New Jersey Medicaid uses this one-page, letter-style certification when a hospital claim needs the attending physician to confirm that a stay was medically necessary or emergent. The physician fills in the hospital, the treatment dates and the reason for treatment, then signs. The hospital attaches it to the paper claim it mails to Gainwell Technologies for NJ Medicaid.
The attending physician completes the certification, prints their name, signs and adds a 7-digit NJ Medicaid provider number and 10-digit NPI. The hospital's 7-digit Medicaid provider number and the beneficiary's 12-digit ID also go on the form.
Download the current version from the source each time; forms change without notice.
Emergency Certification Form (New Jersey Medicaid)
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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The attending physician signs it and prints their name, then enters their 7-digit NJ Medicaid provider number and 10-digit NPI. The physician is certifying that the hospital treatment plan was medically necessary and/or emergent for the beneficiary between the dates shown, for the reason written on the form.
It is not sent on its own. The hospital attaches the signed certification to the hospital claim and mails both to Gainwell Technologies, as printed at the bottom of the form. The current version, revised January 30, 2021, is posted on the NJMMIS forms page.