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  • COVID-19 InformationCOVID-19 Information
    • COVID-19 Information
    • Coverage for Out-of-Network COVID-19 Testing EndingCoverage for Out-of-Network COVID-19 Testing Ending
    • Code Terminations as the PHE EndsCode Terminations as the PHE Ends
    • PHE Update: Prescription Limitation Change for Braven Health, HMO D-SNP and Medicare Part D membersPHE Update: Prescription Limitation Change for Braven Health, HMO D-SNP and Medicare Part D members
    • Pre-Certification/Prior Authorization requirements for Post-Acute Facility AdmissionsPre-Certification/Prior Authorization requirements for Post-Acute Facility Admissions
    • Submitting Pharmacy Claims for OTC, At-Home COVID-19 Test KitsSubmitting Pharmacy Claims for OTC, At-Home COVID-19 Test Kits
    • Submitting Pharmacy Claims for COVID-19 VaccinationsSubmitting Pharmacy Claims for COVID-19 Vaccinations
    • Antibody testing: FDA and CDC do not recommend use to determine immunityAntibody testing: FDA and CDC do not recommend use to determine immunity
    • Reminder: Use correct codes when evaluating for COVID-19Reminder: Use correct codes when evaluating for COVID-19
    • Policy Update: Antibody Testing ClaimsPolicy Update: Antibody Testing Claims
    • Submitting claims for COVID-19 vaccines delivered in non-traditional medical settingsSubmitting claims for COVID-19 vaccines delivered in non-traditional medical settings
    • For Essential Workers, COVID-19 Treatment Covered Under Workers' Compensation BenefitsFor Essential Workers, COVID-19 Treatment Covered Under Workers' Compensation Benefits
    • COVID-19 Vaccine COVID-19 Vaccine
    • COVID-19 vaccines will be covered at 100%COVID-19 vaccines will be covered at 100%
    • Coverage for antibody infusion therapyCoverage for antibody infusion therapy
    • Reminder: Horizon NJ Health members are not responsible for PPE chargesReminder: Horizon NJ Health members are not responsible for PPE charges
    • COVID-19 Frequently Asked QuestionsCOVID-19 Frequently Asked Questions
    • Reminder to use specific codes when evaluating for COVID-19Reminder to use specific codes when evaluating for COVID-19
    • Referrals no longer required for in-network specialistsReferrals no longer required for in-network specialists
    • Telemedicine and Telehealth Services Reimbursement PolicyTelemedicine and Telehealth Services Reimbursement Policy
  • ResourcesResources
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    • 21st Century Cures Act21st Century Cures Act
    • Claim OverpaymentsClaim Overpayments
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      • Clinical and Preventive Guidelines
      • Clinical GuidelinesClinical Guidelines
    • Credentialing and Recredentialing ResponsibilitiesCredentialing and Recredentialing Responsibilities
      • Credentialing and Recredentialing Responsibilities
      • Credentialing and Recredentialing Policy for Participating Physicians and Healthcare ProfessionalsCredentialing and Recredentialing Policy for Participating Physicians and Healthcare Professionals
      • Credentialing and Recredentialing Policy for Ancillary and Managed Long Term Support Service (MLTSS) ProvidersCredentialing and Recredentialing Policy for Ancillary and Managed Long Term Support Service (MLTSS) Providers
    • Demographic UpdatesDemographic Updates
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      • ClaimsXTen FAQsClaimsXTen FAQs
      • Federally Qualified Health Center (FQHC) Resource GuideFederally Qualified Health Center (FQHC) Resource Guide
      • How to Submit Claims with Drug-Related (J or Q) CodesHow to Submit Claims with Drug-Related (J or Q) Codes
      • ClaimsXTen Edit Codes and MessagesClaimsXTen Edit Codes and Messages
      • SimpleClaim Training ResourcesSimpleClaim Training Resources
      • How to Correctly Submit Claims with J or Q CodesHow to Correctly Submit Claims with J or Q Codes
      • Federally Qualified Health Center (FQHC) - Dental Billing GuideFederally Qualified Health Center (FQHC) - Dental Billing Guide
      • DAVIS VISION Federally Qualified Health Center (FQHC) – Vision Billing GuideDAVIS VISION Federally Qualified Health Center (FQHC) – Vision Billing Guide
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      • Focus on Quality
      • Advance DirectivesAdvance Directives
      • Leading the Way on LeadLeading the Way on Lead
      • Well-Being Screening ToolWell-Being Screening Tool
    • FormsForms
      • Forms
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      • COVID Vaccine FormCOVID Vaccine Form
      • Early and Periodic Screening, Diagnosis and Treatment Exam FormsEarly and Periodic Screening, Diagnosis and Treatment Exam Forms
      • Electronic Funds Transfer (EFT) FormsElectronic Funds Transfer (EFT) Forms
      • Forms to Join Our NetworksForms to Join Our Networks
      • Lead Risk Assessment FormLead Risk Assessment Form
      • OBAT Attestation for Nonparticipating ProvidersOBAT Attestation for Nonparticipating Providers
      • Other FormsOther Forms
    • GuidesGuides
    • HealthSphereHealthSphere
    • Helping Patients Understand Their CareHelping Patients Understand Their Care
    • Laboratory Corporation of America (LabCorp)Laboratory Corporation of America (LabCorp)
    • Medicaid Reimbursement and BillingMedicaid Reimbursement and Billing
      • Medicaid Reimbursement and Billing
      • Medicaid Provider Enrollment Requirements by StateMedicaid Provider Enrollment Requirements by State
    • MLTSS Provider ResourcesMLTSS Provider Resources
      • MLTSS Provider Resources
      • MLTSS Bed Type Revenue CodesMLTSS Bed Type Revenue Codes
      • Managed Long Term Services & Supports (MLTSS) OrientationManaged Long Term Services & Supports (MLTSS) Orientation
      • MLTSS Provider ManualMLTSS Provider Manual
        • MLTSS Provider Manual
        • Section 1 - IntroductionSection 1 - Introduction
        • Section 2 – EligibilitySection 2 – Eligibility
        • Section 3 - MLTSS OverviewSection 3 - MLTSS Overview
        • Section 4 - Care Management/AuthorizationsSection 4 - Care Management/Authorizations
        • Section 5 - Billing GuideSection 5 - Billing Guide
        • Section 6 - Grievance and Appeals ProcessSection 6 - Grievance and Appeals Process
        • Section 7 - Service DepartmentsSection 7 - Service Departments
        • Section 8 - Policies and ProceduresSection 8 - Policies and Procedures
        • Appendix A – Glossary of TermsAppendix A – Glossary of Terms
        • Appendix B – Contract ComplianceAppendix B – Contract Compliance
    • NJ FamilyCare Renewal InformationNJ FamilyCare Renewal Information
    • Pharmacy Utilization Management ProgramsPharmacy Utilization Management Programs
      • Pharmacy Utilization Management Programs
      • Pharmacy Medical Necessity DeterminationPharmacy Medical Necessity Determination
      • Maximum Allowable Cost (MAC) Appeal FormMaximum Allowable Cost (MAC) Appeal Form
    • PoliciesPolicies
      • Policies
      • Administrative PoliciesAdministrative Policies
        • Administrative Policies
        • Appointment Availability Access Standards for Primary Care-Type Providers, Ob/Gyns, Specialists and Behavioral Health ProvidersAppointment Availability Access Standards for Primary Care-Type Providers, Ob/Gyns, Specialists and Behavioral Health Providers
        • Digital Member ID Card PolicyDigital Member ID Card Policy
        • Provider Directory Management
        • Provider Telephone Access Standards Policy RequirementsProvider Telephone Access Standards Policy Requirements
      • Medical PoliciesMedical Policies
      • Reimbursement Policies & GuidelinesReimbursement Policies & Guidelines
        • Reimbursement Policies & Guidelines
        • Add-on Payment for COVID-19 Diagnostic Testing Run on High Throughput Technology (U0005)Add-on Payment for COVID-19 Diagnostic Testing Run on High Throughput Technology (U0005)
        • Advance Care PlanningAdvance Care Planning
        • Allergy ServicesAllergy Services
        • Ambulance ServicesAmbulance Services
        • Anesthesia Reimbursement GuidelinesAnesthesia Reimbursement Guidelines
        • Bariatric Surgery Billed With Hiatal Hernia Repair or GastropexyBariatric Surgery Billed With Hiatal Hernia Repair or Gastropexy
        • Billing Requirements for Clinical TrialsBilling Requirements for Clinical Trials
        • Brachytherapy Billing RequirementsBrachytherapy Billing Requirements
        • Breast Pump ReimbursementBreast Pump Reimbursement
        • Cardiac Event DetectionCardiac Event Detection
        • Care Management Services for Substance Use DisordersCare Management Services for Substance Use Disorders
        • Centering Pregnancy Prenatal CareCentering Pregnancy Prenatal Care
        • Chiropractic Manipulation Diagnosis PolicyChiropractic Manipulation Diagnosis Policy
        • Chronic Care ManagementChronic Care Management
        • Claim Editing PolicyClaim Editing Policy
        • Consultation Services PaymentConsultation Services Payment
        • COVID 19 Antibody TestingCOVID 19 Antibody Testing
        • Daily Maximum Units for Surgical Pathology and Microscopic ExaminationDaily Maximum Units for Surgical Pathology and Microscopic Examination
        • Diabetic Screening ServicesDiabetic Screening Services
        • Diabetic SuppliesDiabetic Supplies
        • DIR ServicesDIR Services
        • Distinct Procedural Service Modifiers (59, XE, XP, XS, XU)Distinct Procedural Service Modifiers (59, XE, XP, XS, XU)
        • Doula ServicesDoula Services
        • Early Elective Childbirth DeliveriesEarly Elective Childbirth Deliveries
        • Endoscopic Retrograde Cholangiopancreatography (ERCP)Endoscopic Retrograde Cholangiopancreatography (ERCP)
        • Evaluation and Management Services billed with Global Radiology, Stress Test, Stress Echo or Myocardial Profusion ImagingEvaluation and Management Services billed with Global Radiology, Stress Test, Stress Echo or Myocardial Profusion Imaging
        • False ClaimsFalse Claims
        • FIDE-SNP Hospital Sequestration ReimbursementFIDE-SNP Hospital Sequestration Reimbursement
        • Foot Orthotic Shoes and InsertsFoot Orthotic Shoes and Inserts
        • Free Flap Breast ReconstructionFree Flap Breast Reconstruction
        • Frequency of Ocular PhotographyFrequency of Ocular Photography
        • Home Health Certification and Re-CertificationHome Health Certification and Re-Certification
        • Hospice Room and Board ReimbursementHospice Room and Board Reimbursement
        • Laboratory Services Billed by PhysiciansLaboratory Services Billed by Physicians
        • Maternity ReimbursementMaternity Reimbursement
        • Maximum Units Policy on Hearing Aid BatteriesMaximum Units Policy on Hearing Aid Batteries
        • Medical Nutrition TherapyMedical Nutrition Therapy
        • Modifier JW – Drug WasteModifier JW – Drug Waste
        • Modifier 22 – Increased Procedural ServicesModifier 22 – Increased Procedural Services
        • Modifier 50 – Bilateral and LT/RTModifier 50 – Bilateral and LT/RT
        • Modifier 52 – Reduced ServicesModifier 52 – Reduced Services
        • Modifier 53 – Discontinued ProceduresModifier 53 – Discontinued Procedures
        • Modifier 57 – Decision for SurgeryModifier 57 – Decision for Surgery
        • Modifier 62 – Two SurgeonsModifier 62 – Two Surgeons
        • Modifier 66- Surgical TeamModifier 66- Surgical Team
        • Modifier 73 - Discontinued Outpatient Procedure Prior to the Administration of AnesthesiaModifier 73 - Discontinued Outpatient Procedure Prior to the Administration of Anesthesia
        • Modifier 76- Repeat Procedure or Service by Same PhysicianModifier 76- Repeat Procedure or Service by Same Physician
        • Modifier 77- Repeat Procedure or Service by Another PhysicianModifier 77- Repeat Procedure or Service by Another Physician
        • Modifier 78 – Unplanned Return to the ORModifier 78 – Unplanned Return to the OR
        • Modifiers 80, 81, 82 and AS – Assistant SurgeonModifiers 80, 81, 82 and AS – Assistant Surgeon
        • Multiple Diagnostic Cardiovascular ProceduresMultiple Diagnostic Cardiovascular Procedures
        • Multiple Diagnostic Ophthalmology ProceduresMultiple Diagnostic Ophthalmology Procedures
        • Multiple Procedure ReductionMultiple Procedure Reduction
        • Mutually and Non-Mutually Exclusive NCCI EditsMutually and Non-Mutually Exclusive NCCI Edits
        • Ophthalmology ServicesOphthalmology Services
        • Outpatient Facility Code Edits: Revenue CodesOutpatient Facility Code Edits: Revenue Codes
        • Outpatient Services Prior to Admission or Same Day SurgeryOutpatient Services Prior to Admission or Same Day Surgery
        • Post Payment Documentation Requests for Facility ClaimsPost Payment Documentation Requests for Facility Claims
        • Pre-Payment Coding Reviews Documentation RequestsPre-Payment Coding Reviews Documentation Requests
        • Pre-Payment Documentation Requests for Facility ClaimsPre-Payment Documentation Requests for Facility Claims
        • Preventative Medicine Services with Auditory ScreeningPreventative Medicine Services with Auditory Screening
        • Preventive Medicine ServicesPreventive Medicine Services
        • PT/OT/ST ServicesPT/OT/ST Services
        • Pulmonary Diagnostic Procedures when billed with Evaluation and Management CodesPulmonary Diagnostic Procedures when billed with Evaluation and Management Codes
        • Reimbursement of S0302Reimbursement of S0302
        • Self-Help/Peer Support Billing GuidelinesSelf-Help/Peer Support Billing Guidelines
        • Smoking CessationSmoking Cessation
        • Specimen Collection Travel AllowanceSpecimen Collection Travel Allowance
        • Split Surgical Services (Modifiers -54, -55 and -56)Split Surgical Services (Modifiers -54, -55 and -56)
        • Telemedicine and TelehealthTelemedicine and Telehealth
          • Telemedicine and Telehealth
          • Telemedicine Reimbursement Policy: Temporary UpdateTelemedicine Reimbursement Policy: Temporary Update
        • Transitional Care PlanningTransitional Care Planning
        • Ulcer Debridement and Ulcer StagesUlcer Debridement and Ulcer Stages
        • Unlisted CodesUnlisted Codes
        • Urgent Care Center Billing RequirementsUrgent Care Center Billing Requirements
        • Urine Drug TestingUrine Drug Testing
      • Health Services Policies – Clinical Affairs, Dental, Pharmacy, Quality, Utilization ManagementHealth Services Policies – Clinical Affairs, Dental, Pharmacy, Quality, Utilization Management
    • Provider Administrative ManualProvider Administrative Manual
    • State of New Jersey Contractual RequirementsState of New Jersey Contractual Requirements
    • Surgical and Implantable Device Management ProgramSurgical and Implantable Device Management Program
      • Surgical and Implantable Device Management Program
      • Cardiac ServicesCardiac Services
      • Orthopedic ServicesOrthopedic Services
      • Spine ServicesSpine Services
    • Timely Filing RequirementsTimely Filing Requirements
      • Timely Filing Requirements
      • Billing GuideBilling Guide
      • Electronic Data Interchange (EDI)/Electronic Funds Transfer (EFT)Electronic Data Interchange (EDI)/Electronic Funds Transfer (EFT)
      • Emdeon Electronic Funds Transfer (EFT) FormsEmdeon Electronic Funds Transfer (EFT) Forms
      • Claims AddressesClaims Addresses
      • ClaimsXTen FAQsClaimsXTen FAQs
      • Tips for Claims/Encounters FilingTips for Claims/Encounters Filing
      • NIA Claims MatrixNIA Claims Matrix
      • False Claims PolicyFalse Claims Policy
    • Utilization ManagementUtilization Management
      • Utilization Management
      • Utilization Management Appeal Process for Administrative DenialsUtilization Management Appeal Process for Administrative Denials
    • Digital Member ID CardsDigital Member ID Cards
  • ProgramsPrograms
    • Programs
    • Care ManagementCare Management
    • DentalDental
      • Dental
      • Caries Risk AssessmentCaries Risk Assessment
      • Clinical Criteria GridClinical Criteria Grid
        • Clinical Criteria Grid
        • NJ FamilyCare Dental Services Clinical Criteria Policy (effective January 1, 2023)NJ FamilyCare Dental Services Clinical Criteria Policy (effective January 1, 2023)
      • Noncompliant membersNoncompliant members
      • Prior AuthorizationPrior Authorization
      • Role of the Managed Care Organization (MCO)Role of the Managed Care Organization (MCO)
      • SKYGEN USASKYGEN USA
    • Disease Management Programs to Help Your PatientsDisease Management Programs to Help Your Patients
    • eviCore healthcareeviCore healthcare
      • eviCore healthcare
      • Contrast Agents and Radiopharmaceuticals 2023Contrast Agents and Radiopharmaceuticals 2023
      • MPPR Logic 2023MPPR Logic 2023
      • Radiology Imaging Program Questions and AnswersRadiology Imaging Program Questions and Answers
    • Fluoride Varnish ProgramFluoride Varnish Program
    • Focus on Risk AdjustmentFocus on Risk Adjustment
    • Horizon Behavioral HealthHorizon Behavioral Health
      • Horizon Behavioral Health
      • About the Horizon Behavioral Health ProgramAbout the Horizon Behavioral Health Program
      • Behavioral Health Benefits GridBehavioral Health Benefits Grid
      • Behavioral Health Training WebinarsBehavioral Health Training Webinars
      • Credentialing & RecredentialingCredentialing & Recredentialing
      • Demographic UpdatesDemographic Updates
      • Medical Necessity CriteriaMedical Necessity Criteria
      • Prior AuthorizationPrior Authorization
      • External ResourcesExternal Resources
      • Behavioral Health Patient ResourcesBehavioral Health Patient Resources
    • Horizon NJ TotalCare (HMO D-SNP)Horizon NJ TotalCare (HMO D-SNP)
      • Horizon NJ TotalCare (HMO D-SNP)
      • Educational WebinarsEducational Webinars
      • Cognitive ImpairmentCognitive Impairment
      • Balance BillingBalance Billing
      • FIDE-SNP Quick Reference GuideFIDE-SNP Quick Reference Guide
      • Member BenefitsMember Benefits
      • Medicaid EligibilityMedicaid Eligibility
      • Model of CareModel of Care
      • Critical IncidentsCritical Incidents
      • HEDISHEDIS
      • Results & Recognition ProgramResults & Recognition Program
    • Managed Long Term Services and SupportsManaged Long Term Services and Supports
      • Managed Long Term Services and Supports
      • WelcomeWelcome
      • MLTSS Service DictionaryMLTSS Service Dictionary
      • MLTSS Critical Incident ReportingMLTSS Critical Incident Reporting
    • Mom's GEMS Prenatal ProgramMom's GEMS Prenatal Program
    • New Jersey Integrated Care for Kids (NJ InCK)New Jersey Integrated Care for Kids (NJ InCK)
    • Office Based Addiction Treatment (OBAT) ProgramOffice Based Addiction Treatment (OBAT) Program
      • Office Based Addiction Treatment (OBAT) Program
      • Helpful Hints for Office Based Addiction Treatment (OBAT) Claims SubmissionsHelpful Hints for Office Based Addiction Treatment (OBAT) Claims Submissions
      • Office Based Addictions Treatment - Frequently Asked QuestionsOffice Based Addictions Treatment - Frequently Asked Questions
    • Quality Improvement ProgramQuality Improvement Program
      • Quality Improvement Program
      • Quality Resource CenterQuality Resource Center
      • Results & Recognition ProgramResults & Recognition Program
      • Smoking CessationSmoking Cessation
      • HEDIS®HEDIS®
      • CAHPS (Consumer Assessment of Healthcare Providers and Systems)CAHPS (Consumer Assessment of Healthcare Providers and Systems)
      • Hospital Acquired Conditions and Serious Adverse EventsHospital Acquired Conditions and Serious Adverse Events
  • Join our NetworksJoin our Networks
    • Join our Networks
    • Physicians and Other Health Care ProfessionalsPhysicians and Other Health Care Professionals
    • Doula Services PractitionersDoula Services Practitioners
    • Ancillary ProvidersAncillary Providers
    • Ancillary Application RequestAncillary Application Request
  • NewsNews
    • News
    • Updates and AnnouncementsUpdates and Announcements
    • Horizon Pulse Provider NewsletterHorizon Pulse Provider Newsletter
      • Horizon Pulse Provider Newsletter
      • ArchivesArchives
        • Archives
        • Horizon Pulse - 2023Horizon Pulse - 2023
          • Horizon Pulse - 2023
          • Horizon Pulse March 2023Horizon Pulse March 2023
        • Horizon Pulse - 2022Horizon Pulse - 2022
          • Horizon Pulse - 2022
          • Horizon Pulse June 2022Horizon Pulse June 2022
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          • Horizon Pulse November 2022Horizon Pulse November 2022
        • Horizon Pulse - 2021Horizon Pulse - 2021
          • Horizon Pulse - 2021
          • Horizon Pulse December 2021Horizon Pulse December 2021
          • Horizon Pulse June 2021Horizon Pulse June 2021
          • Horizon Pulse 2021, Issue 1Horizon Pulse 2021, Issue 1
        • Horizon Pulse - OlderHorizon Pulse - Older
      • Provider Newsletter, Issue 1, 2023Provider Newsletter, Issue 1, 2023
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  • COVID-19 Information
      • For Providers: 1-800-682-9091
    • Coverage for Out-of-Network COVID-19 Testing Ending
    • Code Terminations as the PHE Ends
    • PHE Update: Prescription Limitation Change for Braven Health, HMO D-SNP and Medicare Part D members
    • Pre-Certification/Prior Authorization requirements for Post-Acute Facility Admissions
    • Submitting Pharmacy Claims for OTC, At-Home COVID-19 Test Kits
    • Submitting Pharmacy Claims for COVID-19 Vaccinations
    • Antibody testing: FDA and CDC do not recommend use to determine immunity
    • Reminder: Use correct codes when evaluating for COVID-19
    • Policy Update: Antibody Testing Claims
    • Submitting claims for COVID-19 vaccines delivered in non-traditional medical settings
    • For Essential Workers, COVID-19 Treatment Covered Under Workers' Compensation Benefits
    • COVID-19 Vaccine
    • COVID-19 vaccines will be covered at 100%
    • Coverage for antibody infusion therapy
    • Reminder: Horizon NJ Health members are not responsible for PPE charges
    • COVID-19 Frequently Asked Questions
    • Reminder to use specific codes when evaluating for COVID-19
    • Referrals no longer required for in-network specialists
    • Telemedicine and Telehealth Services Reimbursement Policy
  • Resources
      • For Providers: 1-800-682-9091
    • 21st Century Cures Act
    • Claim Overpayments
    • Clinical and Preventive Guidelines
    • Credentialing and Recredentialing Responsibilities
    • Demographic Updates
    • Educational Materials
    • Focus on Quality
    • Forms
    • Guides
    • HealthSphere
    • Helping Patients Understand Their Care
    • Laboratory Corporation of America (LabCorp)
    • Medicaid Reimbursement and Billing
    • MLTSS Provider Resources
    • NJ FamilyCare Renewal Information
    • Pharmacy Utilization Management Programs
    • Policies
    • Provider Administrative Manual
    • State of New Jersey Contractual Requirements
    • Surgical and Implantable Device Management Program
    • Timely Filing Requirements
    • Utilization Management
    • Digital Member ID Cards
  • Programs
      • For Providers: 1-800-682-9091
    • Care Management
    • Dental
    • Disease Management Programs to Help Your Patients
    • eviCore healthcare
    • Fluoride Varnish Program
    • Focus on Risk Adjustment
    • Horizon Behavioral Health
    • Horizon NJ TotalCare (HMO D-SNP)
    • Managed Long Term Services and Supports
    • Mom's GEMS Prenatal Program
    • New Jersey Integrated Care for Kids (NJ InCK)
    • Office Based Addiction Treatment (OBAT) Program
    • Quality Improvement Program
  • Join our Networks
      • For Providers: 1-800-682-9091
    • Physicians and Other Health Care Professionals
    • Doula Services Practitioners
    • Ancillary Providers
    • Ancillary Application Request
  • News
      • For Providers: 1-800-682-9091
    • Updates and Announcements
    • Horizon Pulse Provider Newsletter

Early and Periodic Screening, Diagnosis and Treatment Exam Forms - Horizon NJ Health

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COVID-19
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  • 21st Century Cures Act
  • Claim Overpayments
  • Clinical and Preventive Guidelines
    • Clinical Guidelines
  • Credentialing and Recredentialing Responsibilities
    • Credentialing and Recredentialing Policy for Participating Physicians and Healthcare Professionals
    • Credentialing and Recredentialing Policy for Ancillary and Managed Long Term Support Service (MLTSS) Providers
  • Demographic Updates
  • Educational Materials
    • Educational Webinars
    • ClaimsXTen FAQs
    • Federally Qualified Health Center (FQHC) Resource Guide
    • How to Submit Claims with Drug-Related (J or Q) Codes
    • ClaimsXTen Edit Codes and Messages
    • SimpleClaim Training Resources
    • How to Correctly Submit Claims with J or Q Codes
    • Federally Qualified Health Center (FQHC) - Dental Billing Guide
    • DAVIS VISION Federally Qualified Health Center (FQHC) – Vision Billing Guide
  • Focus on Quality
    • Advance Directives
    • Leading the Way on Lead
    • Well-Being Screening Tool
  • Forms
    • Behavioral Health Forms
    • Clinical Authorization Forms
    • COVID Vaccine Form
    • Early and Periodic Screening, Diagnosis and Treatment Exam Forms
    • Electronic Funds Transfer (EFT) Forms
    • Forms to Join Our Networks
    • Lead Risk Assessment Form
    • OBAT Attestation for Nonparticipating Providers
    • Other Forms
  • Guides
  • HealthSphere
  • Helping Patients Understand Their Care
  • Laboratory Corporation of America (LabCorp)
  • Medicaid Reimbursement and Billing
    • Medicaid Provider Enrollment Requirements by State
  • MLTSS Provider Resources
    • MLTSS Bed Type Revenue Codes
    • Managed Long Term Services & Supports (MLTSS) Orientation
    • MLTSS Provider Manual
      • Section 1 - Introduction
      • Section 2 – Eligibility
      • Section 3 - MLTSS Overview
      • Section 4 - Care Management/Authorizations
      • Section 5 - Billing Guide
      • Section 6 - Grievance and Appeals Process
      • Section 7 - Service Departments
      • Section 8 - Policies and Procedures
      • Appendix A – Glossary of Terms
      • Appendix B – Contract Compliance
  • NJ FamilyCare Renewal Information
  • Pharmacy Utilization Management Programs
    • Pharmacy Medical Necessity Determination
    • Maximum Allowable Cost (MAC) Appeal Form
  • Policies
    • Administrative Policies
      • Appointment Availability Access Standards for Primary Care-Type Providers, Ob/Gyns, Specialists and Behavioral Health Providers
      • Digital Member ID Card Policy
      • Provider Directory Management
      • Provider Telephone Access Standards Policy Requirements
    • Medical Policies
    • Reimbursement Policies & Guidelines
      • Add-on Payment for COVID-19 Diagnostic Testing Run on High Throughput Technology (U0005)
      • Advance Care Planning
      • Allergy Services
      • Ambulance Services
      • Anesthesia Reimbursement Guidelines
      • Bariatric Surgery Billed With Hiatal Hernia Repair or Gastropexy
      • Billing Requirements for Clinical Trials
      • Brachytherapy Billing Requirements
      • Breast Pump Reimbursement
      • Cardiac Event Detection
      • Care Management Services for Substance Use Disorders
      • Centering Pregnancy Prenatal Care
      • Chiropractic Manipulation Diagnosis Policy
      • Chronic Care Management
      • Claim Editing Policy
      • Consultation Services Payment
      • COVID 19 Antibody Testing
      • Daily Maximum Units for Surgical Pathology and Microscopic Examination
      • Diabetic Screening Services
      • Diabetic Supplies
      • DIR Services
      • Distinct Procedural Service Modifiers (59, XE, XP, XS, XU)
      • Doula Services
      • Early Elective Childbirth Deliveries
      • Endoscopic Retrograde Cholangiopancreatography (ERCP)
      • Evaluation and Management Services billed with Global Radiology, Stress Test, Stress Echo or Myocardial Profusion Imaging
      • False Claims
      • FIDE-SNP Hospital Sequestration Reimbursement
      • Foot Orthotic Shoes and Inserts
      • Free Flap Breast Reconstruction
      • Frequency of Ocular Photography
      • Home Health Certification and Re-Certification
      • Hospice Room and Board Reimbursement
      • Laboratory Services Billed by Physicians
      • Maternity Reimbursement
      • Maximum Units Policy on Hearing Aid Batteries
      • Medical Nutrition Therapy
      • Modifier JW – Drug Waste
      • Modifier 22 – Increased Procedural Services
      • Modifier 50 – Bilateral and LT/RT
      • Modifier 52 – Reduced Services
      • Modifier 53 – Discontinued Procedures
      • Modifier 57 – Decision for Surgery
      • Modifier 62 – Two Surgeons
      • Modifier 66- Surgical Team
      • Modifier 73 - Discontinued Outpatient Procedure Prior to the Administration of Anesthesia
      • Modifier 76- Repeat Procedure or Service by Same Physician
      • Modifier 77- Repeat Procedure or Service by Another Physician
      • Modifier 78 – Unplanned Return to the OR
      • Modifiers 80, 81, 82 and AS – Assistant Surgeon
      • Multiple Diagnostic Cardiovascular Procedures
      • Multiple Diagnostic Ophthalmology Procedures
      • Multiple Procedure Reduction
      • Mutually and Non-Mutually Exclusive NCCI Edits
      • Ophthalmology Services
      • Outpatient Facility Code Edits: Revenue Codes
      • Outpatient Services Prior to Admission or Same Day Surgery
      • Post Payment Documentation Requests for Facility Claims
      • Pre-Payment Coding Reviews Documentation Requests
      • Pre-Payment Documentation Requests for Facility Claims
      • Preventative Medicine Services with Auditory Screening
      • Preventive Medicine Services
      • PT/OT/ST Services
      • Pulmonary Diagnostic Procedures when billed with Evaluation and Management Codes
      • Reimbursement of S0302
      • Self-Help/Peer Support Billing Guidelines
      • Smoking Cessation
      • Specimen Collection Travel Allowance
      • Split Surgical Services (Modifiers -54, -55 and -56)
      • Telemedicine and Telehealth
        • Telemedicine Reimbursement Policy: Temporary Update
      • Transitional Care Planning
      • Ulcer Debridement and Ulcer Stages
      • Unlisted Codes
      • Urgent Care Center Billing Requirements
      • Urine Drug Testing
    • Health Services Policies – Clinical Affairs, Dental, Pharmacy, Quality, Utilization Management
  • Provider Administrative Manual
  • State of New Jersey Contractual Requirements
  • Surgical and Implantable Device Management Program
    • Cardiac Services
    • Orthopedic Services
    • Spine Services
  • Timely Filing Requirements
    • Billing Guide
    • Electronic Data Interchange (EDI)/Electronic Funds Transfer (EFT)
    • Emdeon Electronic Funds Transfer (EFT) Forms
    • Claims Addresses
    • ClaimsXTen FAQs
    • Tips for Claims/Encounters Filing
    • NIA Claims Matrix
    • False Claims Policy
  • Utilization Management
    • Utilization Management Appeal Process for Administrative Denials
  • Digital Member ID Cards
COVID-19
Stay informed.
Get the latest information on COVID-19.

Early and Periodic Screening, Diagnosis and Treatment Exam Forms

Pdf ImageDiagnosis and Treatment Exam (2-6 Weeks)  

Pdf ImageDiagnosis and Treatment Exam (2 Months)  

Pdf ImageDiagnosis and Treatment Exam (4 Months)  

Pdf ImageDiagnosis and Treatment Exam (6 Months)  

Pdf ImageDiagnosis and Treatment Exam (9 Months)  

Pdf ImageDiagnosis and Treatment Exam (12 Months)  

Pdf ImageDiagnosis and Treatment Exam (15 Months)  

Pdf ImageDiagnosis and Treatment Exam (18 Months)  

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Pdf ImageDiagnosis and Treatment Exam (9 Years)  

Pdf ImageDiagnosis and Treatment Exam (10 Years)  

Pdf ImageDiagnosis and Treatment Exam (11 Years)  

Pdf ImageDiagnosis and Treatment Exam (12 Years)  

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Pdf ImageDiagnosis and Treatment Exam (14 Years)  

Pdf ImageDiagnosis and Treatment Exam (15 Years)  

Pdf ImageDiagnosis and Treatment Exam (16 Years)  

Pdf ImageDiagnosis and Treatment Exam (17 Years)  

Pdf ImageDiagnosis and Treatment Exam (18 Years)  

Pdf ImageDiagnosis and Treatment Exam (19 Years)  

Pdf ImageDiagnosis and Treatment Exam (20 Years)  

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