Exhibit 2D - MAP SPB ASAM Ambulatory LOC Authorization Parameters.pdf
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- Solicitation number
- 25DPP01060
- Issued by
- Mercer County, New Jersey
About this file
This document outlines the ASAM Ambulatory Level of Care Authorization Parameters for the Mutual Agreement Program - State Parole Board (MAP SPB) in the state for Fiscal Year 2025, effective July 1, 2024. The authorization parameters cover various ambulatory services such as Ambulatory Withdrawal Management (Detox), Outpatient, Intensive Outpatient, and Partial Care, with specific unit limitations, authorization timelines, and maximum annual client limits for each service. The document provides details on the ASAM Level of Care, CPT codes, unit values, and authorization values for each service.
The pricing information includes the rate per unit for each service, ranging from $6.61 per unit for Psychoeducational Group Services to $209.33 per diem for Ambulatory Withdrawal Management (Detox). The document also outlines the weekly and daily limits for each service, as well as the number of days at which an initial Extended Review Level (ERL) is needed and when an ERL can be submitted.
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Exhibit 2D - Mutual Agreement Program - State Parole Board (MAP SPB) ASAM Ambulatory LOC Authorization Parameters SFY 2025 Effective 07/01/2024 Revised 04/08/2024
Service Assessment
Ambulatory Withdrawal
Management (Detox)
Outpatient 2 units per
30 day authorization
Outpatient 6 units per
30 day authorization
Outpatient 2 units per week
Outpatient 3 units per week
Outpatient 5 units per week
Outpatient 6 units per week
Intensive Outpatient Partial Care
Modality/Type Pre-Admission Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory
ASAM LOC N/A AWM2D Level 1 Level 1 Level 1 Level 1 Level 1 Level 1 Level 2.1 Level 2.5
CPT Code H0001 HF H0014 HF see OP rate table see OP rate table see OP rate table see OP rate table see OP rate table see OP rate table H0015 HF H2036 HF
Maximum units per Authorization 4 5 2 6 10 13 22 26 18 22
Authorization time frame (days) 30 5 30 30 30 30 30 30 30 30
Unit 30 minutes Per diem Per service Per service Per service Per service Per service Per service Per diem Per diem
Daily Limits 4 1 2 2 2 3 3 3 1 1
Weekly Limits 4 7 2 2 2 3 5 6 4 5
# of days at which initial ERL needed N/A 5 N/A N/A N/A N/A N/A N/A 120 120
# of days at which ERL can be submitted N/A 3 N/A N/A N/A N/A N/A N/A 89 89
Authorization RED ZONE (67% of annual allocation) 10 N/A N/A N/A N/A N/A N/A N/A 67 89
Adult Annual Client Limits (units) 15 N/A N/A N/A N/A N/A N/A N/A 100 133
Rate Per Unit 28.49$ 209.33$ 109.38$ 78.23$
Authorization Value 113.96$ 1,046.65$ 208.30$ 624.90$ 1,041.50$ 1,056.96$ 1,371.26$ 1,481.18$ 1,968.84$ 1,721.06$
Shared Service Name N/A Detox Outpatient Non-Methadone
Intensive Outpatient and
Opioid Maintenance -
Intensive Outpatient
Partial Hospitalization/
Care see OP rate table
Standard/Traditional Outpatient and Opioid Maintenance Outpatient
Mutual Agreement Program - State Parole Board (MAP SPB) Fee for Service - Adult Co-occurring Capable Ambulatory
ASAM Level of Care Authorization Parameters
Page 1 of 2 DMHAS MAP SPB
Exhibit 2D - Mutual Agreement Program - State Parole Board (MAP SPB) ASAM Ambulatory LOC Authorization Parameters SFY 2025 Effective 07/01/2024 Revised 04/08/2024
Service Family Therapy Individual Therapy Individual Therapy Psychoeducational Group Services Group Therapy
Unit 60 minutes 30 minutes 45 - 50 minutes 90 minutes 90 minutes
Weekly Limits See LOC Limits See LOC Limits See LOC Limits See LOC Limits See LOC Limits
Rate Per Unit $113.84 $71.39 $94.46 $6.61 $27.48
Max units per diem 1 1 1 3 2
CPT Code 90847 HF 90832 HF 90834 HF Z3355 90853 HF
Page 2 of 2 DMHAS MAP SPB
| MAPSPB |
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