Exhibit 1L - SJI 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 1L - South Jersey Initiative (SJI) Enhancements Authorization Parameters, which outlines the authorization parameters for the South Jersey Initiative enhancements provided by the New Jersey Division of Mental Health and Addiction Services (DMHAS).

The exhibit details the service rates, unit types, CPT codes, authorization limits, and annual client limits for various clinical, co-occurring, medication monitoring, psychiatric evaluation, medication-assisted treatment, recovery support, medical, and laboratory services that are part of the SJI enhancements. The authorization parameters are provided for the current state fiscal year and subsequent years, with effective dates of July 1, 2024 and revisions made on April 8, 2024. The exhibit covers the encounter entry requirements and service limits for the different levels of care, including inpatient, outpatient, intensive outpatient, and partial care.

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Exhibit 1L - South Jersey Initiative (SJI) 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

South Jersey Initiative (SJI)

Fee for Service Enhancement Authorization Parameters

Encounter entry required before expiration of authorization (days) -

Encounter entry required before expiration of authorization (days) -

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

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

DMHAS SJI Page 1 of 6

SFY 2025

Effective 07/01/24

Revised 04/08/24

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

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

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

DMHAS SJI Page 2 of 6

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 MAT IS-M Z3353 2 4 n/a Z3353 2 4 n/a Z3353 2 2 n/a Z3353 0 0 0 n/a

Methadone Maintenance $ 4.05 unit MAT IS-M H0020 HF 1 31 n/a H0020 HF 1 31 n/a H0020 HF 1 31 n/a H0020 HF 0 0 0 n/a

Limit Med Assist-Induction/Stabilization

Methadone Enhancements $315.71 $315.71 $220.63 $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

Medication Monitoring - MAT $ 47.54 15 minutes MAT- MM Z3353 2 4 n/a Z3353 2 4 n/a Z3353 2 2 n/a Z3353 0 0 0 n/a

Methadone Maintenance $ 4.05 unit MAT- MM H0020 HF 1 31 n/a H0020 HF 1 31 n/a H0020 HF 1 31 n/a H0020 HF 0 0 0 n/a

Limit Medication Assisted-Methadone

Maintenance Enhancements $315.71 $315.71 $220.63 $0.00

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) -

Medication Assisted - Methadone Maintenance

Medication Assisted - Induction/Stabilization Methadone

Encounter entry required before expiration of authorization (days) -

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

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

DMHAS SJI Page 3 of 6

SFY 2025

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

Encounter entry required before expiration of authorization (days) -

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

DMHAS SJI Page 4 of 6

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

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

Encounter entry required before expiration of authorization (days) -

Encounter entry required before expiration of authorization (days) -

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

Vivitrol or Buprenorphine: Vivitrol - Pre-Induction

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

DMHAS SJI Page 5 of 6

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

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 5 n/a H0003 HF 1 5 n/a H0003 HF 1 5 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 Laboratory Services Enhancements $46.14 $46.14 $46.14 $0.00

AWM (Detox) Limits

Vivitrol or Buprenorphine: Lab Services

IWM, STR & LTRT2 Limits HWH Limits PC, IOP & OP Limits

Encounter entry required before expiration of authorization (days) -

DMHAS SJI Page 6 of 6

SFY 2025

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