Exhibit 2H - NJSI ASAM Ambulatory LOC Authorization Parameters.pdf
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- Solicitation number
- 25DPP01060
- Issued by
- Mercer County, New Jersey
About this file
This document is Exhibit 2H of the New Jersey Statewide Initiative (NJSI) and outlines the ASAM Ambulatory Level of Care (LOC) Authorization Parameters for State Fiscal Year 2025, effective July 1, 2024, with a revision date of April 8, 2024. The exhibit details the authorization parameters for various ambulatory services, including Ambulatory Withdrawal Management (Detox), Outpatient, Intensive Outpatient, Family Therapy, Individual Therapy, Psychoeducational Group Services, and Group Therapy. It specifies the ASAM LOC, CPT codes, maximum units per authorization, authorization timeframes, daily and weekly limits, and the number of days at which an Early Review Letter (ERL) is needed or can be submitted. The document also provides the rate per unit and authorization value for each service.
The pricing terms, set asides, incumbents, funding requirements and sources, and other salient information are not explicitly stated in this exhibit. However, it is clear that this document is part of the NJSI Fee for Service - Adult Co-occurring Capable Ambulatory ASAM Level of Care Authorization Parameters, which likely outlines additional details related to the overall contract opportunity.
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Exhibit 2H - New Jersey Statewide Initiative (NJSI) 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
Modality/Type Pre-Admission 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
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
Maximum units per Authorization 4 5 2 6 10 13 22 26 18
Authorization time frame (days) 30 5 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
Daily Limits 4 1 2 2 2 3 3 3 1
Weekly Limits 4 7 2 2 2 3 5 6 4
# of days at which initial ERL needed N/A 5 N/A N/A N/A N/A N/A N/A 60
# of days at which ERL can be submitted N/A 3 N/A N/A N/A N/A N/A N/A 50
Authorization RED ZONE (67% of annual allocation) N/A N/A N/A N/A N/A N/A N/A N/A N/A
Adult Annual Client Limits (units) N/A N/A N/A N/A N/A N/A N/A N/A N/A
Rate Per Unit 28.49$ 209.33$ 109.38$
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$
Shared Service Name N/A Detox Outpatient Non-Methadone
Intensive Outpatient
New Jersey Statewide Initiative (NJSI) Fee for Service - Adult Co-occurring Capable Ambulatory
ASAM Level of Care Authorization Parameters see OP rate table
Standard/Traditional Outpatient
Page 1 of 2 DMHAS NJSI
Exhibit 2H - New Jersey Statewide Initiative (NJSI) ASAM Ambulatory LOC Authorization Parameters SFY 2025 Effective 07/01/2024 Revised 04/08/2024 rsey Statewide Initiative 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 NJSI
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