MedicaidPrior AuthHigh impact
Newsletter Vol. 2, No. 29
New Jersey Medicaid·NJ · General Surgery, OB-GYN, Neurosurgery +2 more·Provider Notice
We identified it
Jun 20, 2026
Summary
This Medicaid policy establishes a Second Surgical Opinion requirement for certain elective surgical procedures effective immediately. Specific procedures are exempt (cholecystectomy, hernia repair under age threshold, primary adenoidectomy under age threshold, and spinal fusion/laminectomy for scoliosis under age threshold). The requirement is waived for urgent/emergent cases with physician attestation. Billing teams must ensure claims for hysterectomy, spinal fusion, laminectomy, hernia repair (age 18+), and tonsillectomy/adenoidectomy include second opinion documentation or meet urgent/emergent criteria.
Action Required
Immediately: Billing team must implement Second Surgical Opinion verification process for elective procedures (hysterectomy, spinal fusion, laminectomy, bilateral/unilateral hernia repair for recipients age 18+, and tonsillectomy/adenoidectomy). Specifically: (1) Before claim submission, verify that elective cases have documented second surgical opinion from Medicaid Fiscal Agent, or (2) If urgent/emergent, obtain and attach physician attestation statement to claim form explaining urgent/emergent nature. Update billing system to flag these HCPCS codes for second opinion requirement. Providers must submit Medicaid Second Surgical Opinion Referral Form FD for operating physicians and assistant surgeons. Note: Anesthesiologists do NOT require the referral form. Claims submitted without required second opinion documentation or attestation for urgent/emergent cases will be denied by Medicaid.