Exhibit 1F - NJSI 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 is the Exhibit 1F - New Jersey Statewide Initiative (NJSI) Enhancements Authorization Parameters, which outlines the fee-for-service enhancement authorization parameters for the New Jersey Department of Human Services. The document provides details on the various clinical, co-occurring, recovery support, medical, Vivitrol or Buprenorphine, and laboratory services covered under the NJSI program, including service rates, unit types, CPT codes, authorization limits, and encounter requirements. It specifies the authorized parameters for services such as urine drug screens, Mantoux tests, continuing care, case management, therapy, psychiatric evaluation, medication monitoring, and E&M visits across different service settings including Ambulatory Withdrawal Management, Short-Term Residential, Long-Term Residential, High-Level Withdrawal Management, Intensive Outpatient, and Outpatient.

The document outlines the annual client limits, service rates, and authorization parameters for each covered service, providing a comprehensive overview of the NJSI program's fee-for-service enhancement structure. It also includes specific details on Vivitrol and Buprenorphine services, including medication monitoring, induction, and maintenance. The document appears to be an internal reference for the Department of Human Services to manage the NJSI program and ensure consistent authorization and reimbursement for the covered services.

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Exhibit 1F - New Jersey Statewide Initiative (NJSI) 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 5 n/a H0003HF 1 5 n/a H0003HF 1 5 n/a H0003HF 1 5 n/a n/a

Oral Swab $ 8.46 service Clinical ZSWB 1 5 n/a ZSWB 1 5 n/a ZSWB 1 5 n/a ZSWB 1 5 n/a n/a

Mantoux Tuberculin Test $ 10.57 service Clinical 86580 1 1 n/a 86580 1 1 n/a 86580 1 1 n/a 86580 1 1 n/a n/a

Continuing Care LOCI $ 26.43 20 minutes Clinical ZLOCI 1 1 n/a ZLOCI 1 1 n/a ZLOCI 1 1 n/a ZLOCI 1 2 n/a n/a

Limit Clinical Review Enhancements $79.30 $79.30 $79.30 $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 2 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) -

Encounter entry required before expiration of authorization (days) -

New Jersey Statewide Initiative (NJSI)

Fee for Service Enhancement Authorization Parameters

AWM (Detox) Limits

STR & LTRT2 Limits HWH Limits IOP & OP Limits AWM (Detox) Limits

STR & LTRT2 Limits HWH Limits IOP & OP Limits

DMHAS NJSI Page 1 of 4

SFY 2025

Effective 07/01/2024

Revised 04/08/2024

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 2 n/a 90862 HF 2 2 n/a 90862 HF 0 0 n/a n/a

Limit Co-occurring Medication Monitoring

Service Enhancement $0.00 $95.08 $95.08 $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

STR & LTRT2 Limits

Encounter entry required before expiration of authorization (days) -

STR & LTRT2 Limits

Encounter entry required before expiration of authorization (days) -

Co-occurring Med Monitoring Services Enhancement

IOP & OP Limits AWM (Detox) Limits

HWH Limits IOP & OP Limits AWM (Detox) Limits

HWH Limits

DMHAS NJSI Page 2 of 4

SFY 2025

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

Medical 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

E & M visit - new patient (20 min) $ 82.94 20 minutes Medical Srvcs 99202 0 0 0 99202 1 1 n/a 99202 1 1 n/a 99202 0 0 0 n/a

E & M visit - new patient (30 min) $ 117.03 30 minutes Medical Srvcs 99203 0 0 0 99203 1 1 n/a 99203 1 1 n/a 99203 0 0 0 n/a

E & M visit - new patient (45 min) $ 177.73 45 minutes Medical Srvcs 99204 0 0 0 99204 1 1 n/a 99204 1 1 n/a 99204 0 0 0 n/a

E & M visit - new patient (60 min) $ 224.19 60 minutes Medical Srvcs 99205 0 0 0 99205 1 1 n/a 99205 1 1 n/a 99205 0 0 0 n/a

E & M visit - established patient (10 min) $ 49.91 10 minutes Medical Srvcs 99212 0 0 0 99212 1 1 n/a 99212 1 1 n/a 99212 0 0 0 n/a

E & M visit - established patient (15 min) $ 81.64 15 minutes Medical Srvcs 99213 0 0 0 99213 1 1 n/a 99213 1 1 n/a 99213 0 0 0 n/a

E & M visit - established patient (25 min) $ 118.08 25 minutes Medical Srvcs 99214 0 0 0 99214 1 1 n/a 99214 1 1 n/a 99214 0 0 0 n/a

E & M visit - established patient (40 min) $ 158.24 40 minutes Medical Srvcs 99215 0 0 0 99215 1 1 n/a 99215 1 1 n/a 99215 0 0 0 n/a

Limit Medical Services Enhancements $0.00 $469.11 $469.11 $0.00

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

STR & LTRT2 Limits

Encounter entry required before expiration of authorization (days) -

Encounter entry required before expiration of authorization (days) -

Encounter entry required before expiration of authorization (days) -

STR & LTRT2 Limits HWH Limits IOP & OP Limits AWM (Detox) Limits

HWH Limits IOP & OP Limits AWM (Detox) Limits

STR & LTRT2 Limits HWH Limits IOP & OP Limits AWM (Detox) Limits

Vivitrol or Buprenorphine: Vivitrol - Pre-Induction

DMHAS NJSI Page 3 of 4

SFY 2025

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 2 n/a Z3353 2 2 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 $1,616.29 $1,666.20 $1,666.20 $0.00

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 1 1 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 1 1 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 1 1 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 1 1 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 1 1 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 1 1 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 1 1 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 1 1 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 1 1 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 1 1 6 6

Limit Laboratory Services Enhancements $46.14 $46.14 $46.14 $46.14

Encounter entry required before expiration of authorization (days) -

Encounter entry required before expiration of authorization (days) -

STR & LTRT2 Limits

Vivitrol or Buprenorphine

HWH Limits IOP & OP Limits AWM (Detox) Limits

STR & LTRT2 Limits HWH Limits IOP & OP Limits AWM (Detox) Limits

Vivitrol or Buprenorphine: Lab Services

DMHAS NJSI Page 4 of 4

SFY 2025

File details come from the government source that posted it. Updated .