Exhibit 1D - MAP SPB Enhancements Authorization Parameters.pdf

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Attached to
T2590 - Fiscal Agent for the Division of Mental Health and Addiction Services (DMHAS)
Solicitation number
25DPP01060
Issued by
Mercer County, New Jersey

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This document outlines the Mutual Agreement Program - State Parole Board (MAP SPB) Enhancements Authorization Parameters from the Connecticut Department of Mental Health and Addiction Services (DMHAS). The document provides details on the clinical review services, co-occurring clinical services, medication monitoring, psychiatric evaluation, recovery support, and vivitrol or buprenorphine services, including service rates, unit types, CPT codes, and annual client limits. It also includes information on encounter entry requirements before expiration of authorization for various service categories. The document covers the authorization parameters for the fiscal year 2025, effective from July 1, 2024, and revised on April 8, 2024.

The pricing terms are provided for each service category, including the service rate, unit type, and annual client limits. The document also includes information on laboratory services, such as comprehensive metabolic panel, transferase panels, bilirubin panel, and urine drug screening, along with their respective service rates and annual client limits. The document does not mention any set-asides, incumbents, or funding requirements and sources.

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Exhibit 1D - Mutual Agreement Program - State Parole Board (MAP SPB) Enhancements Authorization Parameters

Clinical Review

Service Rate Unit Type CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year Annual client limit

Urine Drug Screen - Presumptive Testing $ 8.46 service Clinical H0003HF 1 4 n/a H0003HF 1 4 n/a H0003HF 1 4 n/a H0003HF 1 5 n/a n/a Oral Swab $ 8.46 service Clinical ZSWB 1 4 n/a ZSWB 1 4 n/a ZSWB 1 4 n/a ZSWB 1 5 n/a n/a

Mantoux Tuberculin Test $ 10.57 service Clinical 86580 0 0 0 86580 0 0 0 86580 0 0 0 86580 1 1 n/a 0 Continuing Care LOCI $ 26.43 20 minutes Clinical ZLOCI 2 2 n/a ZLOCI 2 2 n/a ZLOCI 2 2 n/a ZLOCI 1 2 n/a n/a

Limit Clinical Review Enhancements $86.70 $86.70 $86.70 $105.73 Co-occurring Clinical Services

Service Rate Unit Type CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year Annual client limit

Case Management - COOC $ 13.32 15 minutes Co-occurring T2022 HF 8 16 n/a T2022 HF 8 16 n/a T2022 HF 0 0 0 T2022 HF 0 0 n/a 0 Comprehensive Intake Evaluation $ 171.99 service Co-occurring 90791 1 1 n/a 90791 1 1 n/a 90791 1 1 n/a 90791 1 1 n/a n/a

Crisis Intervention - Individual $ 15.12 15 minutes Co-occurring S9484 HF 0 0 0 S9484 HF 4 8 n/a S9484 HF 0 0 0 S9484 HF 0 0 n/a 0 Family Therapy $ 113.84 60 minutes Co-occurring 90847 HF 0 0 0 90847 HF 1 5 n/a 90847 HF 0 0 0 90847 HF 0 0 n/a 0

Individual Therapy $ 71.39 30 minutes Co-occurring 90832 HF 0 0 0 90832 HF 1 5 n/a 90832 HF 0 0 0 90832 HF 0 0 n/a 0 Individual Therapy $ 94.46 45 - 50 minutes Co-occurring 90834 HF 0 0 0 90834 HF 1 5 n/a 90834 HF 0 0 0 90834 HF 0 0 n/a 0

Group Therapy $ 27.48 90 min Co-occurring 90853 HF 0 0 0 90853 HF 1 5 n/a 90853 HF 0 0 0 90853 HF 0 0 n/a 0 Clinical Consultation $ 27.75 15 minutes Co-occurring 90887 0 0 0 90887 4 6 n/a 90887 0 0 0 90887 0 0 n/a 0

Limit Co-occurring Clinical Services Enhancement $385.11 $908.35 $171.99 $171.99

Encounter entry required before expiration of authorization (days) -

Mutual Agreement Program - State Parole Board (MAP SPB) Fee for Service Enhancement Authorization Parameters

Encounter entry required before expiration of authorization (days) -

IWM, STR & LTRT2 Limits HWH Limits PC, IOP & OP Limits AWM (Detox) Limits

IWM, STR & LTRT2 Limits HWH Limits PC, IOP & OP Limits AWM (Detox) Limits

DMHAS MAPSPB Page 1 of 4

SFY 2025

Effective 07/01/24 Revised 04/08/24

Exhibit 1D - Mutual Agreement Program - State Parole Board (MAP SPB) Enhancements Authorization Parameters

Service Rate Unit Type CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year Annual client limit

Medication Monitoring $ 47.54 15 minutes CO Med 90862 HF 0 0 0 90862 HF 2 6 n/a 90862 HF 2 6 n/a 90862 HF 0 0 n/a n/a Limit Co-occurring Medication Monitoring

Service Enhancement $0.00 $285.24 $285.24 $0.00 Psychiatric Evaluation

Service Rate Unit Type CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year Annual client limit

Psychiatric Evaluation $ 437.76 service Psych Eval 90792 1 1 4 90792 1 1 4 90792 1 1 4 90792 1 1 4 4 Limit Co-occurring Pyschiatric Evaluation

Service Enhancement $437.76 $1,751.04 $437.76 $1,751.04 $437.76 $1,751.04 $437.76 $1,751.04 $1,751.04 Recovery Support

Service Rate Unit Type CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year Annual client limit

Recovery Support Care Management $ 26.40 15 minutes Recovery Sup H0023 HF 4 16 n/a H0023 HF 4 16 n/a H0023 HF 4 16 n/a H0023 HF 4 16 n/a 0

Limit Recovery Support Enhancements $422.40 $422.40 $422.40 $422.40

Encounter entry required before expiration of authorization (days) -

Co-occurring Med Monitoring Services Enhancement

Encounter entry required before expiration of authorization (days) -

Encounter entry required before expiration of authorization (days) -

IWM, STR & LTRT2 Limits

IWM, STR & LTRT2 Limits HWH Limits PC, IOP & OP Limits AWM (Detox) Limits

HWH Limits PC, IOP & OP Limits AWM (Detox) Limits

IWM, STR & LTRT2 Limits HWH Limits PC, IOP & OP Limits AWM (Detox) Limits

DMHAS MAPSPB Page 2 of 4

SFY 2025

Exhibit 1D - Mutual Agreement Program - State Parole Board (MAP SPB) Enhancements Authorization Parameters

Service Rate Unit Type CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year Annual client limit

Case Management - Vivitrol $ 13.32 15 minutes V or B T2022 HF 4 4 n/a T2022 HF 4 4 n/a T2022 HF 4 4 n/a T2022 HF 0 0 n/a n/a Urine Preg Test Visual Color Comp $ 2.85 1 test V or B 81025 1 1 6 81025 1 1 6 81025 1 1 6 81025 1 1 n/a n/a E & M visit - new patient (20 min) $ 82.94 20 minutes V or B 99202 0 0 0 99202 1 n/a n/a 99202 1 n/a n/a 99202 0 0 0 n/a

Limit V or B: Vivitrol - Pre-Induction Enhancements $56.13 $139.07 $139.07 $2.85

Service Rate Unit Type CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year Annual client limit

Medication Monitoring - MAT $ 47.54 15 minutes V or B Z3353 2 4 n/a Z3353 2 4 n/a Z3353 2 2 n/a Z3353 0 0 0 n/a Buprenorphine/Naloxone Maint. (2mg/0.5mg) $ 7.66 unit V or B ZM05 3 93 n/a ZM05 3 93 n/a ZM05 3 93 n/a ZM05 0 0 0 n/a Buprenorphine/Naloxone Maint. (8mg/2mg) $ 10.40 unit V or B ZM2G 4 124 n/a ZM2G 4 124 n/a ZM2G 4 124 n/a ZM2G 0 0 0 n/a

Buprenorphine Maintenance (8mg) $ 12.03 unit V or B ZM8G 4 124 n/a ZM8G 4 124 n/a ZM8G 4 124 n/a ZM8G 0 0 0 n/a Case Management - Vivitrol $ 13.32 15 minutes V or B T2022 HF 2 2 n/a T2022 HF 2 2 n/a T2022 HF 2 2 n/a T2022 HF 0 0 0 n/a

Urine Preg Test Visual Color Comp $ 2.85 1 test V or B 81025 1 1 6 81025 1 1 6 81025 1 1 6 81025 0 0 0 n/a E & M visit - established patient (10 min) $ 49.91 10 minutes V or B 99212 0 0 0 99212 1 n/a n/a 99212 1 n/a n/a 99212 0 0 0 n/a

Vivitrol Medication and Injection $ 1,232.34 injection V or B ZVIV 1 1 6 ZVIV 1 1 6 ZVIV 1 1 6 ZVIV 0 0 0 n/a Limit V or B: Vivitrol - On-going Induction

Enhancements $1,711.37 $1,761.28 $1,761.28 $0.00

Vivitrol or Buprenorphine: Vivitrol - On-going Induction Encounter entry required before expiration of authorization (days) -

Encounter entry required before expiration of authorization (days) - Vivitrol or Buprenorphine

IWM, STR & LTRT2 Limits HWH Limits PC, IOP & OP Limits AWM (Detox) Limits

HWH Limits PC, IOP & OP Limits AWM (Detox) LimitsIWM, STR & LTRT2 Limits

DMHAS MAPSPB Page 3 of 4

SFY 2025

Exhibit 1D - Mutual Agreement Program - State Parole Board (MAP SPB) Enhancements Authorization Parameters

Service Rate Unit Type CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year Annual client limit

Comprehensive Metabolic Panel $9.99 service V or B - Lab 80053 1 1 n/a 80053 1 1 n/a 80053 1 1 n/a 80053 0 0 n/a n/a Transferase, Alanine Amino Panel (ALT) $2.85 service V or B - Lab 84460 1 1 n/a 84460 1 1 n/a 84460 1 1 n/a 84460 0 0 n/a n/a

Transferase, Aspartate Amino Panel (AST) $2.85 service V or B - Lab 84450 1 1 n/a 84450 1 1 n/a 84450 1 1 n/a 84450 0 0 n/a n/a Bilirubin Panel $2.85 service V or B - Lab 82247 1 1 n/a 82247 1 1 n/a 82247 1 1 n/a 82247 0 0 n/a n/a

Mantoux Tuberculin Test $10.57 service V or B - Lab 86580 1 1 n/a 86580 1 1 n/a 86580 1 1 n/a 86580 0 0 n/a n/a Hepatic Function Panel $6.66 service V or B - Lab 80076 1 1 n/a 80076 1 1 n/a 80076 1 1 n/a 80076 0 0 n/a n/a Complete Blood Count $4.76 service V or B - Lab 85025 1 1 n/a 85025 1 1 n/a 85025 1 1 n/a 85025 0 0 n/a n/a

Quantitative Syphilis Test $2.85 service V or B - Lab 86593 1 1 n/a 86593 1 1 n/a 86593 1 1 n/a 86593 0 0 n/a n/a Urine Drug Screen - Presumptive Testing $8.46 service V or B - Lab H0003 HF 1 1 n/a H0003 HF 1 1 n/a H0003 HF 1 1 n/a H0003 HF 0 0 n/a n/a

Urine Preg Test Visual Color Comp $2.85 service V or B - Lab 81025 1 1 6 81025 1 1 6 81025 1 1 6 81025 0 0 n/a 6

Limit V or B: Lab Services Enhancements $46.14 $46.14 $46.14 $0.00

Encounter entry required before expiration of authorization (days) - Vivitrol or Buprenorphine: Lab Services

IWM, STR & LTRT2 Limits HWH Limits PC, IOP & OP Limits AWM (Detox) Limits

DMHAS MAPSPB Page 4 of 4

SFY 2025

SPB

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