MedicaidAdministrativeHigh impact
Newsletter Vol. 36, No.09
New Jersey Medicaid·NJ·Coding
Effective date
Jan 1, 2027
We identified it
Sep 15, 2026
Summary
New Jersey Medicaid/NJ FamilyCare mandates that Personal Care Assistance (PCA) and Home Health Services (HHS) providers must achieve 80% Electronic Visit Verification (EVV) compliance by January 1, 2027, with no more than 20% manual edits allowed. Providers failing to meet this threshold face progressive sanctions including loss of new referrals, contract termination, and one-year ineligibility. The policy includes a three-month compliance period (October 1 – December 31, 2026) and defines six required EVV data elements with specific edit reason codes.
Action Required
REQUIREMENTS:
1. By December 31, 2026: Billing team and PCA/HHS providers must audit current EVV submission processes to identify and reduce manual edits below 20% threshold. Review all visits for dates of service in October–December 2026 to ensure compliance documentation is complete.
2. Immediately: Billing team must validate that all manual edits include one of the 28 defined reason codes (200–228) from the policy. Claims with manual edits but missing reason codes will be rejected by MCOs and not paid. Implement system controls to require mandatory reason code selection before claim submission.
3. By January 1, 2027: Providers must ensure EVV system captures all six required data elements electronically: (1) service type, (2) individual receiving service, (3) date of service, (4) location of delivery, (5) individual providing service, and (6) service start/end times. Do not alter or manually add these elements unless a valid exempt edit reason applies (codes 207, 223, 224, 225, 226, 227 do not impact compliance).
4. Ongoing (Monthly): Billing team must monitor EVV compliance reports provided by MCOs, calculated as: (Visits Without Manual Edits) ÷ (Total Visits – Exempt Manual Edits) ≥ 80%. Document all manual edits with reason codes and maintain supporting documentation, especially for codes 224 and 225 (retro-authorization scenarios).
5. Consequences of Non-Compliance:
- After 1 month below 80%: MCO will issue non-compliance notice; provider must remediate or lose new referrals
- After 3 consecutive months: MCO stops sending new referrals
- After 4–5 consecutive months: MCO may terminate contract for cause
- After 6 consecutive months: MCO must terminate contract; provider ineligible for contracts or single case agreements for minimum 1 year
6. Training: Ensure all billing staff and PCA/HHS providers understand the distinction between compliant edits (Y codes) and exempt edits (N codes). Educate on common failure scenarios (codes 208, 209, 210, 216, 218) that DO impact compliance and should be minimized.