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UnitedHealthcareMedicaid · Billing Codes · Medical Policy · NJ · Genetics, Neurology, Pediatrics +1 moreMedium impact

Whole Exome and Whole Genome Sequencing (Non-Oncology Conditions) (for New Jersey Only)

Effective date
Jan 1, 2027
Identified
Nov 7, 2026

Summary

UnitedHealthcare Community Plan of New Jersey revised its Whole Exome and Whole Genome Sequencing (Non-Oncology Conditions) medical policy for New Jersey Medicaid, effective 2027-01-01. Revisions include broadening who may order the test to 'by or in consultation with' a medical geneticist, neonatologist, neurologist, immunologist, or developmental pediatrician, adding criteria for exome and genome data reanalysis after at least 18 months, restricting the policy to outpatient testing or testing upon discharge from an inpatient setting, and adding CPT codes 0670U through 0677U. The policy also notes that CPT codes 0657U, 0658U, 0659U, 0670U-0677U, and 81354 are not on the New Jersey Medicaid fee schedule and may not be covered by the New Jersey Medicaid program.

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What to do

Action · 4 steps
01By 2027-01-01: Billing team should update charge entry and claim edits for New Jersey Medicaid members so CPT 0657U, 0658U, 0659U, 0670U, 0671U, 0672U, 0673U, 0674U, 0675U, 0676U, 0677U, and 81354 are checked against the State of New Jersey Medicaid Fee Schedule before claims are submitted, since the payer notes these codes may not be covered.
02Providers and front desk staff should be told that the policy applies only to outpatient testing or testing on discharge from an inpatient setting, and that the ordering provider must be a medical geneticist, neonatologist, neurologist, immunologist, or developmental pediatrician, or the order must be placed in consultation with one of them, and that documentation should show the criteria being met.
03Pretest genetic counseling is recommended and should be documented in the medical record.
04Claims for these services that do not meet the revised criteria are expected to be denied, so the billing team should confirm documentation supports each criterion before submission.

Codes mentioned

81354

Original notice

Whole Exome and Whole Genome Sequencing (Non-Oncology Conditions) (for New Jersey Only)
uhcprovider.com · Always check the source before changing claims.
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Related changes

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Related policy hubs

UnitedHealthcare policiesNJ policy changesGeneticsNeurologyPediatricsInternal MedicineCode 81354

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