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If you are not enrolled with DDD, MLTSS or FIDE-SNP, you should call your local Medical Assistance Customer Center (MACC) for mental health services. To find the number of a local MACC, visit state.nj.us/humanservices/dmahs/info/resources/macc/.

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        • Modifier 62 – Two SurgeonsModifier 62 – Two Surgeons
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        • 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
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        • 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
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        • 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
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  • COVID-19 Information
      • For Providers: 1-800-682-9091
    • 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
    • Clinical and Preventive Guidelines
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      • For Providers: 1-800-682-9091
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    • Office Based Addiction Treatment (OBAT) Program
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  • Join our Networks
      • For Providers: 1-800-682-9091
    • Physicians and Other Health Care Professionals
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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
  • 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
  • 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 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)  

Pdf ImageDiagnosis and Treatment Exam (3 Years)  

Pdf ImageDiagnosis and Treatment Exam (4 Years)  

Pdf ImageDiagnosis and Treatment Exam (5 Years)  

Pdf ImageDiagnosis and Treatment Exam (6 Years)  

Pdf ImageDiagnosis and Treatment Exam (7 Years)  

Pdf ImageDiagnosis and Treatment Exam (8 Years)  

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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