilateral/unilateral/umbilical for age 18+), and tonsillectomy/adenoidectomy (age 18+); (2) Configure system exceptions to waive SSO requirement for: spinal fusion and laminectomy in patients under [age] with scoliosis diagnosis, primary adenoidectomy in children under [age], hernia repair in patients under [age], and all cholecystectomy procedures; (3) Create flag in billing system to identify urgent/emergent cases where SSO waiver applies, requiring physician attestation statement attached to claim; (4) Train hospital billing staff and providers on SSO requirements, exemptions, and documentation; (5) Establish process with operating physicians to obtain and submit SSO Referral Form with each applicable claim. Failure to submit required SSO documentation will result in claim denials. Contact Paramax Unisys Medicaid Fiscal Agent Second Opinion Referral Center for questions.