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Reinstatement of Prior Authorization Requests

August 19, 2022

State of New Jersey Department of Human Services Division of Medical Assistance & Health Services

TO: Medicaid/NJ FamilyCare Providers, Managed Care Organizations

EFFECTIVE: July 15, 2022

BACKROUND: On March 30, 2020, the Department of Human Services (DHS) issued guidance that suspended prior authorization (PA) for the duration of the COVID-19 Public Health Emergency to ensure that Medicaid/NJ FamilyCare members were able to access medically necessary services without delayor interruption. As a result, the Division of Medical Assistance and Health Service (DMAHS) temporarily disabled select edits requiring PA for payment.

ACTION: The Federal Public Health Emergency is expected to end on July 15, 2022. In anticipation, DMAHS is reinstating PA requirements effective July 15, 2022. This will allow providers adequate time to identify claims requiring prior authorization, and to complete PA requests for any service that will be billed on or after July 15, 2022. After this date, PA edits will deny any claim for services delivered without prior authorization, regardless of service date.

DMAHS recommends that providers resume submitting requests for prior authorization as early as possible to allow adequate time for PAs to be approved and recorded prior to billing. State staff and/or their designees will begin accepting PA requests immediately.  Providers are  encouraged  to  take  advantage  of  early  submission  to  spread  out  PA requests. Early submission allows reviewers sufficient time to address potential requests for additional information, reducing the need for retroactive authorization.

Please note that several provider groups and services were required to continue prior authorization during the pandemic. Those services and/or providers that were required to continue to obtain prior authorization during the pandemic should continue to follow their current guidance.

If you have any policy questions regarding this Newsletter, please contact the Division of Medical Assistance, Office of the Medical Director, at 609-631-4642. If you have any billing questions, please contact Gainwell Technologies Provider Services at 1-800-776-6334.

Download and Retain this Newsletter for Further Reference (PDF)