Exhibit 2O - SAPTI 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 Substance Abuse Prevention and Treatment Initiative (SAPTI) ASAM Ambulatory Level of Care (LOC) Authorization Parameters for State Fiscal Year 2025, effective July 1, 2024 and revised on April 8, 2024. It provides the service assessment, modality/type, ASAM LOC, CPT code, maximum units per authorization, authorization time frame, unit, daily and weekly limits, and authorization value for various ambulatory treatment services including Methadone Outpatient Phases I-VI and Intensive Outpatient. The document also includes information on the shared service name, prior attestation message, and relevant fee-for-service parameters.
The document details the authorization and billing requirements for these SAPTI ASAM ambulatory services, including the specific ASAM LOC, weekly service minimums, and applicable rates per unit. It specifies the adult annual client limits, authorization "red zone" thresholds, and other key parameters to govern the utilization and reimbursement of these substance abuse treatment services.
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Exhibit 2O - Substance Abuse Prevention and Treatment Initiative (SAPTI) ASAM Ambulatory LOC Authorization Parameters SFY 2025 Effective 07/01/2024 Revised 04/08/2024
Service Assessment Methadone OP Phase I
Methadone OP Phase II
Methadone OP Phase III
Methadone OP Phase IV
Methadone OP Phase V
Methadone OP Phase VI
Intensive Outpatient
Modality/Type Pre-Admission Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory
ASAM LOC N/A Level 1 - MOT Level 1 - MOT Level 1 - MOT Level 1 - MOT Level 1 - MOT Level 1 - MOT Level 2.1
CPT Code H0001 HF H0020 HF26 I H0020 HF26 II H0020 HF26 III H0020 HF26IV H0020 HF26V H0020 HF26VI H0015 HF
Maximum units per Authorization 4 4 4 4 4 4 4 18
Authorization time frame (days) 30 28 28 28 28 28 28 30
Unit 30 minutes Weekly Bundle Weekly Bundle Weekly Bundle Weekly Bundle Weekly Bundle Weekly Bundle Per diem
Daily Limits 4 N/A N/A N/A N/A N/A N/A 1
Weekly Limits 4 1 1 1 1 1 1 4
# of days at which initial ERL needed N/A N/A N/A N/A N/A N/A N/A 60
# of days at which ERL can be submitted N/A 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
Adult Annual Client Limits (units) 16 N/A N/A N/A N/A N/A N/A N/A
Rate Per Unit 28.49$ 91.07$ 91.07$ 91.07$ 91.07$ 91.07$ 91.07$ 109.38$
Authorization Value 113.96$ 364.28$ 364.28$ 364.28$ 364.28$ 364.28$ 364.28$ 1,968.84$
Shared Service Name N/A
Opioid Maintenance -
Intensive Outpatient
Opioid Maintenance Outpatient (OMO)
Substance Abuse Prevention and Treatment Initiative (SAPT)
ASAM Level of Care Authorization Parameters Fee for Service - Adult Co-occurring Capable Ambulatory
Bundled service claim. Prior to claim, attestation message: "I am attesting that the client received the minimum weekly service requirement per Annex A2 for this phase."
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