Exhibit 2J - RCI ASAM Ambulatory LOC Authorization Parameters.pdf
PDF 116 KB Posted
- Solicitation number
- 25DPP01060
- Issued by
- Mercer County, New Jersey
About this file
This document is the Recovery Court Initiative (RCI) ASAM Ambulatory LOC Authorization Parameters for SFY 2025, effective July 1, 2024 and revised on April 8, 2024. It outlines the authorization parameters for various ambulatory substance abuse treatment services, including Ambulatory Withdrawal Management (Detox), Outpatient, Intensive Outpatient, and Partial Hospitalization/Care. The document specifies the ASAM Levels of Care, CPT codes, maximum units per authorization, authorization time frames, daily and weekly limits, and authorization "red zones" for adult clients. It also includes the rates per unit for these services, which range from $6.61 for Psychoeducational Group Services to $209.33 for Ambulatory Withdrawal Management (Detox).
The document further provides details on the maximum units per authorization and rates per unit for additional ambulatory services, such as Family Therapy, Individual Therapy, and Group Therapy. These services have their own weekly limits and rates per unit, which range from $71.39 for Individual Therapy to $113.84 for Family Therapy.
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Text version
Exhibit 2J - Recovery Court Initiative (RCI) ASAM Ambulatory LOC Authorization Parameters SFY 2025 Effective 07/01/2024 Revised 04/08/2024
Service
Ambulatory Withdrawal
Management (Detox)
Outpatient 2 units per
30 day authorization
Outpatient 6 units per
30 day authorization
Outpatient 2 units per week
Outpatient 3 units per week
Outpatient 5 units per week
Outpatient 6 units per week
Intensive Outpatient Partial Care
Type/Modality Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory
ASAM LOC AWM2D Level 1 Level 1 Level 1 Level 1 Level 1 Level 1 Level 2.1 Level 2.5
CPT Code H0014 HF see OP rate table see OP rate table see OP rate table see OP rate table see OP rate table see OP rate table H0015 HF H2036 HF
Maximum units per Authorization 5 2 6 10 13 22 26 18 22
Authorization time frame (days) 5 30 30 30 30 30 30 30 30
Unit Per diem Per service Per service Per service Per service Per service Per service Per diem Per diem
Daily Limits 1 2 2 2 3 3 3 1 1
Weekly Limits 7 2 2 2 3 5 6 4 5
# of days at which initial ERL needed 5 N/A N/A N/A N/A N/A N/A 120 120
# of days at which ERL can be submitted 3 N/A N/A N/A N/A N/A N/A 89 89
Authorization RED ZONE (67% of annual allocation) N/A N/A N/A N/A N/A N/A N/A 67 89
Adult Annual Client Limits (units) N/A N/A N/A N/A N/A N/A N/A 100 133
Rate Per Unit 209.33$ 109.38$ 78.23$
Authorization Value 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 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
Recovery Court Initiative (RCI) Fee for Service - Adult Co-occurring Capable Ambulatory
ASAM Level of Care Authorization Parameters
Page 1 of 2 DMHAS RCI
Exhibit 2J - Recovery Court Initiative (RCI) ASAM Ambulatory LOC Authorization Parameters SFY 2025 Effective 07/01/2024 Revised 04/08/2024 overy Court Initiative (R 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 RCI
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