How to Complete and Submit the NJ Medicaid Prior Authorization Form

To complete and submit an NJ Medicaid prior authorization form, first confirm whether your patient is enrolled in one of NJ FamilyCare’s managed care organizations or receives fee-for-service benefits, because that determines which form you use and where it goes. Managed care requests are sent to the member’s MCO through its provider portal, fax, or phone line using that plan’s own authorization form. Fee-for-service requests go to the county Medical Assistance Customer Center (MACC), sometimes on state-specific forms such as FD-07/FD-07A for mental health services.

Figure Out Where the Request Goes

Most NJ FamilyCare members are enrolled in one of five managed care organizations: Aetna, Fidelis Care, Horizon, UnitedHealthcare Community Plan, and Wellpoint.¹ If your patient belongs to one of these plans, you submit the request directly to that MCO. Each plan publishes its own authorization forms, clinical criteria, and contact numbers, so the paperwork is not interchangeable across plans.

Members with presumptive eligibility or who have not yet been assigned to an MCO fall under fee-for-service Medicaid. For those members, requests go to the MACC office serving the county where care will be delivered.² Certain service categories require state-issued forms. Mental health services under fee-for-service, for example, use Forms FD-07 and FD-07A, forwarded to the appropriate MACC.³

Under NJAC 10:49-6.1, obtaining prior authorization is the provider’s responsibility, and payment for services requiring PA depends on getting that approval before care is rendered, outside of a medical emergency.⁴ Whether a specific service needs PA depends on the provider services chapter of the code that governs that specialty and, for MCO members, on the plan’s own clinical criteria grid. Check the MCO’s authorization search tool before assuming a code is covered without approval. Common categories that need PA include durable medical equipment, long-term home health and personal care, inpatient psychiatric admissions and other behavioral health services, non-preferred prescription drugs, and various surgeries, advanced imaging studies, and specialized therapies.

Information the Form Requires

Every request, regardless of channel, needs the same core identifying data. Mistakes in these fields are the fastest way to have a request rejected before anyone reviews the clinical question.

Member’s NJ FamilyCare identification number. This is a 12-digit number that includes a two-digit person number and links to the beneficiary’s eligibility record. You can verify it through the NJMMIS eligibility lookup by entering the CCN from the HBID card.⁵
Provider identifiers: your National Provider Identifier and federal Tax Identification Number.
Diagnosis codes. NJ Medicaid requires valid, HIPAA-compliant ICD-10-CM codes on all claims and authorization requests for services dated October 1, 2015 or later.⁶
Procedure codes. CPT or HCPCS codes for the specific service, drug, or equipment requested.
Service details: quantity, duration, expected start date, and estimated cost.

Documentation That Supports Medical Necessity

The state’s approval standard is medical necessity: the service must be needed to diagnose or treat an illness or injury and must meet accepted standards of medicine. Attach the records that prove it. Physician notes, lab results, and diagnostic imaging reports should all point to the same clinical picture described on the form. When the two do not match, for example a request for a power wheelchair paired with notes that document only mild mobility limitations, reviewers will ask for more information or deny the request outright. Insufficient clinical documentation is the single most common reason PA requests fail.

How to Submit

Through the MCO

For MCO-enrolled members, the fastest route is the plan’s online provider portal. You enter the authorization data, attach documentation, and submit directly to the MCO, which then returns its decision through the portal, by fax, phone, or mail.² Every MCO also accepts faxed forms with attached clinical records; Fidelis Care, for instance, posts its authorization forms on its provider website with fax numbers printed on each form.⁷ Urgent or emergent requests should be called in rather than sent by portal or fax, to avoid delays.

Pharmacy Prior Authorization

Prescription drugs run on a separate track through each MCO’s pharmacy unit. Non-preferred medications generally require a faxed or phoned PA. UnitedHealthcare Community Plan, for example, accepts pharmacy PA requests by fax at 866-940-7328 or by phone at 800-310-6826.⁸ Electronic prior authorizations can also be submitted through platforms such as CoverMyMeds.⁷

If a patient needs a non-preferred drug immediately and the prescriber cannot be reached to complete a full PA, the pharmacy can dispense a one-time three-day temporary supply by submitting a claim using PA Type 8 with the prior authorization number 00000000120.⁸ The prescriber still has to file the full PA afterward.

Fee-for-Service

For members not enrolled in an MCO, submit to the MACC in the county where services will be provided. Gainwell Technologies is the state’s Medicaid fiscal agent and operates NJMMIS; its provider services line is 1-800-776-6334.⁹ Which form to use, and which fax number to send it to, depends on the service category; the relevant provider services chapter of the administrative code names the form.

How Long a Decision Takes

Under 42 CFR 438.210, effective for rating periods starting January 1, 2026, an MCO must issue a standard authorization decision within seven calendar days of receiving the request. The MCO may extend that deadline by up to 14 additional calendar days if the member or provider asks for more time, or if the MCO can justify to the state that more information is needed and the delay serves the member’s interest.¹⁰

When you indicate that following the standard timeline could seriously jeopardize the member’s life, health, or ability to function, the MCO must decide within 72 hours.¹⁰ Some plans have adopted shorter windows; Fidelis Care processes urgent requests within 24 hours or its current business-day turnaround time, whichever is shorter.¹¹ Both you and the member receive written notice of the decision, including the reasons for any denial and instructions to appeal.

Emergencies and Retroactive Approval

Emergency care does not require prior authorization. NJAC 10:49-6.1 defines a medical emergency as a critical illness or injury where prompt care may be crucial to saving life and limb or sparing the patient significant pain, and services delivered in that context are exempt from PA.⁴ The exemption depends on documentation: a practitioner’s statement describing the nature of the emergency and the relevant clinical facts. A bare assertion that “an emergency existed” will not carry the exemption.

Retroactive authorization is available in narrow circumstances. It can be granted when Medicare, third-party liability, or another insurance denied or partially paid for a service that would otherwise need PA and it would have been unreasonable to expect the provider to seek Medicaid authorization first; when the member is later determined eligible for the period the service was provided; and when communication with the Medicaid program was impossible because of weekends, holidays, or evenings and the service should not have been delayed. In that last case, submit the retroactive request with an explanation and supporting records to the MACC or Central Office within five calendar days of the service. For situations outside those categories, the state applies a reasonableness standard. Retroactive PA is treated as exceptional, evaluated case by case, and granted only if the service would have been authorized had the request come in first.⁴

If the Request Is Denied

Read the denial notice first. If it points to missing information rather than a coverage exclusion, resubmitting with stronger documentation is usually faster than a formal appeal.

Both providers and members have the right to appeal. Under NJAC 10:49-9.14, a provider may request a fair hearing after a PA denial, and a beneficiary may request one when a claim for medical assistance is denied or not acted on promptly. The request goes in writing to the Medicaid agent at the address listed on the denial notice, which also states the specific reasons for denial and the filing deadline. Members enrolled in NJ FamilyCare Plans B, C, or certain Plan D tiers follow a separate grievance review process under NJAC 10:78-8 rather than the standard fair hearing track.¹²

For MCO members, the first step is usually the plan’s internal appeal. If the MCO upholds the denial, the member can then escalate to a state fair hearing. The MCO’s denial letter explains both options along with the deadlines and contact information you need.

1
NJ FamilyCare. Choosing a Health Plan
2
NJ Department of Human Services. Managed Care Prior Authorization Guidance for Phase 1 Mental Health Services
3
Legal Information Institute. New Jersey Administrative Code 10:66-1.4 – Prior Authorization (PA)
4
Legal Information Institute. New Jersey Administrative Code 10:49-6.1 – Prior and Retroactive Authorization (General)
5
Legal Information Institute. New Jersey Administrative Code 10:49-2.12 – Medicaid or NJ FamilyCare Eligibility Identification Number and Health Benefits Identification (HBID) Card
6
New Jersey Medicaid Management Information System. ICD-10 Frequently Asked Questions
7
Fidelis Care. Authorizations – Fidelis Care
8
UnitedHealthcare Community Plan. New Jersey Family Care Preferred Drug List (PDL)
9
New Jersey Medicaid Management Information System. Welcome to New Jersey Medicaid NJMMIS
10
eCFR. 42 CFR 438.210 – Coverage and Authorization of Services
11
Fidelis Care. CMS Prior Authorization Change Summary: Effective 01/01/2026
12
Legal Information Institute. New Jersey Administrative Code 10:49-9.14 – Provisions for Appeals; Fair Hearings