Exhibit 2R - SJI ASAM Ambulatory LOC Authorization Parameters.pdf
PDF 117 KB Posted
- Solicitation number
- 25DPP01060
- Issued by
- Mercer County, New Jersey
About this file
This document is the Exhibit 2R - South Jersey Initiative (SJI) ASAM Ambulatory Level of Care (LOC) Authorization Parameters for State Fiscal Year 2025, effective July 1, 2024. It outlines the authorization parameters for various ambulatory substance abuse treatment services provided through the SJI program, including Ambulatory Withdrawal Management (Detox), Outpatient, Intensive Outpatient, and Partial Care levels of care. The document specifies the maximum units per authorization, authorization timeframe, unit definition, daily and weekly limits, and authorization requirements for each service. It also includes the associated Current Procedural Terminology (CPT) codes, rates per unit, and shared service names.
The document provides detailed pricing information, including the authorization value for each service. It also notes that there are no annual client limits or "Red Zone" authorization thresholds defined. The services are provided on a fee-for-service basis for the adult co-occurring capable ambulatory ASAM levels of care covered by the SJI program.
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Exhibit 2R - South Jersey Initiative (SJI) 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 60 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 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 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 N/A
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
Fee for Service - Adult Co-occurring Capable Ambulatory ASAM Level of Care Authorization Parameters
South Jersey Initiative (SJI)
Standard/Traditional Outpatient and Opioid Maintenance Outpatient
Page 1 of 2 DMHAS SJI
Exhibit 2R - South Jersey Initiative (SJI) ASAM Ambulatory LOC Authorization Parameters SFY 2025 Effective 07/01/2024 Revised 04/08/2024 outh Jersey Initiative (SJ 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 SJI
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