New Jersey NJ

New Jersey (NJ FamilyCare / DMAHS) has NO single canonical PA criteria hub. (1) FFS/medical PA CRITERIA live in regulation: N.J.A.C. Title 10 (Medicaid in 10:49 et seq.), hosted on LexisNexis free public access (www.lexisnexis.com/hottopics/njcode) - DMAHS migrated its old Eligibility & Service Manuals page to point there; no DMAHS-hosted manual PDFs anymore. (2) DMAHS publishes a CMS-0057-F FFS Prior Authorization Metrics report (medical items/services, excluding drugs) - CY-2025 report live. FFS PA had NO required decision timeframes before 2026-01-01; CMS rule now mandates 72h expedited / 7d standard. (3) Pharmacy FFS: NO statewide carve-out; clinical PA/DUR guidance via DURB Educational Newsletters (MME opioid edits, pharmacy edits/utilization review); PDL/criteria adjudicated through NJMMIS. (4) Managed care: 5 NJ FamilyCare MCOs (Aetna Better Health, Fidelis Care/WellCare, Horizon NJ Health, UnitedHealthcare Community Plan, Wellpoint fka Amerigroup) - DMAHS Health Plans page only LINKS OUT to each MCO external site; PA criteria are per-MCO, off-state. (5) DMAHS Medicaid Communications circulars are ELIGIBILITY-focused (income standards, penalty divisor) NOT PA criteria - matches existing corpus docs 98-107. NJMMIS portal (njmmis.com) has a browser/bot wall (redirects to browserNotSupported.aspx).

carve-in to MCOs (each MCO uses its own PBM)

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

Last award: None. Next due: None. Contracts extended through: None.

# NJ — learned PA profile (local Qwen synthesis, 2026-05-28) Synthesized by local `qwen2.5-coder:32b` on M2 Ultra reading NJ's full corpus: 13 documents (3 PA-relevant — doc 610 CY-2025 FFS PA Metrics, docs 611/612 DURB pharmacy newsletters; docs 98–107 eligibility-only bulletins) + 11 `state_research_finding` rows + [[state_shape_NJ]]. NJ is a SPARSE / no-canonical-hub state; the gap-mapping in Dimension 5 is the load-bearing part. Baseline; re-run as docs change. > **Reviewer caveat (human, not model):** the synthesis mis-expands "WISeR" as "Widespread Implementation of Simple, Scalable Electronic Reporting." That is WRONG. WISeR is the CMS Innovation Center **"Wasteful and Inappropriate Service Reduction"** Medicare prior-authorization model (original Medicare, NOT Medicaid). See [[reference_wiser_model]]. NJ's WISeR status is uncertain (MAC-jurisdiction ambiguity — CMS fact sheet lists JH/Novitas vs NJ's traditional Novitas JL). ## DIMENSION 1 — HOW NJ REQUIRES PA (operational shape) New Jersey's prior authorization (PA) requirements are structured across multiple loci, reflecting a decentralized approach that lacks a central hub. The primary decision-making authorities and criteria locations are as follows: - **FFS Criteria:** The Fee-for-Service (FFS) medical PA criteria are embedded within the New Jersey Administrative Code (N.J.A.C.), specifically Title 10, which covers Human Services and Medicaid (Medicaid in 10:49 et seq.). Providers must navigate to LexisNexis to access these regulations, making it a regulation-based system rather than a document-based one (discovered_shape finding). - **Managed-Care Criteria:** The five Managed Care Organizations (MCOs) in New Jersey—Aetna Better Health, Fidelis Care (WellCare), Horizon NJ Health, UnitedHealthcare Community Plan, and Wellpoint (fka Amerigroup)—each maintain their own PA criteria. These are hosted on the respective MCO websites; the DMAHS "NJ FamilyCare Health Plans" page only LINKS OUT to each MCO external site. There is no centralized location for managed-care PA requirements. - **Pharmacy Criteria:** For pharmacy services under FFS, New Jersey does not have a statewide carve-out. Clinical PA and utilization review guidance are provided through DURB (Drug Utilization Review Board) Educational Newsletters (docs 611, 612). Pharmacy PA decisions are adjudicated via NJMMIS (New Jersey Medicaid Management Information System), with point-of-sale edits run through the Medication Exception Process (MEP): therapeutic duplication 405/407, mandatory generic 417, max dose 537, GA edit 577, refill-too-soon 830, ddi 916 (doc 612). - **Behavioral Health and Long-Term Services and Supports (LTSS):** Behavioral health services were previously carved out but are transitioning to carve-in as part of Phase 1 BH integration effective January 1, 2025 (bh_carve_out_detail finding). LTSS services are already carved in under the MLTSS (Managed Long Term Services and Supports) model since 2014-07-01 (ltss_carve_out_detail finding). ## DIMENSION 2 — HOW NJ PUBLISHES / REPORTS PA New Jersey publishes its PA criteria and metrics through a variety of channels, each serving distinct purposes: - **FFS Medical Criteria:** Found in N.J.A.C. Title 10, hosted on LexisNexis (`www.lexisnexis.com/hottopics/njcode`), requiring acceptance of terms to access. DMAHS retired its old "Eligibility & Service Manuals" page; there are NO DMAHS-hosted provider-manual PDFs anymore. - **FFS PA Metrics Report:** DMAHS publishes an annual report under CMS-0057-F covering PA requests for medical items and services (EXCLUDING prescription drugs). The CY-2025 report (doc 610) is live. Key metrics: - **Standard (non-urgent):** 883,132 approved of 889,627 total (99.27%); 2,388 denied (.27%); 1,266 approved with extended timeframe (.14%); 0 approved only after appeal. - **Expedited (urgent):** 0 of 0 — no expedited requests recorded for CY-2025. - **Time to decision (standard):** mean 1 day / median 1 day. Expedited: NA. - **Pharmacy Criteria:** Disseminated through DURB Educational Newsletters — opioid prescribing guidelines (Morphine Milligram Equivalents, doc 611, Vol. 34 No. 01 March 2024) and common pharmacy edits / utilization review (doc 612). - **Managed-Care Criteria:** Hosted on each MCO's respective external website; providers must visit the individual MCO sites. - **Eligibility Circulars Trap:** The "Medicaid Communications" circulars (25-xx, 26-xx — docs 98–107) contain ELIGIBILITY content (income/resource standards, penalty divisor, spousal maintenance, Medical Review Team process). These are NOT PA criteria and should not be confused with PA guidelines. ## DIMENSION 3 — COMPLIANCE POSTURE New Jersey's compliance posture regarding prior authorization is evolving, particularly in light of recent federal and state changes: - **CMS-0057-F (Interoperability & Prior Authorization Final Rule):** Prior to January 1, 2026 there were NO required timeframes for NJ FFS PA decisions (doc 610 states this explicitly). The rule now mandates 72 hours for expedited (urgent) and 7 calendar days for standard (non-urgent), effective 2026-01-01. The CY-2025 metrics therefore pre-date any binding timeframe. - **State PA Reform — P.L.2023, c.296 "Ensuring Transparency in Prior Authorization Act"** (signed 2024-01-16; gold_card_law finding): imposes 24 hours urgent / 72 hours non-urgent response windows on health benefit plans plus public posting of PA statistics. Critically, it contains NO gold-card exemption (no approval-threshold auto-approval) — it is a transparency/timing statute, not a volume-based exemption regime. - **WISeR Pilot:** Recorded as uncertain (wiser_pilot finding; `is_participating: true`, participant Genzeon Corporation, PY1 start 2026-01-01, model end 2031-12-31) with MAC-jurisdiction ambiguity flagged. See reviewer caveat above and [[reference_wiser_model]] — this is the Medicare "Wasteful and Inappropriate Service Reduction" model, NOT a Medicaid program. - **1115 Waiver:** "NJ FamilyCare Comprehensive Demonstration" (approved 2023-03-30; period 2023-04-01 → 2028-06-30; 1115_waiver finding). PA-relevant authorities: MLTSS (LTSS carved in), BH Integration Phase 1 (1/1/2025), Autism Adjunct Services Pilot, Community Health Workers Pilot, 12-month continuous eligibility for MAGI. HRSN investment cap $655M. ## DIMENSION 4 — HOW NJ RUNS ITS PROGRAM New Jersey's Medicaid program operates with a mix of FFS and managed-care components (~90% managed-care penetration — mco_inventory finding), each governed by different authorities and systems: - **DMAHS Authority:** The Division of Medical Assistance & Health Services sets FFS policy via N.J.A.C. Title 10 and publishes the CMS-0057-F FFS metrics report. - **NJMMIS / Gainwell:** NJMMIS, currently administered by Gainwell Technologies (DURB Secretary email @gainwelltechnologies.com — doc 611), serves as fiscal agent for FFS claims and pharmacy adjudication. Fiscal-agent history (fiscal_agent_history finding): Molina Medicaid Solutions (acquired by DXC Oct 2018) → Gainwell; watch for dead *.acs-inc / *.conduent / *.xerox subdomains. The NJMMIS portal (njmmis.com) is bot-walled — redirects to browserNotSupported.aspx. - **Managed-Care Organizations (MCOs):** The five MCOs own their own PA criteria and operations on their own external sites. - **Pharmacy FFS:** NOT carved out at the state level; each MCO runs its own pharmacy via a contracted PBM (commonly PerformRx) under carve-in (carve_out_detail finding: "carve-in to MCOs, each MCO uses its own PBM"). FFS pharmacy edits historically ran through the Unisys MEP Center (doc 612). - **Behavioral Health Carve-Out Transition:** Transitioning carve-out → carve-in; Phase 1 BH integration into MCOs effective 1/1/2025. Youth under 21 access BH/IDD/SUD through PerformCare/CSOC (AmeriHealth Caritas affiliate, single point of access) regardless of MCO (bh_carve_out_detail, foster_care_program findings). - **LTSS:** Carved IN under MLTSS (since 2014-07-01), integrated into the MCO benefit package. - **Foster-Care Program:** DCP&P Medicaid-eligible children enroll in the general 5-MCO lineup (no dedicated foster-care MCO); their BH/IDD/SUD is accessed through PerformCare/CSOC (foster_care_program finding). - **MCO Procurement Model:** NJ does NOT run a fixed-term competitive RFP cycle; the MCO contract is a continuing document amended periodically — "modified any-willing-provider (statewide)" (temporal_anchor finding). No procurement date to anchor refresh timing. ## DIMENSION 5 — PATTERNS, NOTABLE THINGS, AND WHAT'S MISSING New Jersey's structure presents distinctive patterns and significant coverage gaps: - **No Canonical PA Hub — the defining trait.** Unlike states with a single harvestable criteria index, NJ scatters its PA reality across four loci, none of which is a downloadable criteria hub: regulation (FFS), per-MCO sites (managed care), DURB newsletters + NJMMIS (pharmacy), and a single annual metrics PDF (CMS-0057-F). - **FFS Criteria Are Regulation-Locked.** FFS medical PA criteria live in N.J.A.C. Title 10 on LexisNexis behind a terms-of-service click and pop-ups — regulation-as-criteria, NOT PDF-harvestable, and currently NOT captured. Capturing it requires statute-scraping, a different ingest shape than the document corpus uses. - **Managed-Care Criteria Are Off-State.** PA criteria for the five MCOs sit on five separate external sites (Aetna `aetnabetterhealth.com/newjersey`, Fidelis `fideliscarenj.com`, Horizon `horizonnjhealth.com`, UHC `uhccommunityplan.com/nj/...`, Wellpoint `myamerigroup.com/NJ`). With ~90% managed-care penetration, the MAJORITY of real-world NJ PA decisions are governed by criteria we do NOT hold — the single biggest content gap. - **NJMMIS Portal Is Bot-Walled.** Automated harvesting of FFS pharmacy forms/edits is blocked (browserNotSupported.aspx); would require a stealth/UA workaround. - **CY-2025 Metrics Are the Only State-Published PA Data — and Pre-Date Binding Rules.** Doc 610 is the lone state-published PA dataset, covers FFS medical only (excludes drugs and all managed-care), and pre-dates the 2026-01-01 timeframe mandate. The 99.27% approval / 1-day median is a baseline, not a compliance measurement. The CY-2026 report (filename pattern `CY-<year>-FFS-Prior-Authorization-Metrics-Report.pdf`) will be the first to carry 72h/7d compliance data; re-pull annually. - **Unresolved Items:** - **WISeR MAC Jurisdiction Ambiguity:** JH/Novitas per CMS fact sheet vs NJ's actual Novitas JL — needs CMS confirmation. - **MCO Procurement Model:** continuing-contract / any-willing-provider model with no fixed cycle, so no procurement date to track. - **Dead pin:** `state_meta.bulletin_archive` = `.../info/resources/medicaid/` returns 404; live replacement is the Medicaid Communications page (recorded in finding 655 `repin_candidates`, NOT silently patched — see [[feedback_url_repin_is_symptom_treating]]). - **What a Complete NJ PA Picture Would Require:** - Statute-scraping of N.J.A.C. Title 10 (10:49 et seq.) for the actual FFS medical criteria. - Per-MCO criteria harvests from all five MCO external sites (the bulk of real PA volume). - A stealth/UA workaround to reach NJMMIS FFS pharmacy forms/edits. - Continuous DURB newsletter monitoring (sparse/infrequent; only MME + pharmacy-edits ones are PA-load-bearing). - Annual re-pull of the CMS-0057-F FFS PA Metrics PDF, watching for the first post-2026 timeframe-compliant report. - Resolution of the WISeR MAC ambiguity with CMS. NJ is a fragmented, sparse, no-canonical-hub state. The corpus we hold (3 PA-relevant docs) captures the FFS-medical metrics surface, the pharmacy/DURB surface, and the structural map — but NOT the FFS medical criteria themselves (regulation-locked) nor the managed-care criteria (off-state per-MCO), which together govern the overwhelming majority of NJ PA decisions. Related: [[state_shape_NJ]], [[reference_wiser_model]], [[feedback_operational_vs_organizational_shape]], [[feedback_url_repin_is_symptom_treating]], [[feedback_stop_uniformizing_states]], [[project_document_corpus]].