MLTSS Service Dictionary

MLTSS members receive their benefits through the NJ FamilyCare program and non-traditional services, based on need. For a detailed list of the MLTSS non-traditional services, review the MLTSS Service Dictionary.

For a list of MLTSS claim codes for non-traditional services, review the MLTSS Crosswalk Grid. Please note, when multiple therapies are entered as part of a plan of care, the Modifier ‘59’ must be added to authorization.

Tikka Attach
Main Sheet
Former Waiver Service Former Code (s) MLTSS Service MLTSS Code MLTSS Code Description HMO Authorization Needed? HMO ReAuthorization Needed Provider Referral Needed? Claim Type
Code Mod Method/ Unit Amerigroup Healthfirst Horizon NJ Health UnitedHealthcare Amerigroup Healthfirst Horizon NJ Health UnitedHealthcare Amerigroup Healthfirst Horizon NJ Health UnitedHealthcare
Adult Family Care (GO) Y7573 Adult Family Care S5140 Per Diem Foster care, adult; per diem
Assisted Living Residence - 1 day (GO) Y9633, T2031 Assisted Living Services
(ALR - Assisted Living Residence) T2031 Per Diem Assisted living, waiver; per diem
Comprehensivce Personal Care Home - 1 day (GO) Y7574 Assisted Living Services
(CPCH - Comprehensive Personal Care Home) T2031 U1 Per Diem Assisted living, waiver; per diem
Assisted Living Program - 1 day (GO) Y9634 Assisted Living Program
(ALP) T2031 U2 Per Diem Assisted living, waiver; per diem
Behavioral Programs (TBI) H0004 ST 22, Y7564, Y7566 Behavior Management (TBI) H0004 15 minutes Behavioral health counseling and therapy, per 15 minutes (Individual)
Behavioral Programs (TBI) H0004 ST 22, Y7564, Y7566 H0004 HQ 15 minutes Behavioral health counseling and therapy, per 15 minutes (Group)
Caregiver/Participant Training (GO) Y9848, S5111, Y9849 Caregiver/ Participant Training S5111 One Visit per day Home care training, family; per session
Chore Service (GO) S5120 52, Y9838, S5120 22, S5121, Y9837 Chore Service S5120 15 minutes Chore services; per 15 minutes
S5121 Per Diem Chore services; per diem
Therapies through a CRS or Day Program ? Cognitive Rehabilitative Therapy AND Therapies through a CRS or Day Program - Cognitive Rehabilitation Group Therapy (TBI) 97532 ST 22; T2012 HQ ST Cognitive Therapy T2013 One Hour Habilitation, educational; waiver; per hour (Individual)
T2013 HQ One Hour Habilitation, educational; waiver; per hour (Group)
Community Residential Services Low, Moderate and High Level of Supervision (TBI) Y7435, Y7436, Y7437 Community Residential Services
(CRS)
T2033 Per Diem Residential care, not otherwise specified (NOS), waiver; per diem (e.g., Low Level Supervision)
T2033 TF Per Diem Residential care, not otherwise specified (NOS), waiver; per diem (e.g., Moderate Level Supervision)
T2033 TG Per Diem Residential care, not otherwise specified (NOS), waiver; per diem (e.g., High Level Supervision)
Community Transition Services (CRPD, GO) T2038 (CRPD), T2038, T2038 HC (GO) Community Transition Services T2038 Per Service Community transition, waiver; per service
T2038 U6 Per Service Administration
Home Based Supportive Care (GO) Y9845, T1022. Y9846, Z1200, Z1205, Z1290, Z1295, S5130 22, S5130 TV 22 Home Based Supportive Care S5130 15 Minutes Individual Homemaker service, NOS; per 15 minutes
S5130 HQ 15 Minutes Group Homemaker service, NOS, per 15 minutes
S5130 U1 15 minutes Homemaker service, NOS, per 15 minutes. The code is to be used ONLY as a continuity of care code for existing recipients of HBSC when the member requires assistance with both ADLs and IADLs for a period of no longer than 180 days. This code is being implemented to allow HBSC providers who are not accredited as PCA providers to continue to provide services and be paid for a continuity of care period of no longer than 180 days beginning July 1, 2014. This code will expire 1/1/2015. THIS CODE EXPIRES 1/1/2015
S5130 U2 15 minutes Group Homemaker service, NOS, per 15 minutes. The code is to be used ONLY as a continuity of care code for existing recipients of HBSC when the member requires assistance with both ADLs and IADLs for a period of no longer than 180 days. This code is being implemented to allow HBSC providers who are not accredited as PCA providers to continue to provide services and be paid for a continuity of care period of no longer than 180 days beginning July 1, 2014. This code will expire 1/1/2015. THIS CODE EXPIRES 1/1/2015
Home Delivered Meal Service (GO) S5170, Y9847 Home Delivered Meals S5170 Per Service -One meal per day Home delivered meals, including preparation; per meal
Personal Emergency Response System Pill Dispenser ? 1 Installation (GO) S5160 22 Medication Dispensing Device
(Set Up) T1505 Per Service Electronic medication compliance management device, includes all components and accessories, not otherwise classified
Personal Emergency Response System Pill Dispenser ? 1 Monthly Monitoring Fee (GO) S5161 22 Medication Dispensing Device
(Monthly Monitoring) S5185 Monthly Medication reminder service, nonface-to-face; per month
NA MLTSS PCA Current codes Codes per State Plan - Not a stand alone MLTSS benefit
Transportation - Non Medical (GO) Y9835, T2002, Y9834, A0080 Non-Medical Transportation T2002 per diem Nonemergency transportation; per diem; Not a stand alone MLTSS benefit.
T2003 Per Service Nonemergency transportation; encounter trip; Not a stand alone MLTSS benefit.
NA Nursing Facility Services
(Custodial) Revenue Codes 0100, 0119, 0129, 0139, 0149, 0159, 0169 NA Revenue Codes 0100, 0119, 0129, 0139, 0149, 0159, 0169.
SCNF - Revenue Codes 0100, 0119, 0129, 0139, 0149, 0159, 0169. NA SCNF - Revenue Codes 0100, 0119, 0129, 0139, 0149, 0159, 0169.
Therapies through a CRS or Day Program ? Occupational - Individual and Group (TBI) 97535 ST (Indiv), S9129 HQ ST (Group) Occupational Therapy
(Group & Individual) 97535 U2 15 minutes Occupational Therapy, per diem (Individual) NOTE: For Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIER MUST be included.
97535 U3 15 minutes Occupational Therapy, (Group) NOTE: For Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIER MUST be included.
97535 U4 15 minutes Occupational Therapy (Individual) 15 minutes: Rehabilitation for MLTSS members with TBI diagnosis. Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIER MUST be included on any claim where the service is for MLTSS members with TBI diagnosis. One session per day.
97535 U5 15 minutes Occupational Therapy: (Group), 15 minutes: Rehabilitation for MLTSS members with TBI diagnosis. Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIER MUST be included on any claim where the service is for MLTSS members with TBI diagnosis. One session per day.
Personal Emergency Response System ? 1 Installation (CRPD, GO) S5160 (CRPD); S5160, Y9839 (GO) Personal Emergency Response System
(PERS: Set up) S5160 Per Service Emergency response system; service fee, Installation
Personal Emergency Response System ? 1 Monthly Monitoring Fee (CRPD, GO) S5161 (CRPD); S5161, Y9843 (GO) Personal Emergency Response System
(PERS: Monthly Monitoring) S5161 Per Month Emergency response system; service fee, per month - Standard Landline Unit
S5161 U1 Per Month Emergency response system; service fee, per month - Cellular Unit
S5161 U2 Per Month Emergency response system; service fee, per month - Cellular Unit with Fall Detection
S5161 U3 Per Month Emergency response system; service fee, per month - Mobile Unit
Therapies through a CRS or Day Program ? Physical (Group and Individual) (TBI) S8990 ST (Indiv); S9131 HQ ST (Group) Physical Therapy
(Group & Individual) 97110 U2 15 minutes Physical therapy; per diem (Individual - Maintenance Therapy) NOTE: For Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIER MUST be included. on any claim where the service is for habilitative therapy.
97110 U3 15 minutes Physical therapy; per diem (Group - Maintenance Therapy) NOTE: For Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIER MUST be included on any claim where the service is for habilitative therapy.
97110 U4 15 minutes Physical Therapy: (Individual), 15 minutes: Rehabilitation for MLTSS members with TBI diagnosis. Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIER of U4 for Individual and U5 for Group MUST be included on any claim where the service is for MLTSS members with TBI diagnosis. One Session per day.
97110 U5 15 minutes Physical Therapy: (GROUP), 15 minutes, Rehabilitation for MLTSS members with TBI diagnosis. Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIER of U4 for Individual and U5 for Group MUST be included on any claim where the service is for MLTSS members with TBI Diagnosis. One Session per day
PDN (Private Duty Nursing) - CRPD Z1710, Z1715, S9124, Z1720, Z1725, Z1730, Z1735, Z1740, Z1745 Private Duty Nursing T1000 UA 15 minutes RN/LPN Private duty / independent nursing service(s) - licensed, up to 15 minutes
T1002 UA 15 minutes RN only Private duty / independent nursing service(s) - licensed, up to 15 minutes
T1003 UA 15 minutes LPN Only Private duty/independent nursing service(s); licensed, up to 15 minutes
Environmental Modifications (CRPD); (EAA) Environmental Accessibility Adaptation (GO) S5165, S5165 52 (CRPD); S5165, Y9795 (GO) Residential Modifications S5165 Per Service Home modifications; per service
T1028 (Eval) Per Service Assessment of home, physical and family environment, to determine suitability to meet patient's medical needs
Respite Care (TBI); Respite Care: 8 hour Day. Respite Care : 8 hour night. Respite Care - Day >8<12, Respite Care Night >8<12, Respite Care - >12 <24, Respite Care ? Nursing Facility, Respite Care ? ALF or AFC ? Per Diem (GO) Y7456, Y7458, Y7463, (TBI): Z1210, S9125, Y9793, Z1215, Z1220, Z1225, Z1230, Z1285, Y9792, S5151 (GO) Respite
(Daily & Hourly)
T1005 15 minutes Respite care, in the home, per 15 minutes
S5151 Per Diem Unskilled respite care, not hospice; per diem
NF Respite REV 0663 DAILY Daily respite Care in a Nursing Facility
Social Adult Day Care (GO) Z1235, Y9853, S5102 Social Adult Day Care S5102 U3 Per Diem Day care services, adult; per diem
Therapies through a CRS or Day Program ? Speech Individual and Group (TBI) Y7556 Speech, Language & Hearing Therapy
(Group & Individual) 92507 U3 15 minutes Speech therapy, per diem (Individual) NOTE: For Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIER MUST be included on any claim where the service is for habilitative therapy.
92508 U3 15 minutes Speech therap, per diem (Group) NOTE: For Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIER MUST be included on any claim where the service is for habilitative therapy.
92507 U4 15 minutes Speech Therapy: (Individual), 15 minutes: Rehabilitation for MLTSS members with TBI diagnosis. Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIER MUST be included on any claim where the service is for MLTSS members with TBI diagnosis. One Session per day.
92508 U4 15 minutes Speech Therapy: (Individual), 15 minutes: Rehabilitation for MLTSS members with TBI diagnosis. Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIER MUST be included on any claim where the service is for MLTSS members with TBI diagnosis. One Session per day.
Structured Day Program (TBI) S5102 ST, S5109, S5101 ST Structured Day Program S5100 15 minutes Day care services, adult; per 15 minutes
Supported Day Program (TBI) Y7443 Supported Day Services T2021 15 minutes Day habilitation, waiver; per 15 minutes
Environmental Adaptations- Vehicle (GO) ; S5165, S5165 52, Y9795, Y9854 Vehicle Modifications T2039 Per Service Vehicle modifications, waiver; per service
T2039 U7
(Eval) Per Service

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Former to New
Former Waiver Service Former Code (s) MLTSS Service MLTSS Code MLTSS Code Description
Code Mod Method/ Unit
Adult Family Care (GO) Y7573 Adult Family Care S5140 Per Diem Foster care, adult; per diem
Assisted Living Residence - 1 day (GO) Y9633, T2031 Assisted Living Services
(ALR - Assisted Living Residence) T2031 Per Diem Assisted living, waiver; per diem
Comprehensivce Personal Care Home - 1 day (GO) Y7574 Assisted Living Services
(CPCH - Comprehensive Personal Care Home) T2031 U1 Per Diem Assisted living, waiver; per diem
Assisted Living Program - 1 day (GO) Y9634 Assisted Living Program
(ALP) T2031 U2 Per Diem Assisted living, waiver; per diem
Behavioral Programs (TBI) H0004 ST 22, Y7564, Y7566 Behavior Management (TBI) H0004 15 minutes Behavioral health counseling and therapy, per 15 minutes (Individual)
Behavioral Programs (TBI) H0004 ST 22, Y7564, Y7566 H0004 HQ 15 minutes Behavioral health counseling and therapy, per 15 minutes (Group)
Caregiver/Participant Training (GO) Y9848, S5111, Y9849 Caregiver/ Participant Training S5111 One Visit per day Home care training, family; per session
Chore Service (GO) S5120 52, Y9838, S5120 22, S5121, Y9837 Chore Service S5120 15 minutes Chore services; per 15 minutes
S5121 Per Diem Chore services; per diem
Therapies through a CRS or Day Program ? Cognitive Rehabilitative Therapy AND Therapies through a CRS or Day Program - Cognitive Rehabilitation Group Therapy (TBI) 97532 ST 22; T2012 HQ ST Cognitive Therapy T2013 One Hour Habilitation, educational; waiver; per hour (Individual)
T2013 HQ One Hour Habilitation, educational; waiver; per hour (Group)
Community Residential Services Low, Moderate and High Level of Supervision (TBI) Y7435, Y7436, Y7437 Community Residential Services
(CRS)
T2033 Per Diem Residential care, not otherwise specified (NOS), waiver; per diem (e.g., Low Level Supervision)
T2033 TF Per Diem Residential care, not otherwise specified (NOS), waiver; per diem (e.g., Moderate Level Supervision)
T2033 TG Per Diem Residential care, not otherwise specified (NOS), waiver; per diem (e.g., High Level Supervision)
Community Transition Services (CRPD, GO) T2038 (CRPD), T2038, T2038 HC (GO) Community Transition Services T2038 Per Service Community transition, waiver; per service
T2038 U6 Per Service Administration
Home Based Supportive Care (GO) Y9845, T1022. Y9846, Z1200, Z1205, Z1290, Z1295, S5130 22, S5130 TV 22 Home Based Supportive Care S5130 15 Minutes Individual Homemaker service, NOS; per 15 minutes
S5130 HQ 15 Minutes Group Homemaker service, NOS, per 15 minutes
S5130 U1 15 Minutes Group Homemaker service, NOS, per 15 minutes. Group Homemaker service, NOS, per 15 minutes. The code is to be used ONLY as a continuity of care code for existing recipients of HBSC when the member requires assistance with both ADLs and IADLs for a period of no longer than 180 days. This code is being implemented to allow HBSC providers who are not accredited as PCA providers to continue to provide services and be paid for a continuity of care period of no longer than 180 days beginning July 1, 2014. This code will expire 1/1/2015. THIS CODE EXPIRES 1/1/2015
S5130 U2 15 minutes Group Homemaker service, NOS, per 15 minutes. Group Homemaker service, NOS, per 15 minutes. The code is to be used ONLY as a continuity of care code for existing recipients of HBSC when the member requires assistance with both ADLs and IADLs for a period of no longer than 180 days. This code is being implemented to allow HBSC providers who are not accredited as PCA providers to continue to provide services and be paid for a continuity of care period of no longer than 180 days beginning July 1, 2014. This code will expire 1/1/2015. THIS CODE EXPIRES 1/1/2015
Home Delivered Meal Service (GO) S5170, Y9847 Home Delivered Meals S5170 Per Service -One meal per day Home delivered meals, including preparation; per meal
Personal Emergency Response System Pill Dispenser ? 1 Installation (GO) S5160 22 Medication Dispensing Device
(Set Up) T1505 Per Service Electronic medication compliance management device, includes all components and accessories, not otherwise classified
Personal Emergency Response System Pill Dispenser ? 1 Monthly Monitoring Fee (GO) S5161 22 Medication Dispensing Device
(Monthly Monitoring) S5185 Monthly Medication reminder service, nonface-to-face; per month
NA MLTSS PCA Current codes Codes per State Plan - Not a stand alone MLTSS benefit
Transportation - Non Medical (GO) Y9835, T2002, Y9834, A0080 Non-Medical Transportation T2002 per diem Nonemergency transportation; per diem; Not a stand alone MLTSS benefit.
T2003 Per Service Nonemergency transportation; encounter trip; Not a stand alone MLTSS benefit.
NA Nursing Facility Services
(Custodial) Revenue Codes 0100, 0119, 0129, 0139, 0149, 0159, 0169 NA Revenue Codes 0100, 0119, 0129, 0139, 0149, 0159, 0169.
SCNF - Revenue Codes 0100, 0119, 0129, 0139, 0149, 0159, 0169. NA SCNF - Revenue Codes 0100, 0119, 0129, 0139, 0149, 0159, 0169.

Therapies through a CRS or Day Program ? Occupational - Individual and Group (TBI) 97535 ST (Indiv), S9129 HQ ST (Group) Occupational Therapy
(Group & Individual) 97535 U2 15 minutes Occupational Therapy, 15 Minutes, (Individual - Maintenance Therapy) NOTE: For Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIERS MUST be included.
97535 U3 15 minutes Occupational Therapy, (Group - Maintenance Therapy) NOTE: For Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIERS MUST be included.
97535 U4 15 minutes Occupational Therapy (Individual) 15 minutes: Rehabilitation for MLTSS members with TBI diagnosis. Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIERS MUST included on any claim where the service is for MLTSS members with TBI diagnosis. One session per day.
97535 U5 15 minutes Occupational Therapy: (Group), 15 minutes: Rehabilitation for MLTSS members with TBI diagnosis. Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIER MUST be included on any claim where the service is for MLTSS members with TBI diagnosis. One session per day.
Personal Emergency Response System ? 1 Installation (CRPD, GO) S5160 (CRPD); S5160, Y9839 (GO) Personal Emergency Response System
(PERS: Set up) S5160 Per Service Emergency response system; service fee, Installation
Personal Emergency Response System ? 1 Monthly Monitoring Fee (CRPD, GO) S5161 (CRPD); S5161, Y9843 (GO) Personal Emergency Response System
(PERS: Monthly Monitoring) S5161 Per Month Emergency response system; service fee, per month - Standard Landline Unit
S5161 U1 Per Month Emergency response system; service fee, per month - Cellular Unit
S5161 U2 Per Month Emergency response system; service fee, per month - Cellular Unit with Fall Detection
S5161 U3 Per Month Emergency response system; service fee, per month - Mobile Unit
Therapies through a CRS or Day Program ? Physical (Group and Individual) (TBI) S8990 ST (Indiv); S9131 HQ ST (Group) Physical Therapy
(Group & Individual) 97110 U2 15 minutes Physical therapy; 15 Minutes (Individual - Maintenance Therapy) NOTE: For Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIER of U4 for Individual and U5 for Group MUST be included on any claim where the service is for habilitative therapy.
97110 U3 15 minutes Physical therapy; 15 minutes (Group - Maintenance Therapy) NOTE: For Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIER of U4 for Individual and U5 for Group MUST be included on any claim where the service is for habilitative therapy.
97110 U4 15 minutes Physical Therapy: (Individual), 15 minutes: Rehabilitation for MLTSS members with TBI diagnosis. Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIER MUST be included on any claim where the service is for MLTSS members with TBI diagnosis. One Session per day.
97110 U5 15 minutes Physical Therapy: (GROUP), 15 minutes, Rehabilitation for MLTSS members with TBI diagnosis. Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIER MUST be included on any claim where the service is for MLTSS members with TBI Diagnosis. One Session per day
PDN (Private Duty Nursing) - CRPD Z1710, Z1715, S9124, Z1720, Z1725, Z1730, Z1735, Z1740, Z1745 Private Duty Nursing T1000 UA 15 minutes RN/LPN Private duty / independent nursing service(s) - licensed, up to 15 minutes
T1002 UA 15 minutes RN only Private duty / independent nursing service(s) - licensed, up to 15 minutes
T1003 UA 15 minutes LPN Only Private duty/independent nursing service(s); licensed, up to 15 minutes
Environmental Modifications (CRPD); (EAA) Environmental Accessibility Adaptation (GO) S5165, S5165 52 (CRPD); S5165, Y9795 (GO) Residential Modifications S5165 Per Service Home modifications; per service
T1028 (Eval) Per Service Assessment of home, physical and family environment, to determine suitability to meet patient's medical needs
Respite Care (TBI); Respite Care: 8 hour Day. Respite Care : 8 hour night. Respite Care - Day >8<12, Respite Care Night >8<12, Respite Care - >12 <24, Respite Care ? Nursing Facility, Respite Care ? ALF or AFC ? Per Diem (GO) Y7456, Y7458, Y7463, (TBI): Z1210, S9125, Y9793, Z1215, Z1220, Z1225, Z1230, Z1285, Y9792, S5151 (GO) Respite
(Daily & Hourly)
T1005 15 minutes Respite care, in the home, per 15 minutes
S5151 Per Diem Unskilled respite care, not hospice; per diem
NF Respite REV 0663 DAILY Daily respite Care in a Nursing Facility
Social Adult Day Care (GO) Z1235, Y9853, S5102 Social Adult Day Care S5102 U3 Per Diem Day care services, adult; per diem
Therapies through a CRS or Day Program ? Speech Individual and Group (TBI) Y7556 Speech, Language & Hearing Therapy
(Group & Individual) 92507 U3 15 minutes Speech therapy, per diem (Individual - Maintenance Therapy) NOTE: For Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIERS MUST be included.
92508 U3 15 minutes Speech therap, per diem (Group - Maintenance Therapy) NOTE: For Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIERS MUST be included.
92507 U4 15 minutes Speech Therapy: (Individual), 15 minutes: Rehabilitation for MLTSS members with TBI diagnosis. Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIER MUST be included on any claim where the service is for MLTSS members with TBI diagnosis. One Session per day.
92508 U4 15 minutes Speech Therapy: (Group), 15 minutes: Rehabilitation for MLTSS members with TBI diagnosis. Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIER MUST be included on any claim where the service is for MLTSS members with TBI diagnosis. One Session per day.
Structured Day Program (TBI) S5102 ST, S5109, S5101 ST Structured Day Program S5100 15 minutes Day care services, adult; per 15 minutes
Supported Day Program (TBI) Y7443 Supported Day Services T2021 15 minutes Day habilitation, waiver; per 15 minutes
Environmental Adaptations- Vehicle (GO) ; S5165, S5165 52, Y9795, Y9854 Vehicle Modifications T2039 Per Service Vehicle modifications, waiver; per service
T2039 U7
(Eval) Per Service


New Only
MLTSS Service MLTSS Code MLTSS Code Description
Code Mod Method/ Unit
Adult Family Care S5140 Per Diem Foster care, adult; per diem
Assisted Living Services
(ALR - Assisted Living Residence) T2031 Per Diem Assisted living, waiver; per diem
Assisted Living Services
(CPCH - Comprehensive Personal Care Home) T2031 U1 Per Diem Assisted living, waiver; per diem
Assisted Living Program
(ALP) T2031 U2 Per Diem Assisted living, waiver; per diem
Behavior Management (TBI) H0004 15 minutes Behavioral health counseling and therapy, per 15 minutes (Individual)
H0004 HQ 15 minutes Behavioral health counseling and therapy, per 15 minutes (Group)
Caregiver/ Participant Training S5111 One Visit per day Home care training, family; per session
Chore Service S5120 15 minutes Chore services; per 15 minutes
S5121 Per Diem Chore services; per diem
Cognitive Therapy T2013 One Hour Habilitation, educational; waiver; per hour (Individual)
T2013 HQ One Hour Habilitation, educational; waiver; per hour (Group)
Community Residential Services
(CRS)
T2033 Per Diem Residential care, not otherwise specified (NOS), waiver; per diem (e.g., Low Level Supervision)
T2033 TF Per Diem Residential care, not otherwise specified (NOS), waiver; per diem (e.g., Moderate Level Supervision)
T2033 TG Per Diem Residential care, not otherwise specified (NOS), waiver; per diem (e.g., High Level Supervision)
Community Transition Services T2038 Per Service Community transition, waiver; per service
T2038 U6 Per Service Administration
Home Based Supportive Care S5130 15 Minutes Individual Homemaker service, NOS; per 15 minutes
S5130 HQ 15 Minutes Group Homemaker service, NOS, per 15 minutes
S5130 U1 15 Minutes Homemaker service, NOS, per 15 minutes. The code is to be used ONLY as a continuity of care code for existing recipients of HBSC when the member requires assistance with both ADLs and IADLs for a period of no longer than 180 days. This code is being implemented to allow HBSC providers who are not accredited as PCA providers to continue to provide services and be paid for a continuity of care period of no longer than 180 days beginning July 1, 2014. This code will expire 1/1/2015. THIS CODE EXPIRES 1/1/2015
S5130 U2 15 minutes Group Homemaker service, NOS, per 15 minutes. Group Homemaker service, NOS, per 15 minutes. The code is to be used ONLY as a continuity of care code for existing recipients of HBSC when the member requires assistance with both ADLs and IADLs for a period of no longer than 180 days. This code is being implemented to allow HBSC providers who are not accredited as PCA providers to continue to provide services and be paid for a continuity of care period of no longer than 180 days beginning July 1, 2014. This code will expire 1/1/2015. THIS CODE EXPIRES 1/1/2015
Home Delivered Meals S5170 Per Service -One meal per day Home delivered meals, including preparation; per meal
Medication Dispensing Device
(Set Up) T1505 Per Service Electronic medication compliance management device, includes all components and accessories, not otherwise classified
Medication Dispensing Device
(Monthly Monitoring) S5185 Monthly Medication reminder service, nonface-to-face; per month
MLTSS PCA Current codes Codes per State Plan - Not a stand alone MLTSS benefit
Non-Medical Transportation T2002 per diem Nonemergency transportation; per diem; Not a stand alone MLTSS benefit.
T2003 Per Service Nonemergency transportation; encounter trip; Not a stand alone MLTSS benefit.
Nursing Facility Services
(Custodial) Revenue Codes 0100, 0119, 0129, 0139, 0149, 0159, 0169 NA Revenue Codes 0100, 0119, 0129, 0139, 0149, 0159, 0169.
SCNF - Revenue Codes 0100, 0119, 0129, 0139, 0149, 0159, 0169. NA SCNF - Revenue Codes 0100, 0119, 0129, 0139, 0149, 0159, 0169.
Occupational Therapy
(Group & Individual) 97535 U2 15 minutes Occupational Therapy, 15 minutes (Individual - Maintenance Therapy) NOTE: For Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIERS MUST be included.
97535 U3 Per Diem Occupational Therapy, (Group - Maintenance Therapy) NOTE: For Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIERS MUST be included.
97535 U4 15 minutes Occupational Therapy (Individual) 15 minutes: Rehabilitation for MLTSS members with TBI diagnosis. Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIER of U4 for Individual and U5 for Group MUST be included on any claim where the service is for MLTSS members with TBI diagnosis. One session per day.
97535 U5 15 minutes Occupational Therapy: (Group), 15 minutes: Rehabilitation for MLTSS members with TBI diagnosis. Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIER of U4 for Individual and U5 for Group MUST be included on any claim where the service is for MLTSS members with TBI diagnosis. One session per day.
Personal Emergency Response System
(PERS: Set up) S5160 Per Service Emergency response system; service fee, Installation
Personal Emergency Response System
(PERS: Monthly Monitoring) S5161 Per Month Emergency response system; service fee, per month - Standard landline unit
U1 Per Month Emergency response system; service fee, per month - Cellular Unit
U2 Per Month Emergency response system; service fee, per month - Cellular Unit with Fall Detection
U3 Per Month Emergency response system; service fee, per month - Mobile Unit
Physical Therapy
(Group & Individual) 97110 U2 15 minutes Physical therapy; 15 minutes - (Individual - Maintenance Therapy) NOTE: For Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIERS MUST be included. .
97110 U3 15 minutes Physical therapy; per diem (Group - Maintenance Therapy) NOTE: For Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIERS MUST be included.
97110 U4 15 minutes Physical Therapy: (Individual), 15 minutes: Rehabilitation for MLTSS members with TBI diagnosis. Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIERS MUST be included on any claim where the service is for MLTSS members with TBI diagnosis. One Session per day.
97110 U5 15 minutes Physical Therapy: (GROUP), 15 minutes, Rehabilitation for MLTSS members with TBI diagnosis. Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIERS MUST be included on any claim where the service is for MLTSS members with TBI Diagnosis. One Session per day
Private Duty Nursing T1000 UA 15 minutes RN/LPN Private duty / independent nursing service(s) - licensed, up to 15 minutes
T1002 UA 15 minutes RN only Private duty / independent nursing service(s) - licensed, up to 15 minutes
T1003 UA 15 minutes LPN Only Private duty/independent nursing service(s); licensed, up to 15 minutes
Residential Modifications S5165 Per Service Home modifications; per service
T1028 (Eval) Per Service Assessment of home, physical and family environment, to determine suitability to meet patient's medical needs
Respite
(Daily & Hourly)
T1005 15 minutes Respite care, in the home, per 15 minutes
S5151 Per Diem Unskilled respite care, not hospice; per diem
REV 0663 DAILY Daily respite Care in a Nursing Facility
Social Adult Day Care S5102 U3 Per Diem Day care services, adult; per diem
Speech, Language & Hearing Therapy
(Group & Individual) 92507 U3 15 minutes Speech therapy, 15 minutes, (Individual - Maintenance Therapy) NOTE: For Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIER of U4 for Individual and U5 for Group MUST be included on any claim where the service is for habilitative therapy.
92508 U3 15 minutes Speech therap, 15minutes (Group - Maintenance Therapy) NOTE: For Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIER of U4 for Individual and U5 for Group MUST be included on any claim where the service is for habilitative therapy.
92507 U4 15 minutes Speech Therapy: (Individual), 15 minutes: Rehabilitation for MLTSS members with TBI diagnosis. Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIERS MUST be included on any claim where the service is for MLTSS members with TBI diagnosis. One Session per day.
92508 U4 15 minutes Speech Therapy: (Group), 15 minutes: Rehabilitation for MLTSS members with TBI diagnosis. Free Standing Clinic or ANY therapy service provided out of the home; EXISTING Codes should be used. THE MODIFIERS MUST be included on any claim where the service is for MLTSS members with TBI diagnosis. One Session per day.
Structured Day Program S5100 15 minutes Day care services, adult; per 15 minutes
Supported Day Services T2021 15 minutes Day habilitation, waiver; per 15 minutes
Vehicle Modifications T2039 Per Service Vehicle modifications, waiver; per service
T2039 U7
(Eval) Per Service
Self Directed Services
PCA T2025 SE Per Hour Self Directed PCA services, per hour rate of $15.50
PCA New Enrollee T2025 SE 52 Per Hour Self Directed PCA services, per hour, rate of $15.00
PCA Group ?S9122 SE Per Hour Self Directed PCA Services, GROUP, per hour rate of $11.76
PCA NEW Enrollee Group S9122 SE 52 Per Hour Self Directed PCA Services, GROUP, per hour rate of $11.40
Chore Services S5120 SE 15 minutes Self Directed Chore Services, Rate of $15.00
Home Based Supportive Care T1022 SE per occurrence Serl-Directed Home Based Supportive Care Rate of $9.00
Non - Medical Transportation T2003 SE per occurrence Self Directed Non-Medical Transportation Rate od $25.00




7/2018 Accepted


MLTSS SERVICES DICTIONARY


A program that applies solely to individuals who meet MLTSS eligibility requirements and
encompasses the NJ FamilyCare A benefit package, NJ FamilyCare ABP as specified in Article
4.1.1.C, HCBS and institutionalization for long term care in a nursing facility or special care
nursing facility.





7/2018 Accepted


Adult Family Care (Eligible for MFP 25%)

Adult Family Care (AFC) enables up to three unrelated individuals to live in the community in
the primary residence of a trained caregiver who provides support and health services for the
resident. Adult Family Care may provide personal care, meal preparation, transportation,
laundry, errands, housekeeping, socialization and recreational activities, monitoring of
participant?s funds when requested by the participant, up to 24 hours a day of supervision, and
medication administration.

Service Limitations:

Individuals that opt for Adult Family Care do not receive Personal Care Assistant services,
Chore Service, Home-Delivered Meals, Home-Based Supportive Care, Caregiver/Participant
Training, Assisted Living, or Assisted Living Program. Those services would duplicate services
integral to and inherent in the provision of Adult Family Care services. A person may not
receive long term care nursing home care at the same time they are in Adult Family Care. The
individual service recipient or their authorized representative is responsible to pay the cost of
room and board.

Adult Family Care Members may attend Social Adult Day Care two (2) days per week.

Provider Specifications:

? Licensed Adult Family Care (AFC) Sponsor Agency (Agency):
? Licensed by HFEL

MLTSS HIPAA COMPLIANT CODE:
S5140

Unit of Service: 1 day (Per Diem)

Licensing Entity: HFEL

Accredited by:

Regulation Cites:

Taxonomy Code:





7/2018 Accepted


Assisted Living Services (ALR, CPCH)

Assisted Living Services means a coordinated array of supportive personal and health services, ,
medication administration, available 24 hours per day, to residents who have been assessed to
need these services including persons who require a nursing home level of care. Assisted Living
Services include personal care, and medication oversight and administration throughout the day.
A planned, diversified program of resident activities shall be offered daily for residents,
including individual and/or group activities, on-site or off-site, to meet the individual needs of
residents. Assisted Living facilities also either arrange or provide for transportation that is
specified in the Plan of Care and periodic nursing evaluations. Assisted Living promotes
resident self-direction and participation in decisions that emphasize independence, individuality,
privacy, dignity, and homelike surroundings.

1. Assisted Living Residence (ALR) means a facility which is licensed by the Department

of Health to provide apartment-style housing and congregate dining and to ensure that
assisted living services are available when needed, for four or more adult persons
unrelated to the proprietor. Apartment units within the assisted living residence offer, at a
minimum, one unfurnished room, a private bathroom, a kitchenette, and a lockable door
on the unit entrance. Residents in ALRs have access to both their own living unit?s
kitchen 24/7 and to a facility food and beverages 24/7.


Comprehensive Personal Care Home (CPCH) means a facility which is licensed by the
Department of Health to provide room and board and to ensure that assisted living services are
available when needed, to four or more adults unrelated to the proprietor. Residential units in
comprehensive personal care homes house no more than two residents and have a lockable door
on the unit entrance. Residents in CPCHs have access to facility food and beverages 24/7 and, if
equipped, access to their own unit?s food preparation area.

Service Limitations:

Individuals that opt for Assisted Living Services in an ALR/CPCH do NOT receive: Personal
Care Assistant (PCA) services, Adult Day Health Services (ADHS), Adult Family Care, Assisted
Living Program, Environmental Accessibility Adaptations, Chore Services, Personal Emergency
Response Services, Home-Delivered Meals, Caregiver/Participant Training, Adult Day Health
Services, Social Adult Day Care, Attendant Care, Home-Based Supportive Care, or Respite as
they would duplicate services integral to and inherent in the provision of Assisted Living
Services.

Individuals in an ALR/CPCH are responsible to pay their room and board costs.

Provider Specifications:

Assisted Living Facility licensed by the Department of Health pursuant to N.J.A.C. 8:36 as an
Assisted Living Facility. Appropriateness for this type of housing is subject to screening through
the housing screening process. Must meet licensing requirements, as applicable per:





7/2018 Accepted


? N.J.A.C. 8:34 - Rules for Licensing Nursing Home Administrators and Rules Regulating
the Nursing Home Administrators Licensing Board

? N.J.A.C. 8:36 - Standards For Licensure of Assisted Living Residences, Comprehensive
Personal Care Homes, and Assisted Living Programs

? N.J.A.C. 8:43E - Standards For Licensure of Residential Health Care Facilities, General
Licensure Procedures and Enforcement of Licensure Regulations

? N.J.A.C. 8:43I - Criminal Background Investigations: Nurse Aides, Personal Care
Assistants and Assisted Living Administrators


MLTSS HIPAA COMPLIANT CODE:
T2031 (ALR 1 DAY); T2031_U1 (CPCH 1 DAY)

Unit of Service: 1 day (per diem)

Licensing Entity: Health Facilities Evaluation and Licensing (HFEL)

Accredited by:

Regulation Cites: N.J.A.C. 8:34, 8:36, 8:43E, 8:43I

Taxonomy Code:





7/2018 Accepted


Assisted Living Program (ALP) (Eligible for MFP 25%)

Assisted Living Program means the provision of assisted living services to the tenants/residents
of certain publicly subsidized housing buildings. Assisted Living Programs (ALPs) are available
in some subsidized senior housing buildings. Each ALP provider shall be capable of providing
or arranging for the provision of assistance with personal care, and of nursing, pharmaceutical,
dietary and social work services to meet the individual needs of each resident.

Assisted Living Services include personal care, homemaker, chore, and medication oversight and
administration throughout the day.

Individuals receiving services from an ALP reside in their own independent apartments. The
individual is responsible for his or her own rent and utility payments as defined in a lease with
the landlord. Individuals are also responsible for the cost of meals and other household
expenses.

Having an ALP provider offers the subsidized housing tenants the opportunity to remain in their
own apartments with the support of others, while maintaining their independence and dignity.

Participation in the services of an Assisted Living Program (ALP) is voluntary on the part of any
tenant of any ALP contracted publicly subsidized housing building.

The ALP is to make available dining services and/or meal preparation assistance to meet the
daily nutritional needs of residents.

ALP providers work with participants to ensure a strong sense of connectedness in each
apartment community as well as with the larger communities in which they are located.
Individuals may participate in tenant/resident meetings, attend community-based civic
association meetings and plan recreational activities. Sometimes, ALP providers host
community health screening events to encourage wellness for the tenant population at large.

By State regulation, ALP providers shall have written policies and procedures for arranging
resident transportation to and from health care services provided outside of the program site, and
shall provide reasonable plans for security and accountability for the resident and his or her
personal possessions. ALP Providers shall develop a mechanism for the transfer of appropriate
resident information to and from the providers of service, as required by individual residents and
as specified in their service plans. ALP participants, not ALR or CPCH participants may attend
Social Adult Day Care 2 (two) days a week; (3) three days with prior authorization.

Service Limitations:

Individuals that opt for Assisted Living Program (ALP) do NOT receive: Personal Care Assistant
(PCA) services, Chore Service, Home-Based Supportive Care, Caregiver/Participant Training,
Assisted Living, or Adult Family Care as they would duplicate services integral to and inherent
in the provision of Assisted Living Program services. The subsidized housing provider is
responsible for Environmental Accessibility Adaptations.




7/2018 Accepted



A person enrolled in the ALP is NOT permitted to attend Adult Day Health Services (also called
medical day care) as it would duplicate an ALP service as required by N.J.A.C. 8:36-23.14(a).

The ALP provider must agree to accept the individual in the facility as a Medicaid MLTSS
participant.

Provider Specifications:

Assisted Living Facility licensed by the Department of Health pursuant to N.J.A.C. 8:36 as an
Assisted Living Facility. Appropriateness for this type of housing is subject to screening through
the housing screening process. Must meet licensing requirements, as applicable per:

? N.J.A.C. 8:34 - Rules for Licensing Nursing Home Administrators and Rules Regulating

the Nursing Home Administrators Licensing Board
? N.J.A.C. 8:36 - Standards For Licensure of Assisted Living Residences, Comprehensive

Personal Care Homes, and Assisted Living Programs
? N.J.A.C. 8:43E - Standards For Licensure of Residential Health Care Facilities, General

Licensure Procedures and Enforcement of Licensure Regulations
? N.J.A.C. 8:43I - Criminal Background Investigations: Nurse Aides, Personal Care

Assistants and Assisted Living Administrators

MLTSS HIPAA COMPLIANT CODE:
T2031_U2 (ALP 1 DAY)

Unit of Service: 1 day (per diem)

Licensing Entity: Health Facilities Evaluation and Licensing (HFEL)

Accredited by:

Regulation Cites: N.J.A.C 8:34, 8:36, 8:43E, 8:43I

Taxonomy Code:





7/2018 Accepted


Behavioral Management - TBI (Group and Individual) (Eligible for MFP 25%)

A daily program provided by, and under the supervision of, a licensed psychologist or board-
certified/board-eligible psychiatrist and by trained behavioral aides designed to service recipients
who display severe maladaptive or aggressive behavior which is potentially destructive to self or
others. The program, provided in the home or out of the home, is time-limited and designed to
treat the individual and caregivers, if appropriate, on a short-term basis. Behavioral
programming includes a complete assessment of the maladaptive behavior(s); development of a
structured behavioral modification plan, implementation of the plan, ongoing training and
supervision of caregivers and behavioral aides, and periodic reassessment of the plan. The goal
of the program is to return the individual to the prior level of functioning which is safe for
him/her and others.

Service Limitations:

Entry to this service is based on medical necessity criteria as defined in the contract. The
individual must have a diagnosis of acquired, non-degenerative, or traumatic brain injury or
formerly a TBI waiver participant who transitions into MLTSS. Program enrollment requires
prior evaluation and recommendation of a board-certified and eligible psychiatrist, a licensed
neuro-psychologist or neuro-psychiatrist with subsequent consultation by same on an as-needed
basis.

Provider Specifications:

? A board-certified and board-eligible psychiatrist
? Clinical psychologist
? Mental Health Agency
? A rehabilitation hospital
? Community Residential Services (CRS) provider
? Post-acute non-residential rehabilitative services provider agency


MLTSS HIPAA COMPLIANT CODE:
H0004_HQ = GROUP;
H0004 = INDIVIDUAL

Unit of Service: 15 minutes = ONE unit of service

Licensing Entity:

Accredited by:

Regulation Cite:

Taxonomy Code:





7/2018 Accepted


Caregiver/ Participant Training (Eligible for MFP 25%)

Instruction provided to a client and/or caregiver in either a one-to-one or group situation to teach
a variety of skills necessary for independent living, including but not limited to: coping skills to
assist the individual in dealing with disability; coping skills for the caretaker to deal with
supporting someone with long term care needs; skills to deal with care providers and attendants.
Examples include seminars on supporting someone with dementia, seminars to support someone
with mobility difficulties. Training needs must be identified through the comprehensive
evaluation, re-evaluation, or in a professional evaluation and must be identified in the approved
Plan of Care as a required service.

Service Limitations:

Caregiver/Participant Training is not available to participants who have chosen Assisted Living
Services, Assisted Living Program or Adult Family Care. This training will not duplicate the
training that would be inherent in a therapist?s scope of practice on instruction on use of adaptive
equipment.

One visit per day

Provider Specifications:

? Individual with appropriate expertise (i.e. RN, OT) to train the recipient/caregiver as

required by the Plan of Care (Individual Provider)
? Centers for Independent Living (CIL)
? Health Care Service Firm
? Licensed Medicare Certified Home Health Agency
? Adult Family Care Sponsor Agency
? Proprietary or Not-for-Profit Business entity

MLTSS HIPAA COMPLIANT CODE:
S5111

Unit of service: One visit per day

Licensing Entity:

Accredited by:

Regulation Cite:

Taxonomy Code:





7/2018 Accepted


Chore Services (Eligible for MFP 25%)

Services needed to maintain the home in a clean, sanitary and safe environment. The chores are
non-continuous, non-routine heavy household maintenance tasks intended to increase the safety
of the individual. Chore services include cleaning appliances, cleaning and securing rugs and
carpets, washing walls, windows, and scrubbing floors, cleaning attics and basements to remove
fire and health hazards, clearing walkways of ice, snow, leaves, trimming overhanging tree
branches, replacing fuses, light bulbs, electric plugs, frayed cords, replacing door locks, window
catches, replacing faucet washers, installing safety equipment, seasonal changes of screens and
storm windows, weather stripping around doors, and caulking windows.

Service Limitations:

Chore services are not available to those who opt for Assisted Living Services, Assisted Living
Program or Adult Family Care. Chore services are appropriate only when neither the participant,
nor anyone else in the household, is capable of performing the chore; there is no one else in the
household capable of financially paying for the chore service; and there is no relative, caregiver,
landlord, community agency, volunteer, or 3rd party payer capable or responsible to complete
this chore.

Chore Services do not include normal everyday housekeeping tasks such as dusting, vacuuming,
changing bed linens, washing dishes, cleaning the bathroom, etc. Utility providers who offer
free services shall be used first for home weatherization/energy efficiency products. In the case
of rental property, the responsibility of the landlord pursuant to the lease is to be examined prior
to any authorization for service. In the case of an individual residing in a community governed
by a homeowner association or community trust, the obligations of the association or trust to
make repairs and renovations also should be examined prior to any authorization for service

Provider Specifications:

? Private Contractor (Individual Provider)
? Subsidized Independent Housing for Seniors
? Is a business entity with evidence of authority to conduct such business in New Jersey,

(i.e. New Jersey Tax Certificate or Trade Name Registration)
? Has any license required by law to engage in the service, provide furnishings, appliances,

equipment
? Has Product/business Insurance, including Worker?s Compensation, provides required

evidence of qualifications and signs an agreement with the MCO to provide services prior
to providing initial service.

? Participant Directed Provider


MLTSS HIPAA COMPLIANT CODE:
S5120 (15 minutes); S5121 (PER DIEM)
S5120 SE (15 minutes)

Unit of service = 15 Minutes; PER DIEM. No current limit on the maximum number of hours




7/2018 Accepted



Licensing Entity:

Accredited by:

Regulation Cite:

Taxonomy Code:




7/2018 Accepted


Cognitive Rehabilitation Therapy (Group and Individual) (Eligible for MFP 25%)

Therapeutic interventions for maintenance and prevention of deterioration which include direct
retraining, use of compensatory strategies, use of cognitive orthotics and prostheses, etc.
Activity type and frequency are determined by assessment of the participant, the development of
a treatment plan based on recognized deficits, and periodic reassessments. Cognitive
Rehabilitation therapy can be provided in various settings, including but not limited to the
individual?s own home and community, outpatient rehabilitation facilities, or residential
programs. This service may be provided by professionals with the credentials, training,
experience, and supervision noted in Provider Specifications.

MLTSS Cognitive Rehabilitation Therapy Services may be considered medically necessary
when the following conditions are met:

1. The therapy is for a condition that requires a provider with the unique knowledge and

skills in the provision of Cognitive Rehabilitation Therapy as delineated in the Provider
Specifications noted below, and is a part of the beneficiary?s skilled treatment plan; and

2. There is an expectation that the therapy will incrementally (minimal unpredictable
changes over longer lengths of time) improve and/or prevent the loss of previously
achieved/attained progress ; and

3. An individual would either not be expected to develop the function or would be expected
to permanently lose the function without the MLTSS Cognitive Rehabilitation Therapy
service (not merely fluctuate); and

4. The MLTSS Cognitive Rehabilitation Therapy on-going clinical documentation
objectively continues to verify that, at a minimum, functional status is preserved while
continued pursuit of incremental progress toward further development; and

5. The services are delivered by a qualified provider of Cognitive Rehabilitation Therapy
services who has experience in delivery of therapy services to individuals with TBI.


Clinical assessment by the provider shall be used to objectively determine and verify that, at a
minimum, functional status is preserved while continued incremental (minimal unpredictable
changes over longer lengths of time) progress towards further development is pursued. This will
be utilized to establish member?s need of MLTSS Cognitive Rehabilitation Therapy.

Service Limitations:


? The individual must have a diagnosis of acquired, non-degenerative, or traumatic
brain injury or formerly a TBI waiver participant who is assessed to be in need of
Cognitive Rehabilitation Therapy and who transitions to MLTSS.

? MLTSS Cognitive Rehabilitation Therapy is provided for an individual with a
TBI diagnosis. This therapy is not eligible under Medicare, Medicaid State Plan
and/or Third Party coverage/benefits for this service.

? The ratio for group sessions may not be larger than ONE therapist to FIVE
patients.

? The MCO will determine the number of authorized therapy units that will be
included in a member?s plan of care.




7/2018 Accepted


? A member may receive individual and group units of the same therapy; e.g.
morning units of individual therapy and afternoon units of group therapy in the
same day.

? A member may receive different therapies on the same day of service; e.g.,
morning units of individual ST, morning units of OT, and afternoon units of CRT.


Provider Specifications:


? Minimum of a master?s degree or a degree in an allied health field from an
accredited institution or holds licensure and/or certification; or

? Minimum of a bachelor?s degree from an accredited institution in an allied health
field where the degree is sufficient for licensure, certification or registration or in
fields where licensure, certification or registration is not available (i.e., special
education);

? Applicable degree programs including but not limited to communication disorders
(speech), counseling, education, psychology, physical therapy, occupational
therapy, recreation therapy, social work, and special education;

? Certified Occupational Therapy Assistants (COTAs) and Physical Therapy
Assistants (PTAs) may provide this service only under the guidelines described in
the New Jersey practice acts for occupational and physical therapists.

? Staff members who meet the above-mentioned degree requirements, but are not
licensed or certified, may practice under the supervision of a practitioner who is
licensed and/or meets the criteria for certification by the Society for Cognitive
Rehabilitation (actual certification is not necessary so long as criteria is met).
o Supervision

? This service must be coordinated and overseen by a provider
holding at least a master?s degree. Provided by a professional that
is licensed or certified. The master?s level provider must ensure
that bachelor?s level providers receive the appropriate level of
supervision, as delineated below.

? Supervision for providers who are not licensed or certified is based
on the number of years of experience

? For staff with less than one year of experience: four hours of
individual supervision per month.

? For staff with one to five years? experience: two hours individual
supervision per month

? For staff with more than five years? experience: one hour per
month.


All individuals who provide or supervise the service must complete 6 hours of relevant ongoing
training in Cognitive Rehabilitation Therapy and/or brain injury rehabilitation. Training may
include, but is not limited to, participation in seminars, workshops, conferences, and in-services.

MLTSS HIPAA COMPLIANT CODE:
INDIVIDUAL: G0515_96 (15 minutes) effective 1/1/2018
GROUP: 96153_96_59 (15 minutes)




7/2018 Accepted



When a member is receiving multiple therapy sessions on the same day of service, the provider
must use the modifier "59" in addition to the modifier for MLTSS when submitting the claim for
payment. This will permit the claim to be processed and not be subject to the NCCI conflict
edits. If the member is only receiving one (a SINGLE) therapy session on a given date, the
provider will NOT use the modifier "59".


Unit of Service: 15 minutes with a maximum allowable of no more than 8 units in a 24 hour
period.

Licensing Entity:

Accredited by:

Regulation Cites:

Taxonomy Code:




7/2018 Accepted


Community Residential Services (CRS) (Eligible for MFP 25%)

A package of services provided to a participant living in the community, residence-owned,
rented, or supervised by a CRS provider. The services include personal care, companion
services, chore services, transportation, night supervision, and recreational activities. A CRS is a
participant?s home. The CRS provider is responsible for coordinating the service to ensure the
participant?s safety and access to services as determined by the participant and care manager.
Participants are assigned one of three levels of supervision. These levels are determined by the
dependency of the participant. The care manager, in conjunction with CRS staff, evaluate
participant, using the ?LEVEL OF CARE GUIDELINES FOR CRS? form as a guide.

Service Limitations:

The individual must have a diagnosis of acquired, non-degenerative, or traumatic brain injury or
formerly a TBI waiver participant who is transitioning to MLTSS. The level of assessment is
assessed minimally on an annual basis, more frequently if there is a change in participants? care.
Only one level of service can be billed per 24-hour period (12:00 a.m. to 11:59 p.m.)

? The participant must have a diagnosis of TBI and meet MLTSS Nursing Facility Level of

Care
? The participant or their responsible party must pay room and board costs
? The participant must agree to receive the therapy services of the CRS provider


Provider Specifications:

? Current license per N.J.A.C 10:44C to operate as a group home for individuals with a

diagnosis of TBI

MLTSS HIPAA COMPLIANT CODES:
SERVICE BASED ON LEVEL OF NEED:
? Low Level Supervision: T2033
? Moderate Level Supervision: T2033_TF
? High Level Supervision: T2033_TG

Unit of Service = per diem

Licensing Entity:
STATE OF NEW JERSEY
DEPARTMENT OF HUMAN SERVICES
OFFICE OF LICENSING
DEVELOPMENTAL DISABILITIES LICENSING

Accredited by:

Regulation Cites: N.J.A.C. 10:44C





7/2018 Accepted


Taxonomy Code:




7/2018 Accepted


Community Transition Services (Eligible for MFP 25%)

Those services provided to a participant that may aid in the transitioning from institutional
settings to his/her own home in the community through coverage of non-recurring, one-time
transitional expenses. This service is provided to support the health, safety and welfare of the
participant. Allowable expenses are those necessary to enable a person to establish a basic
household that do not constitute room and board and may include:

? security deposits and necessary application fees that are required to obtain a lease on an

apartment or home;
? essential household furnishings and moving expenses required to occupy and use a

community domicile, including furniture, window coverings, food preparation items, and
bed/bath linens;

? set-up fees or deposits for utility or service access, including telephone, electricity,
heating and water;

? services necessary for the individual?s health and safety such as pest eradication and one-
time cleaning prior to occupancy;

? necessary accessibility adaptations to promote safety and independence; and
? activities to assess need, arrange for and procure needed resources.

Service Limitations:

? Limit of up to $5,000.
? Community Transition Services do not include residential or vehicle modifications.

Community Transition Services do not include recreational items such as televisions,
cable television access or video players.

? Community Transition Services do not include monthly rental or mortgage expenses.
Payment for security deposit is not considered rent.

? Community Transition Services do not include recurring expenses such as food and
regular utility charges.

? Community Transition Services do not include payment for room and board.
? Community Transition Services are one-time per the life of the individual.
? Community Transition Services are furnished only to the extent that they are reasonable

and necessary as determined through the service plan development process, clearly
identified in the service plan, and the person is unable to meet such expense or when the
services cannot be obtained from other sources.

? Service is based on identified need as indicated in the plan of care.

MLTSS HIPAA COMPLIANT CODE:
T2038; T2038_U6 for administration

Unit of Service: As negotiated per the MCO.

Licensing Entity:

Accredited by:




7/2018 Accepted



Regulation Cites:

Taxonomy Code:





7/2018 Accepted


Home Based Supportive Care (Eligible for MFP 25%)

Home-Based Supportive Care (HBSC) services are designed to assist MLTSS participants with
their Instrumental Activities of Daily Living (IADL) needs. HBSC are available to individuals
whose Activities of Daily Living (ADL) needs are provided by non-paid caregivers such as a
family member or as a wrap-around service to non-Medicaid programs such as Veterans Health
Care System that are assisting participants with their ADL health related tasks. HBSC services
must address IADL deficits identified through the NJ Choice comprehensive assessment process
and go beyond ?health-related? services.

Home-Based Supportive Care is distinct from the State Plan service of Personal Care Assistant in
that it does not include ?hands on personal care.? According to N.J.A.C. 10:60-1.2, Personal
Care Assistant (PCA) services means ?health related tasks performed by a qualified individual in
a beneficiary?s home, under the supervision of a Registered Nurse, as certified by a physician in
accordance with a beneficiary?s written plan of care.

Home-Based Supportive Care includes services such as, but not limited to the following: meal
preparation, grocery shopping, money management, light housework, laundry.

Service Limitations:

Home-Based Supportive Care is not available for those who have chosen Assisted Living
Services (ALR, CPCH, ALP). Since the PCA State Plan Service can assist with IADL, HBSC is
offered only when Activities of Daily Living related tasks are provided by a caregiver or another
non-Medicaid program.

Provider Specifications:

? Licensed Home Health Agency
? Licensed Health Care Service Firm
? Licensed Employment Agency or Temporary Help Agency
? Congregate Housing Services Program
? Licensed Hospice Provider
? Participant Directed Provider

MLTSS HIPAA COMPLIANT CODE:
S5130 (15 minutes)
S5130 HQ - Group Homemaker Service, NOS per 15 minutes; T1022_SE Self Directed

Unit of Service = 15 minutes

Licensing Entity:

Accredited by:

Regulation Cites: N.J.A.C. 10:60-1.2




7/2018 Accepted



Taxonomy Codes:




7/2018 Accepted


Home-Delivered Meals (Eligible for MFP 25%)

Nutritionally balanced meals delivered to the participant?s home when this meal provision is
more cost effective than having a personal care provider prepare the meal. These meals do not
constitute a full nutritional regimen, but each meal must provide at least 1/3 of the current
Dietary Reference Intakes (DRIs) established by the Food & Nutrition Board of the National
Academy of Sciences, and National Research Council.

Criteria: Home-delivered meals are provided to an individual residing in an unlicensed residence,
only when the participant is unable to prepare the meal, unable to leave the home independently,
and there is no other caregiver, paid or unpaid, to prepare the meal. No more than one meal per
day will be provided through the MLTSS benefit.

Persons eligible for home delivered meals are those individuals:


1. Who are home-bound;
2. Are 18 years of age and older;
3. Incapacitated due to accident, illness, or frailty;
4. Unable to prepare meals because of lack of facilities, inability to shop or cook for self,

unable to prepare meals safely, or lack knowledge and skills to prepare meals;
5. Lacking support from family, friends, neighbors or other caregivers to help secure meals.
6. Receives home health aide services less than three hours a day.


Menus for Home Delivered Nutrition programs must be certified and documented as meeting DRI
standards by a qualified nutritionist.

An in home assessment is required, to determine if a weekly or biweekly delivery of refrigerated or
frozen meals is suitable for the participant. Specifically:


? The client indicates a preference for refrigerated /frozen meal;
? The client must have adequate storage to safely store the frozen meals;
? The client must have the needed appliance to safely prepare the frozen meals and must

demonstrate their ability in using the appliance safely;


The individual delivering the meal must bring to the attention of appropriate officials, conditions or
circumstances that place the older person or household in imminent danger.

Service Limitations:

When the participant?s needs cannot be met due to: geographic inaccessibility, special dietary
needs, the time of day or week the meal is needed, a meal may be provided by restaurants,
cafeterias, or caterers who comply with current DRIs, the New Jersey State Department of
Health and local Board of Health regulations for food service establishments.

Home-Delivered Meals are not provided in an Assisted Living Facility (ALR/CPCH ONLY) or
Adult Family Care as meal provision is included in the Assisted Living Facility or Adult Family




7/2018 Accepted


Care service package. A Home-Delivered Meal is not to be used to replace the regular form of
?board? associated with routine living in an Assisted Living Facility or Adult Family Care
Home.

A Home Delivered Meal may be provided in Assisted Living Program (ALP)

Provider Specifications:

? Area Agency on Aging (AAA) Title III Nutrition Program
? Provider of Meal Service, who meets the criteria set forth in New Jersey Standards for the

Nutrition Program for Older Americans, PM 2011-33, I-164, dated January 3, 2012.
? All Home Delivered Nutrition providers must ensure that the meals meet one-third (1/3)

RDI requirements and all food handling must comply with NJAC 8:24-1, ?Chapter 24
Sanitation in Retail Food Establishments and Food and Beverage Vending Machines.?
Additionally, the State Department of Health/Division of Epidemiology, Environmental
and Occupational Health and/or local health department personnel will conduct routine
unannounced operational inspections of all caterers, kitchens and sites involved in the
program annually as often as deemed necessary. Follow-up inspections are conducted
and/or initiate legal action when conditions warrant.

? Home Delivered Nutrition programs will provide at least one hot or other appropriate
home delivered meal, daily for five or more days per week


MLTSS HIPAA COMPLIANT CODE:
S5170

Unit of Service: One Meal per day

Licensing Entity: Department of Health

Accredited by:

Regulation Cite: NJAC 8:24-1, ?Chapter 24 Sanitation in Retail Food Establishments and Food
and Beverage Vending Machines.?, New Jersey Standards for the Nutrition Program for Older
Americans, PM 2011-33, I-164, dated January 3, 2012

Taxonomy Code:




7/2018 Accepted


Medication Dispensing Device: SET UP (Eligible for MFP 25%)

This may include an electronic medication-dispensing device that allows for a set amount of
medications to be dispensed as per the dosage instructions. If the medication is not removed
from the unit in a timely manner the unit will "lock" that dosage, not allowing the participant
access to the missed medication. Before locking, the unit will use a series of verbal and/or
auditory reminders that the participant is to take his or her medication. If there is no response, a
telephone call will be made to the participant, participant's contact person, and care management
site in that order until a "live" person is reached. Installation, upkeep and maintenance of
device/systems are provided.

Service Limitations:

Per Medical Necessity as defined in the contract. Medication Dispensing Device is for an
individual who lives alone or who is alone for significant amounts of time per the plan of care.
Individuals might not have a regular care giver for extended periods of time or would require
extensive routine supervision.

Provider Specifications:

The provider must apply and become approved through the MCO.

MLTSS HIPAA COMPLIANT Code:
T1505

Unit of Service: Per Occurrence

Licensing Entity:

Accredited by:

Regulation Cites:

Taxonomy Code:





7/2018 Accepted


Medication Dispensing Device: Monthly Monitoring (Eligible for MFP 25%)

This may include an electronic medication-dispensing device that allows for a set amount of
medications to be dispensed as per the dosage instructions. If the medication is not removed
from the unit in a timely manner the unit will "lock" that dosage, not allowing the participant
access to the missed medication. Before locking, the unit will use a series of verbal and/or
auditory reminders that the participant is to take his or her medication. If there is no response, a
telephone call will be made to the participant, participant's contact person, and care management
site in that order until a "live" person is reached. Installation, upkeep and maintenance of
device/systems are provided.

Service Limitations:

Per Medical Necessity as defined in the contract. Medication Dispensing Device is for an
individual who lives alone or who is alone for significant amounts of time per the plan of care.
Individuals might not have a regular care giver for extended periods of time or would require
extensive routine supervision.

Provider Specifications:

The provider must apply and become approved through the MCO.

MLTSS HIPAA COMPLIANT CODE:
S5185

Unit of Service: Monthly Monitoring Fee

Licensing Entity:

Regulation Cites:

Accredited by:

Taxonomy Code:





7/2018 Accepted


Non-Medical Transportation (Eligible for MFP 25%)

Service offered to enable individuals to gain access to community services, activities and
resources specified in the Plan of Care. This service is offered in addition to medical
transportation required under 42 Code of Federal Regulations 431.53 and transportation services
under the State plan, defined at 42 Code of Federal Regulations 440.170(a) (if applicable), and
shall not replace them. Transportation services shall be offered in accordance with the
individual?s Plan of Care. Transportation is a service that enhances the individual?s quality of
life. An approved provider may transport the participant to locations including but not limited
to: shopping; beauty salon; financial institution; or religious services of his or her choice.

Service Limitations:

Services are limited to those that are required for implementation of the Plan of Care.
Whenever possible, family, neighbors, friends, public transit, tickets, or community agencies,
which can provide this service without charge, will be utilized.

Provider Specifications

? Vehicle must be maintained in proper operating condition and must meet the

requirements of New Jersey regulations, as evidenced by a valid inspection sticker.
? Owner must have proof of liability insurance coverage for the vehicle
? Owners and drivers are required to undergo civil and criminal background checks
? Evidence of Insurance, i.e. Declaration Page from Insurance Company
? Provides Description of vehicles used in service and copies of any required licenses.
? Vehicle appropriately registered, inspected and insured. Driver licensed to operate the

vehicle.
? Provides proof of New Jersey Business Authority, i.e. tax certificate or trade name

registration.
? Provides Fee Schedule.
? Participant Directed Provider

MLTSS HIPAA COMPLIANT CODES:
T2002 (per diem)
T2003: Per service (Encounter/Trip)
T2003SE: (self-directed) ? Encounter/Trip

Unit of Service: One Way Trip

Licensing Entity:

Accredited by:

Regulation Cites:

Taxonomy Code:




7/2018 Accepted


Nursing Facility and Special Care Nursing Facility Services (Custodial)

A facility that is licensed (per N.J.A.C 8:39 and 8:85) to provide health care under medical
supervision and continuous nursing care for 24 or more consecutive hours to two or more
patients who do not require the degree of care and treatment which a hospital provides and who,
because of their physical or mental condition, require continuous nursing care and services above
the level of room and board. NF/SCNF residents are those individuals who require services
which address the medical, nursing, dietary and psychosocial needs that are essential to obtaining
and maintaining the highest physical, mental, emotional and functional status of the individual.
Care and treatment shall be directed toward development, restoration, maintenance, or the
prevention of deterioration. Care shall be delivered in a therapeutic health care environment with
the goal of improving or maintaining overall function and health status. The therapeutic
environment shall ensure that the individual does not decline (within the confines of the
individual's right to refuse treatment) unless the individual's clinical condition demonstrates that
deterioration was unavoidable.

All Medicaid participating NFs and SCNFs shall provide or arrange for services in accordance
with statutory and regulatory requirements under 42 CFR 483 and Department of Health
licensing rules at N.J.A.C. 8:39.

Reimbursement of NF services is discussed in N.J.A.C. 8:85-3.

NF and SCNF services shall be delivered within an interdisciplinary team approach. The
interdisciplinary team shall consist of a physician and a registered professional nurse and may
also include other health professionals as determined by the individual's health care needs. The
interdisciplinary team performs comprehensive assessments and develops the interdisciplinary
care plan.

Service Limitations:

The individual must meet Nursing Facility Level of Care as determined and/or authorized by the
NJ Department of Human Services, Office of Community Choice Options or their designee.
Provider Specifications: Current license to operate as a Nursing Facility in NJ as per the
Department of Health's N.J.A.C. 8:39 and 8:85.

Unit of Service: 1 day

MLTSS HIPAA COMPLIANT CODE:
Revenue Codes:
NFs: Rev codes 0100, 0119, 0120, 0129, 0139,0149, 0159,0169
SCNF: Rev codes 0100, 0119, 0120, 0129, 0139,0149, 0159,0169

Licensing Entity: NJ Department of Health, Health Facilities Evaluation and Licensing

Regulation Cite: 42 CFR 483 and N.J.A.C. 8:39 and 8:85.





7/2018 Accepted


Accredited by:

Taxonomy Code:





7/2018 Accepted


Occupational Therapy (Group and Individual) (Eligible for MFP 25%)

MLTSS Occupational Therapy Services are intended to incrementally (minimal unpredictable
changes over longer lengths of time) develop or improve skills, or prevent the loss of previously
achieved/attained progress which is at risk of being lost as a result of a traumatic or acquired
non-degenerative brain injury (TBI/ABI). MLTSS Occupational Therapy is also intended to
allow a member to acquire new skills that will allow them to function optimally in their current
or future least restrictive environment.

MLTSS Occupational Therapy Services may be considered medically necessary when all of the
following conditions are met:

1. The therapy is for a condition that requires the unique knowledge, skills, and judgment of

an Occupational Therapist for education and training that is part of a clinician?s (OT)
skilled plan of treatment; and

2. There is an expectation that the therapy will incrementally (minimal unpredictable
changes over longer lengths of time) improve and/or prevent the loss of previously
achieved/attained progress; and

3. An individual would either not be expected to develop the function or would be expected
to permanently lose the function without the MLTSS Occupational Therapy service (not
merely fluctuate); and

4. The MLTSS Occupational Therapy on-going clinical documentation objectively
continues to verify that, at a minimum, functional status is preserved while continued
pursuit of incremental progress toward further development; and

5. The services are delivered by a qualified provider of occupational therapy services who
has experience in delivery of therapy services to individuals with TBI.


Clinical assessment by the OT shall be used to objectively determine and verify that, at a
minimum, functional status is preserved while continued incremental (minimal unpredictable
changes over longer lengths of time) progress towards further development is pursued. This will
be utilized to establish member?s need of MLTSS Occupational Therapy.

Service Limitations:


? Third party liability shall, if available, be used first and to the fullest extent
possible prior to accessing MLTSS occupational therapy services.

? Per Medical Necessity as defined in the contract.
? The individual must have a diagnosis of acquired, non-degenerative, or traumatic

brain injury or formerly a TBI waiver participant who is assessed to be in need of
occupational therapy and who transitions to MLTSS.

? The ratio for group sessions may not be larger than ONE therapist to FIVE
members.

? The MCO will determine the number of authorized therapy units that will be
included in a member?s plan of care.

? If a clinical evaluation of the member demonstrates that the member has the
potential to achieve significant improvement in restoration of, or compensation




7/2018 Accepted


for loss of function in a reasonable and generally predictable period of time, or,
the member would benefit from the establishment of a maintenance program,
rehabilitation/maintenance programs are available through other payor sources (ie
Medicare, Medicaid State Plan or other third party liability such as commercial
health insurance) and not a covered MLTSS service.

? If skilled therapy services by a qualified therapist are needed to instruct the
patient or appropriate caregiver regarding the maintenance program, such
instruction is covered by other payor sources (i.e., Medicare, Medicaid State Plan
or other third party liability such as commercial health insurance).

? Periodic evaluations of the member?s condition and response to treatment may be
covered via the Medicare, Medicaid State Plan or other third party liability benefit
when medically necessary, as identified by a qualified professional.

? A member may receive individual and group sessions of the same therapy in the
same day; e.g., a morning session of individual therapy and an afternoon session
of group therapy.

? A member may receive different therapies on the same day of service; e.g.,
morning session of individual ST, morning session of OT, and an afternoon
session of CRT.

? A member must be evaluated by a licensed therapist at least annually or upon
change in condition to determine whether the beneficiary has the need for skilled
therapy service delivery and/or qualifies for rehabilitation or habilitation services.
Documentation supporting this evaluation shall be maintained in provider clinical
records.

? Occupational therapy services require the clinical skills of a licensed occupational
therapist or occupational therapy assistant (or their students, in accordance with
State OT licensing guidelines), for the duration of service delivery.


Provider Specifications:


? A rehabilitation hospital per NJAC 8:43 ? 1.1 et.seq. and NJAC 10:54-5
? Community Residential Services (CRS) provider per NJAC 10:44c
? Licensed, certified home health agency per NJAC 8:42 and certified by the center

for Medicare and Medicaid Services
? Post-acute non-residential rehabilitative services provider agency
? Individuals rendering MLTSS Occupational Therapy services shall be registered

as an occupational therapist (OTR) with the American Occupational Therapy
Association (AOTA). A certified occupational therapy assistant (COTA) shall be
registered with the AOTA and work under the supervision and direction of an
OTR.

? Individuals rendering occupational therapy services shall also be
licensed/certified in accordance with state practice law


Unit of Service: 15 Minutes with a maximum allowable of no more than 8 units in a 24 hour
period.

MLTSS CPT CODES:




7/2018 Accepted


CPT Code: 97535_96_59 ? Individual, 15 minutes unit of service
CPT Code 97150_96_59 ? Group, per diem unit of service

NOTE: For Free Standing Clinic or ANY therapy service provided out of the home; EXISTING
Codes should be used. The modifier of 96 must be used to signify the MLTSS benefit is being
used.

When a member is receiving multiple therapy sessions on the same day of service, the provider
must use the modifier "59" in addition to the modifier for MLTSS when submitting the claim for
payment. This will permit the claim to be processed and not be subject to the NCCI conflict
edits. If the member is only receiving one (a SINGLE) therapy session on a given date, the
provider will NOT use the modifier "59".

Unit of Service: 15 minutes

Licensing Entity:

Regulation Cites:

? A rehabilitation hospital per NJAC 8:43 ? 1.1 et.seq. and NJAC 10:54-5
? N.J.A.C. 13:44K
? Community Residential Services (CRS) provider per NJAC 10:44c
? Licensed, certified home health agency per NJAC 8:42 and certified by the center

for Medicare and Medicaid Services
? Medicare Local Coverage Determination (LCD): Therapy and Rehabilitation

Services (PT, OT) (L35036) ? effective 4/1/2016
? Medicare Benefit Policy Manual, Chapter 15 - Section 220.2 - Reasonable and

Necessary Outpatient Rehabilitation Therapy Services (Rev. 221 effective 3-11-
2016)

? 42CFR410.59
? 42CFR410.60


Accredited by:

Taxonomy Code:





7/2018 Accepted


Personal Emergency Response System (PERS): SET UP (Eligible for MFP 25%)

PERS is an electronic device which enables participants at high risk of institutionalization to
secure help in an emergency. The individual may also wear a portable "help" button to allow for
mobility. The system is connected to the person's phone and is programmed to signal a response
center once a "help" button is activated. The response center is staffed by trained professionals.
The service consists of two components both of which are managed by the PERS contractor; first
is the initial installation of the equipment and the second is the monitoring of the service by staff
at the response center. The addition of the fiscal intermediary is the modification to the provider
specifications. Previously the provider of the specific service was required to execute a purchase
agreement with the case management agency; now that agreement is between the fiscal
intermediary and the service provider.

Service Limitations:

Per Medical Necessity as defined in the contract. PERS is for an individual, age 18 or over, who
lives alone or who is alone for significant amounts of time per the plan of care. Individuals might
not have a regular care giver for extended periods of time or would require extensive routine
supervision.

Provider Specifications:

The provider must apply and become approved through the MCO.

MLTSS HIPAA COMPLIANT CODE:
S5160

Unit of Service: One time set-up fee. Cost per provider.

Licensing Entity:

Accredited by:

Regulation Cite:

Taxonomy Code:





7/2018 Accepted


Personal Emergency Response System (PERS): Monitoring (Eligible for MFP 25%)

PERS is an electronic device which enables participants at high risk of institutionalization to
secure help in an emergency. The individual may also wear a portable "help" button to allow for
mobility. The system is connected to the person's phone and is programmed to signal a response
center once a "help" button is activated. The response center is staffed by trained professionals.
The service consists of two components both of which are managed by the PERS contractor; first
is the initial installation of the equipment and the second is the monitoring of the service by staff
at the response center. The addition of the fiscal intermediary is the modification to the provider
specifications. Previously the provider of the specific service was required to execute a purchase
agreement with the case management agency; now that agreement is between the fiscal
intermediary and the service provider.

Service Limitations:

Per medical necessity criteria as defined in the MCO contract. PERS is for an individual who
lives alone or who is alone for significant amounts of time per the plan of care. Individuals might
not have a regular care giver for extended periods of time or would require extensive routine
supervision.

Provider Specifications:

The provider must apply and become approved through the MCO.

MLTSS HIPAA COMPLIANT CODE:
S5161 ? Standard Landline
S5161_U1 ? Cellular Unit
S5161_U2 ? Cellular Unit with fall detection
S5161_U3 ? Mobile Unit
S5161_U4 ? Standard Landline Unit with Fall Detection

Unit of Service: Monthly Monitoring Fee

Licensing Entity:

Accredited by:

Regulation Cites:

Taxonomy Code:





7/2018 Accepted


Physical Therapy (Group and Individual) (Eligible for MFP 25%)

MLTSS Physical Therapy Services are intended to incrementally (minimal unpredictable
changes over longer lengths of time) develop or improve skills, or prevent the loss of previously
achieved/attained progress which is at risk of being lost as a result of a traumatic or acquired,
non degenerative brain injury (TBI/ABI). MLTSS Physical Therapy is also intended to allow a
member to acquire new skills that will allow them to function optimally in their current or future
least restrictive environment.

MLTSS Physical Therapy Services may be considered medically necessary when all of the
following conditions are met:

1. The therapy is for a condition that requires the unique knowledge, skills, and judgment of

s Physical Therapist for education and training that is part of a clinician?s (PT) skilled
plan of treatment; and

2. There is an expectation that the therapy will incrementally (minimal unpredictable
changes over longer lengths of time) improve and/or prevent the loss of previously
achieved/attained progress ; and

3. An individual would either not be expected to develop the function or would be expected
to permanently lose the function without the MLTSS Physical Therapy service (not
merely fluctuate); and

4. The MLTSS Physical Therapy on-going clinical documentation objectively continues to
verify that, at a minimum, functional status is preserved while continued pursuit of
incremental progress toward further development; and

5. The services are delivered by a qualified provider of physical therapy services who has
experience in delivery of therapy services to individuals with TBI.


Clinical assessment by the PT shall be used to objectively determine and verify that, at a
minimum, functional status is preserved while continued incremental (minimal unpredictable
changes over longer lengths of time) progress towards further development is pursued. This will
be utilized to establish member?s need of MLTSS Physical Therapy.

Service Limitations:


? Third party liability shall, if available, be used first and to the fullest extent
possible prior to accessing MLTSS physical therapy services.

? Per Medical Necessity as defined in the contract.
? The individual must have a diagnosis of acquired, non-degenerative, or traumatic

brain injury or formerly a TBI waiver participant who is assessed to be in need of
physical therapy and who transitions to MLTSS.

? The ratio for group sessions may not be larger than ONE therapist to FIVE
members.

? The MCO will determine the number of authorized therapy units that will be
included in a member?s plan of care.

? If a clinical evaluation of the member demonstrates that the member has the
potential to achieve significant improvement in restoration of, or compensation




7/2018 Accepted


for loss of function in a reasonable and generally predictable period of time, or,
the member would benefit from the establishment of a maintenance program,
rehabilitation/maintenance programs are available through other payor sources
(i.e. Medicare, Medicaid State Plan or other third party liability such as
commercial health insurance) and not a covered MLTSS service.

? If skilled therapy services by a qualified therapist are needed to instruct the
patient or appropriate caregiver regarding the maintenance program, such
instruction is covered by other payor sources (i.e., Medicare, Medicaid State Plan
or other third party liability such as commercial health insurance).

? Periodic evaluations of the member?s condition and response to treatment may be
covered via the Medicare, Medicaid State Plan or other third party liability benefit
when medically necessary, as identified by a qualified professional.

? A member may receive individual and group sessions of the same therapy in the
same day; e.g., a morning session of individual therapy and an afternoon session
of group therapy.

? A member may receive different therapies on the same day of service; e.g.,
morning session of individual ST, morning session of OT, and an afternoon
session of CRT.

? A member must be evaluated by a licensed therapist at least annually or upon
change in condition to determine whether the beneficiary has the need for skilled
therapy service delivery and/or qualifies for rehabilitation or habilitation services.
Documentation supporting this evaluation shall be maintained in MCO and
provider clinical records.

? Physical therapy services require the clinical skills of a licensed physical therapist
or licensed physical therapy assistant (or their students, in accordance with State
PT licensing guidelines), for the duration of service delivery.


Provider Specifications:


? A rehabilitation hospital per NJAC 8:43 ? 1.1 et.seq. and NJAC 10:54-5
? Community Residential Services (CRS) provider per NJAC 10:44c
? Licensed, certified home health agency per NJAC 8:42 and certified by the center

for Medicare and Medicaid Services
? Post-acute non-residential rehabilitative services provider agency
? Clinical assessment by the PT shall be used to objectively determine and verify

that, at a minimum, functional status is preserved while continued incremental
(minimal unpredictable changes over longer lengths of time) progress towards
further development is pursued. This will be utilized to establish member?s need
of MLTSS Physical Therapy.


MLTSS CPT CODES:
Individual: 97110_96_59 (15 minutes);
Group: S8990_96_HQ (15 minutes);





7/2018 Accepted


NOTE: For Free Standing Clinic or ANY therapy service provided out of the home; EXISTING
Codes should be used. The modifier of 96 must be used to signify the MLTSS benefit is being
used.

When a member is receiving multiple therapy sessions on the same day of service, the provider
must use the modifier "59" in addition to the modifier for MLTSS when submitting the claim for
payment. This will permit the claim to be processed and not be subject to the NCCI conflict
edits. If the member is only receiving one (a SINGLE) therapy session on a given date, the
provider will NOT use the modifier "59".

Unit of Service:
Individual: 15 minutes with no more than six (6) units maximum allowable in a 24 hour period.

Group: 15 minutes with no more than eight (8) units maximum allowable in a 24 hour period.

Licensing Entity:

Accredited by:

Regulation Cites:

Taxonomy Code:




7/2018 Accepted


Private Duty Nursing (Eligible for MFP 25%)

Private Duty Nursing shall be a covered service only for those beneficiaries enrolled in MLTSS
and the DDD Supports Plus PDN program operated by DDD. When payment for private duty
nursing services is being provided or paid for by another source, the benefit of private duty
nursing hours shall supplement the other source up to a maximum of 16 hours per day, including
services provided or paid for by the other sources, if medically necessary, and if cost of service
provided is less than institutional care.

The 16 hours per day limitation for PDN services noted above and below shall not apply to
children under the age of twenty one years who are eligible for Medicaid/NJ FamilyCare EPSDT
services.

Service Limitations:

Per Medical Necessity as defined in the contract. Private Duty Nursing services are provided in
the community only (the home or other community setting of the individual), and not in hospital
inpatient or nursing facility settings. Private Duty Nursing services are a State Plan benefit for
children under the age of 21. EPSDT services must be exhausted before accessing MLTSS
PDN. Children who meet the eligibility criteria for MLTSS services contained in this dictionary
shall not have their access to Medicaid EPSDT services limited through the language contained
in this document. For adults over the age of 21, private duty nursing is provided under the
MLTSS benefit and through the DDD Supports Plus program.
Persons meeting NF level of Care are eligible to receive private duty nursing. Private Duty
Nursing criteria is based on medical necessity, and is prior approved by the MCO in a plan of
care. Private duty nursing is individual, continuous, ongoing nursing care in the home, and is a
service available to a beneficiary only after enrollment in MLTSS or, in the case of DDD
Supports Plus PDN, being determined as meeting nursing facility level of care.
(a) Private duty nursing services shall be provided in the community only and not in an

inpatient hospital or nursing facility setting. Services shall be provided by a registered
nurse (RN) or a licensed practical nurse (LPN).


1. Private Duty Nursing (PDN) services rendered during hours when the

beneficiary's normal life activities take him or her outside the home will be
reimbursed. If a beneficiary seeks to obtain PDN services to attend school or other
activities outside the home, but does not need such services in the home, there is
no basis for authorizing PDN services. Only those PDN beneficiaries who require,
and are authorized to receive, private duty nursing services in the home may
utilize the approved hours outside the home during those hours when normal life
activities take the beneficiary out of the home.


2. Due to safety concerns, the nurse shall not be authorized to engage in non-medical

activities while accompanying the client, including the operation of a motor
vehicle.






7/2018 Accepted


(b) Private Duty Nursing shall be a covered service only for those beneficiaries enrolled
MLTSS or the DDD Supports Plus program, when payment for Private Duty Nursing
services is being provided or paid for by another source (that is, insurance), Private Duty
Nursing hours shall supplement up to a maximum of 16 hours per day, including services
provided or paid for by the other sources, if medically necessary, and if cost of service
provided is less than institutional care.


(c) Private Duty Nursing services shall be limited to a maximum of 16 hours, including

services provided or paid for by other sources, in a 24-hour period, per person. There
shall be a live-in primary adult caregiver (as defined in N.J.A.C. 10:60-1.2) who accepts
24-hour per day responsibility for the health and welfare of the beneficiary unless the sole
purpose of the private duty nursing is the administration of IV therapy. (See N.J.A.C.
10:60-6.3(b)2 and 7.4(a)2 for exceptions to 16-hour maximum in a 24-hour period.)


Approval for private duty nursing service is provided by the Managed Care Organization
for MLTSS beneficiaries and DDD Supports Plus PDN enrollees. Approval is provided by
the State for Fee For Service beneficiaries.


Provider Specifications:

Registered nurse or a licensed practical nurse under the direction of the enrollee's physician.

Private Duty Nursing services shall be provided by a licensed home health agency, voluntary
non-profit homemaker agency, private employment agency and temporary-help service agency
approved by DMAHS/the MCO. The voluntary nonprofit homemaker agency, private
employment agency and temporary help-service agency shall be accredited, initially and on an
ongoing basis.

?Accreditation organization? means an agency approved by the Department of Human Services
to provide quality oversight of Medicaid/NJ FamilyCare home care agencies and certify that
services are being performed in accordance with acceptable practices and established standards.

MLTSS HIPAA COMPLIANT CODE:
T 1000_UA = Combination of LPN and RN
T 1002_UA = RN
T 1003_UA = LPN

Unit of Service: 15 minutes

Licensing Entity:

Accredited by:

Regulation Cites: N.J.A.C 10:60-5, N.J.A.C. 10:60-1.2, See N.J.A.C. 10:60-6.3(b)2 and 7.4(a)2
for exceptions to 16-hour maximum in a 24-hour period.










7/2018 Accepted


Taxonomy Code:





7/2018 Accepted


Residential Modifications (Eligible for MFP 25%)

Those physical modifications/adaptations to a participant's private primary residence required by
his/her plan of care which are necessary to ensure the health, welfare and safety of the individual,
or which enable him/her to function with greater independence in the home or community and
without which the individual would require institutionalization. Such adaptations may include
the installation of ramps and grab bars, widening of doorways, modifications of bathrooms, or
installation of specialized electrical or plumbing systems that are necessary to accommodate the
medical equipment and supplies which are needed for the health, safety and welfare of the
individual.

Service Limitations:

Residential Modifications are limited to $5,000 per calendar year, $10,000 lifetime.

Participants living in licensed residences (ALR, CPCH, ALP, and Class B & C Boarding Homes)
are not eligible to receive Residential Modifications. Adaptations to rented housing units must
have the prior written approval of the landlord. Continued tenancy of at least one year is to be
assured prior to approval of the request. Modifications to public areas of apartment buildings,
communities governed by a homeowner association or community trust and/or rental properties
are the responsibility of the owner/landlord, association or trust and excluded from this benefit.

Residential Modifications may not be furnished to adapt living arrangements that are owned or
leased by providers of waiver services, except for approved Adult Family Care (AFC)
Caregivers? homes. All residential modifications are limited based on the participant?s assessed
need. The adaptation will represent the most cost effective means to meet the needs of the
participant.

Excluded from this service are those modifications to the home that are of general utility and are
not of direct medical or remedial benefit to the individual, such as carpeting, roof repair, central
air conditioning, etc. Adaptations that add to the total square footage of the home are excluded
from this benefit except when necessary to complete an adaptation (e.g., in order to improve
entrance/egress to a residence or to configure a bathroom to accommodate a wheelchair).

All services shall be provided in accordance with applicable State/local building codes.

If it is determined that one of the above limitations would prevent the MCO from implementing a
more appropriate or cost effective method of support or ensuring the health, safety and well-
being of an individual, the MCO may exceed these limitations in those specific circumstances.
The need to exceed the limitation must be documented in the plan of care.

A letter from the owner of the property approving the modification to the property and
acknowledging that the State/MCO is not responsible for the removal of the modification from
the property is required.

Provider Specifications:




7/2018 Accepted



The provider must be licensed in NJ per the NJ Division of Consumer Affairs, NJSA 56:8?136 et
seq. as a home repair contractor and exist in the NJ Division of Consumer Affairs database
located at:
http://www.njconsumeraffairs.gov/LVinfo.htm

The provider must apply and become approved through the MCO.
? The Contractor must provide his/her license number.
? Each provider must meet applicable State and county requirements for licensure,

certification, or other qualifications necessary to conduct the scope of business.
? Evidence of permits and approvals must be available as required.
? All improvements must meet applicable State and local building and safety codes.

(N.J.A.C. 5:23-2)
? All services shall be provided in accordance with applicable State, local and Americans

with Disabilities Act (ADA) and/or ADA Accessibility Guidelines (ADAAG) and
specifications.


MLTSS HIPAA COMPLIANT CODE:
S5165, T1028 = Evaluation

Unit of Service: Per Occurrence

Licensing Entity: NJ Department of Law and Public Safety, Division of Consumer Affairs

Accredited by:

Regulation Cites: NJAC 5:23-2, NJSA 56:8?136 et seq.

Taxonomy Code:






7/2018 Accepted


Respite (Daily and Hourly) (Eligible for MFP 25%)

Services provided to participants unable to care for themselves that are furnished on a short-term
basis because of the absence or need for relief of an unpaid, informal caregiver (those persons
who normally provide unpaid care) for the participant. In the case where a person is in the
personal preference program or is self-directing services, respite may be used to provide relief
for the temporary absence of the primary paid care giver. Federal financial participation is not
claimed for the cost of room and board except when provided as part of respite care furnished in
a facility approved by the State that is not a private residence.

Service Limitations:

Respite is limited to up to 30 days per participant per calendar year. If respite is provided in a
nursing home, room and board charges are included in the Institutional Respite rate. Respite will
not be reimbursed for individuals who reside permanently in a Community Residential Service
setting (CRS), an Assisted Living Residence or Comprehensive Personal Care Home or for
individuals that are admitted to the Nursing Facility. Respite care shall not be reimbursed as a
separate service during the hours the participant is participating in either Adult Day Health
Services or Social Adult Day Care. Services excluded from additional billing while
simultaneously receiving Respite care include: Chore, Home-Based Supportive Care, Home-
delivered Meals, and Personal Care Assistant services. Sitter, live-in, or companion services are
not considered Respite Services and cannot be authorized as such. Respite services are not
provided for formal, paid caregivers (i.e. Home Health or Certified Nurse Aides). Respite
services are not to be authorized due to the absence of those persons who would normally
provide paid care for the participant. Eight or more hours of respite in one 24-hour period,
provided by the same provider is the DAILY respite service.

Provider Specifications:

Respite care may be provided in the following location(s):
? Individual's home or place of residence
? Medicaid certified Nursing Facility that has a separate Medicaid provider number to bill

for Respite
? Another community care residence that is not a private residence including: an Assisted

Living Residence (AL), a Comprehensive Personal Care Home (CPCH), or an Adult
Family Care (AFC) Home

? Community Residential Services as licensed under N.J.A.C 10:44C for those individuals
with a TBI diagnosis.


MLTSS HIPAA COMPLIANT CODE:
T1005 = In home respite per 15 minutes
S5151 = Institutional respite, per diem (Assisted Living)
REV 0663 is to be used for Daily Respite Care in a NF (per diem)

Unit of service: 15 minutes, per diem





7/2018 Accepted


Licensing Entity:

Accredited by:

Regulation Cites:

Taxonomy Code:




7/2018 Accepted


Social Adult Day Care (Eligible for MFP 25%)

Social Adult Day Care (SADC) is a community-based group program designed to meet the non-
medical needs of adults with functional impairments through an individualized Plan of Care.
Social Adult Day Care is a structured comprehensive program that provides a variety of health,
social and related support services in a protective setting during any part of a day but less than
24-hour care. Individuals who participate in Social Adult Day Care attend on a planned basis
during specified hours. Social Adult Day Care assists its participants to remain in the
community, enabling families and other caregivers to continue caring at home for a family
member with impairment. Social Adult Day Care services shall be provided for at least five
consecutive hours daily, exclusive of any transportation time, up to five days a week.

Service Limitations:

Per the identified need as included in the individual?s plan of care.

Social Adult Day Care services shall be provided for at least five consecutive hours daily,
exclusive of any transportation time, up to five days a week.

Social Adult Day Care is not available to those residing in an Assisted Living Facility as it would
duplicate services required by the Assisted Living Licensing Regulations.

Social Adult Day Care cannot be combined with Adult Day Health Services.

The individual has no specific medical diagnosis requiring the oversight of an RN while in
attendance at the Social Adult Day Care.

Assisted Living Program (ALP) participants, not ALR or CPCH participants may attend Social
Adult Day Care 2 (two) days a week; (3) three days with prior authorization.

Adult Family Care (AFC) participants may attend Social Adult Day Care two (2) days per week.

Provider Specifications:

? Facility that (a) has a license or occupancy permit available, (b) has police and fire

department response agreements, and (c) has written safety and emergency management
policies and procedures.

? Personnel: (a) Program director designated, (b) has adequate Staff to meet program needs
of target population, and (c) and at a minimum, has identified a nurse consultant.

? Client population: Established criteria for target population based on resources and
program capabilities of facility.

? Program activities: Planned and ongoing age appropriate activities based on social,
physical, and cognitive needs of the target population.

? Individualized Plans of Care: Based on identified individual client needs, jointly
developed with client and family.




7/2018 Accepted


? Social Services: Coordination with, and referrals to, available community agencies and
services. Staff has periodic contact with families.

? Nutrition: Provides a minimum of one nutritionally balanced meal per day. Special diet
needs are met. Snacks provided as necessary.

? Health Management: (a) An initial health profile is completed. (b) Monthly weights are
taken and other health related observations are recorded as necessary.

? Personal Care: Personal assistance as needed with mobility and activities of daily living.
? Possesses business authority to conduct such business in New Jersey and is in compliance

with all applicable laws, codes, and regulations, including physical plant requirements,
fire safety and ADA compliance.


MLTSS HIPAA COMPLIANT Code:
S5102_U3 (per Diem)

Unit of service = Per Diem

Licensing Entity:

Accredited by:

Regulation Cites:

Taxonomy Code:





7/2018 Accepted


Speech, Language and Hearing Therapy (Group and Individual) (Eligible for MFP 25%)

MLTSS Speech, Language and Hearing Therapy Services are intended to incrementally
(minimal unpredictable changes over longer lengths of time) develop or improve skills, or
prevent the loss of previously achieved/attained progress which is at risk of being lost as a result
of a traumatic or acquired, non-degenerative brain injury (TBI/ABI). MLTSS Speech, Language
and Hearing Therapy is also intended to allow a member to acquire new skills that will allow
them to function optimally in their current or future least restrictive environment.

MLTSS Speech, Language and Hearing Therapy Services may be considered medically
necessary when all of the following conditions are met:

1. The therapy is for a condition that requires the unique knowledge, skills, and judgment of

a Speech Therapist for education and training that is part of a clinician?s (ST) skilled plan
of treatment; and

2. There is an expectation that the therapy will incrementally (minimal unpredictable
changes over longer lengths of time) improve and/or prevent the loss of previously
achieved/attained progress ; and

3. An individual would either not be expected to develop the function or would be expected
to permanently lose the function without the MLTSS Speech, Language and Hearing
Therapy Service (not merely fluctuate); and

4. The MLTSS Speech, Language and Hearing Therapy Service on-going clinical
documentation objectively continues to verify that, at a minimum, functional status is
preserved while continued pursuit of incremental progress toward further development;
and

5. The services are delivered by a qualified provider of speech therapy services who has
experience in delivery of therapy services to individuals with TBI.


Clinical assessment by the ST shall be used to objectively determine and verify that, at a
minimum, functional status is preserved while continued incremental (minimal unpredictable
changes over longer lengths of time) progress towards further development is pursued. This will
be utilized to establish member?s need of MLTSS Speech, Language and Hearing Therapy
Services.

Service Limitations:

? Third party liability shall, if available, be used first and to the fullest extent
possible prior to accessing MLTSS Speech, Language and Hearing Therapy
Services.

? Per Medical Necessity as defined in the contract.
? The individual must have a diagnosis of acquired, non-degenerative, or traumatic

brain injury or formerly a TBI waiver participant who is assessed to be in need of
speech, language and hearing therapy and who transitions to MLTSS.

? The ratio for group sessions may not be larger than ONE therapist to FIVE
members.

? The MCO will determine the number of authorized therapy units that will be
included in a member?s plan of care.




7/2018 Accepted


? If a clinical evaluation of the member demonstrates that the member has the
potential to achieve significant improvement in restoration of, or compensation
for loss of function in a reasonable and generally predictable period of time, or,
the member would benefit from the establishment of a maintenance program,
rehabilitation/maintenance programs are available through other payor sources
(i.e. Medicare, Medicaid State Plan or other third party liability such as
commercial health insurance) and not a covered MLTSS service.

? If skilled therapy services by a qualified therapist are needed to instruct the
patient or appropriate caregiver regarding the maintenance program, such
instruction is covered by other payor sources (i.e., Medicare, Medicaid State Plan
or other third party liability such as commercial health insurance).

? Periodic evaluations of the member?s condition and response to treatment may be
covered via the Medicare, Medicaid State Plan or other third party liability benefit
when medically necessary, as identified by a qualified professional.

? A member may receive individual and group sessions of the same therapy in the
same day; e.g., a morning session of individual therapy and an afternoon session
of group therapy.

? A member may receive different therapies on the same day of service; e.g.,
morning session of individual ST, morning session of OT, and an afternoon
session of CRT.

? A member must be evaluated by a licensed therapist at least annually or upon
change in condition to determine whether the beneficiary has the need for skilled
therapy service delivery and/or qualifies for rehabilitation or habilitation services.
Documentation supporting this evaluation shall be maintained in MCO and
provider clinical records.

? MLTSS Speech, Language and Hearing Therapy services require the clinical
skills of a licensed speech therapist or speech therapy assistant (or their students,
in accordance with State ST licensing guidelines), for the duration of service
delivery.


Provider Specifications:


? A rehabilitation hospital per NJAC 8:43 ? 1.1 et.seq. and NJAC 10:54-5
? Community Residential Services (CRS) provider per NJAC 10:44c
? Licensed, certified home health agency per NJAC 8:42 and certified by the center

for Medicare and Medicaid Services
? Post-acute non-residential rehabilitative services provider agency
? MLTSS Speech, Language and Hearing Therapy services require the clinical

skills of a licensed speech therapist or speech therapy assistant (or their students,
in accordance with State ST licensing guidelines), for the duration of service
delivery.


MLTSS CPT CODE:
Individual = 92507_96_59 (per diem);
Group = 92508_96_59 (per diem)





7/2018 Accepted


NOTE: For Free Standing Clinic or ANY therapy service provided out of the home; EXISTING
Codes should be used. The modifier of 96 must be used to signify the MLTSS benefit is being
used.

When a member is receiving multiple therapy sessions on the same day of service, the provider
must use the modifier "59" in addition to the modifier for MLTSS when submitting the claim for
payment. This will permit the claim to be processed and not be subject to the NCCI conflict
edits. If the member is only receiving one (a SINGLE) therapy session on a given date, the
provider will NOT use the modifier "59".

Unit of Service: per diem

Licensing Entity:

Accredited by:

Regulation Cites:

Taxonomy Code:




7/2018 Accepted


Structured Day Program (Eligible for MFP 25%)

A program of productive supervised activities, directed at the development and maintenance of
independent and community living skills. Services will be provided in a setting separate from
the home in which the participant lives. Services may include group or individualized life skills
training that will prepare the participant for community reintegration, including but not limited to
attention skills, task completion, problem solving, money management, and safety. This service
will include nutritional supervision, health monitoring, and recreation as appropriate to the
individualized care plan.

Service Limitations:

The individual must have a diagnosis of acquired, non-degenerative, or traumatic brain injury or
formerly a TBI waiver participant who is transitioning to MLTSS. The program will not cover
services paid for by other agencies. The program excludes medical day care.

Provider Specifications:

? Post-acute, non-residential rehabilitation services provider agency
? Comprehensive Outpatient Rehabilitation Facility; Post-acute Day Program
? Community Residential Services (CRS) provider
? Rehabilitation Hospital (outpatient)

MLTSS HIPAA COMPLIANT CODE:
S5100 (15 minutes)

Unit of Service = 15 minutes

Licensing Entity:

Accredited by:

Regulation Cites:

Taxonomy Code:





7/2018 Accepted


Supported Day Services (Eligible for MFP 25%)

A program of individual activities directed at the development of productive activity patterns,
requiring initial and periodic oversight, at least monthly.

The supported day service is intended to be a home and community based service, not provided
in an outpatient setting or within a Community Residential Service Day Program, although it
may be provided by staff that work in either of these settings. The service supports a person?s
plan of care in a community setting, like volunteering, shopping, recreation, building social
supports, etc. The activity is provided one to one, as opposed to a group home outing or group
services provided in a structured program. Individuals tend to be either higher functioning and
able to eventually do the activities they are being supported in independently, or lesser
functioning, capable of such activities in the community with increased support.

Activities that support this service include but are not limited to therapeutic recreation, volunteer
activities, household management, shopping for food, household goods, clothing, etc.,
negotiating various components of activities in the community, building social supports in the
community etc.

Service Limitations:

The individual must have a diagnosis of acquired, non-degenerative, or traumatic brain injury or
formerly a TBI waiver participant who is transitioning to MLTSS.

Supported Day Services are provided as an alternative to Structure Day Program when the
participant does not require continual supervision. Services are not to be provided in a setting
where the setting itself is already paid to supervise the participant. Limits in service should be
delineated by assessment of the person receiving the service, as directed by the Master?s level
Rehabilitation professional. The amount, frequency, and duration of this service are determined
by the recommendation made by the qualified professional. The care manager develops the plan
of care, taking the professional's recommendations into account when developing the total
service package necessary to maintain the participant in the home/community environment.

Provider Specifications:

A professional holding at least a Master?s degree in a rehabilitation related discipline (including
but not limited to; Psychology, Social Work, PT, OT, SLP, Nursing, CRC, etc.) to sustain the
program. This service may be provided by rehabilitation staff at the paraprofessional level
(minimum of 48 college credits) or higher, and the program and service providers will receive
ongoing supervision from a licensed or certified professional at a minimum, in addition to the
clinical oversight provided by the aforementioned Master?s level rehabilitation professional.
Registered nurses (NJSA 45:11-26) and licensed clinical social workers (NJSA 45:1-15) may
provide this service when employed by an approved provider agency such as a mental health
agency or family service agency. Licensed, clinical social worker may provide this service if
under the supervision of a psychologist.





7/2018 Accepted


MLTSS HIPAA COMPLIANT CODE:
T2021

Unit of Service = 15 minutes

Licensing Entity:

Accredited by:

Regulation Cites: NJSA 45:11-26, NJSA 45:1-15

Taxonomy Code:





7/2018 Accepted


Vehicle Modifications (Eligible for MFP 25%)

The service includes needed vehicle modification (such as electronic monitoring systems to
enhance beneficiary safety, mechanical lifts to make access possible) to a participant or family
vehicle as defined in an approved plan of care. Modifications must be needed to ensure the
health, welfare and safety of a participant or which enable the individual to function more
independently in the home or community. All services shall be provided in accordance with
applicable State motor vehicle codes.

Service Limitations:

The vehicle must be owned by the participant or their authorized representative. The vehicle
must be registered in NJ.

Excluded are those adaptations/modifications to the vehicle which are of general utility, and are
not of direct medical or remedial benefit to the participant. Maintenance of the normal vehicle
systems is not permitted as a part of this service; neither is the purchase of a vehicle.

Provider Specifications:

MLTSS HIPAA COMPLIANT CODE:
T2039; T2039_U7 (Eval)

Unit of Service: Per Occurrence

Licensing Entity:

Accredited by:

Regulation Cites:

Taxonomy Code:





7/2018 Accepted



B.9.3 Cost Effectiveness Policy Guidance: Exceptions Process





7/2018 Accepted


Appendix B.9.3
Cost Effectiveness Policy Guidance: Exceptions Process

This Policy Guidance is intended to provide direction to the Managed Care Organizations for the
Cost Effectiveness Exceptions Process which is referenced in full in Section 9.3.2 of the January
2015 contract between the State of New Jersey, Department of Human Services, Division of
Medical Assistance and Health Services and the Managed Care Organization Contractor.

MLTSS Members who wish to receive HCBS have a plan of care whose annual long term
services and support (LTSS) cost is aligned to the Annual Cost Threshold established by the
State. This guidance is intended to be used for people whose plan of care will exceed the cost
threshold and the circumstances in which an exception can be applied. The annualized long term
services and support portion of the capitation rate for residency in a Nursing Facility (NF) or
Special Care Nursing Facility (SCNF) as appropriate to the member?s needs as determined by the
Office of Community Choice Options will herein be referred to as an MLTSS member?s Annual
Cost Threshold (ACT). A member?s costs that reach 85% of the ACT is considered an Annual
Cost Threshold Trigger used to identify those members whose LTSS cost are approaching the
ACT LTSS cost cap.

A member?s LTSS costs cannot exceed the Annual Cost Threshold Cap unless granted an
exception due to the following: 1) temporary higher care needs; or 2) long term complex
medical needs, as identified in the Interdisciplinary Team (IDT) process.

The provision of HCBS for members who exceed the annual cost threshold shall be considered
for members who are identified through the assessment performed by the MCO, plan of care
development, and IDT process as meeting the following criteria:

1. The member has been assessed as having higher care need costs that are required to

adequately meet their care needs, are temporary in nature and expected to fall within the
ACT parameters within the next six months. The temporary higher care needs includes
but is not limited to:
? Temporary loss of primary caregiver
? Acute medical condition which should reasonably resolve in six months or less


2. The member has been clinically assessed as having long term complex medical needs
which can only be met through Private Duty Nursing. The MCO Care Manager or
designee is responsible for the assessment of Private Duty Nursing hour needs and
forwarding to the MCO Medical Director for review. The assessed level of Private Duty
Nursing service hours results in LTSS costs which exceed the Annual Cost Threshold for
the member?s assessed level of care need. Private Duty Nursing hours shall be limited in
scope to 16 hours per day by all payer sources as outlined in the MLTSS Service
Dictionary and in accordance with N.J.A.C. 10:60-1.2. N.J.AC. 10:60-6.3(b) 2 allows for
temporary exceptions to this limit. The MCO shall ensure that the temporary exceptions
are followed if necessary. The complex medical need includes but is not limited to:
? Ventilator Management;




7/2018 Accepted


? Presence of active tracheostomy and need for deep suctioning and/or around the
clock nebulizer treatments with chest physiotherapy requiring skilled Nursing
services;

? Gastrostomy feeding when complicated by frequent regurgitation and/or
aspiration requiring skilled Nursing services;

? A seizure disorder manifested by frequent prolonged seizures, requiring
emergency administration of anticonvulsant medication as a skilled Nursing
service


Interdisciplinary Team (IDT):

The member may invite any individual to participate in the IDT including their physician(s) who
may provide medical input and recommendations. Any information provided during the IDT
process shall be provided to MCO Medical Director and the DHS Medical Director for their
review and consideration.

During the IDT meeting processes, it shall be determined if the member meets the criteria for
temporary LTSS services or complex medical needs that result in costs in excess of the Annual
Cost Threshold and that HCBS services are the preferred service delivery system which can
safely meet the member?s needs. If the criteria are met, the following process shall occur

1. The MCO Care Manager who participated in the IDT process shall complete the MLTSS
Exception Determination request form and submit to the MCO Medical Director for
review and approval. The MCO Medical Director will make a determination within three
(3) business days.

2. Upon approval of the determination by the MCO Medical Director, the MCO shall
submit the Request form to the DHS/DMAHS Medical Director. .

3. The DHS/DMAHS Medical Director shall review the documentation and make a final
agency determination within five (5) business days.
a. If the member meets the Exception criteria, s/he may receive services in excess of

the ACT for a period of six months
b. If the member does not meet the Exception criteria, s/he may receive services up

to the ACT
c. The DHS/DMAHS Medical Director shall notify the DHS Deputy Commissioner,

DMAHS Director, Chief of Managed Health Care, DoAS Director, and OCCO
Program Director.


Expedited timeframes for the IDT and review processes are to be considered for members who
are residing in HCBS and have an acute change in condition such as loss of caregiver. The
expedited review shall occur within three (3) business days of a request. The MCO shall
notify the Office of Community Choice Options of the circumstances and need for expedited
review.

The MCO is responsible for notification to its member of the DHS Medical Director?s
determination including their grievance and appeal rights. These appeal rights include if the
determination is different from the treating physician?s assessment. When informed of their
appeal rights, the MCO shall ensure that the individual and family understand the continuity of




7/2018 Accepted


care provisions remaining in effect through the appeals process. The final Plan of Care shall be
issued to the member within 3 business days of receipt of the agency?s determination.

Members authorized to receive services in excess of the ACT either due to temporary higher
needs or complex medical needs are required to be reassessed at the time their condition changes
or 30 days in advance of the end of the six month or annual approval period.


MCO ACT Guidance Document






7/2018 Accepted



SECTION C

CAPITATION RATES

MANAGED CARE CAPITATION RATES
July 1, 2018 ? June 30, 2019

Capitation Rates

Category Benefit Plan Age/Sex Rating District
7/1/2018 ? 6/30/2019

Rates
Children (< 21 yrs of age) in AFDC,
NJ Care, DCP&P or KidCare A-C NJFC A, B, C

< 21
M&F Statewide $168.87

Children (< 21 yrs of age) in AFDC,
NJ Care, DCP&P or KidCare A-C
DDD

NJFC A, B, C < 21 M&F Statewide $233.69

Parents in AFDC (greater than 21
years of age), or all ages in NJCPW NJFC A

21+
M&F 21+ M&F $368.24

Parents in AFDC (greater than 21
years of age), or all ages in NJCPW -
DDD

NJFC A 21+ M&F 21+ M&F $433.06

NJ Children (< 19 yrs of age) ? No
Copay NJFC C

<19
M&F Statewide

$169.74

KidCare D NJFC D < 21 M&F Statewide $179.49

NJ KidCare D ? No Copay NJFC D <19 M&F Statewide
$192.56

ABD with Medicare and Other Dual
Eligibles NJFC A All Statewide $456.81

ABD with Medicare and Other Dual
Eligibles - DDD NJFC A All Statewide $479.91

ABD with Medicare and D-SNP NJFC A All Statewide $484.80

ABD without Medicare NJFC A All Statewide $1,343.30

ABD without Medicare DDD, All,
Add-on NJFC A All Statewide $1,408.12

Maternity, Northeastern All Northeastern $18,419.96

Maternity, Northwestern All Northwestern $19,108.46

Maternity, Central All Central $21,930.29

Maternity, South Central All South Central $19,075.88

Maternity, Southern All Southern $20,788.83





7/2018 Accepted


MANAGED CARE CAPITATION RATES
July 1, 2018 ? June 30, 2019

Capitation Rates

Category Benefit Plan Age/Sex
Rating
District

7/1/2018 ? 6/30/2019
Rates



Expansion
New Jersey Care Parents
(29% - 133% FPL) ABP All Statewide $320.65

New Jersey Care Adults w/o
Dependent Children(< 134% FPL) ABP All Statewide $501.19



MLTSS

MLTSS- HCBS with Medicare M All Statewide $4,204.12

MLTSS ?Custodial Nursing
Facilities With Medicare M All Statewide $4,204.12

MLTSS in Special Care Nursing
Facilities ?Vents & Pediatrics. With
Medicare

M All Statewide $14,603.96

MLTSS in Special Care Nursing
Facilities ?All Other With Medicare M All Statewide $12,378.30

MLTSS- HCBS without Medicare M All Statewide $7,881.36

MLTSS ?Custodial Nursing
Facilities Without Medicare M All Statewide $7,881.36

MLTSS in Special Care Nursing
Facilities ?Vents & Pediatrics.
Without Medicare

M All Statewide $24,110.47

MLTSS in Special Care Nursing
Facilities ?All Other Without
Medicare

M All Statewide $15,545.53





CONTRACT TO PROVIDE SERVICES
TABLE OF CONTENTS
ARTICLE ONE: DEFINITIONS
ARTICLE TWO: CONDITIONS PRECEDENT
ARTICLE THREE: MANAGED CARE MANAGEMENT INFORMATION SYSTEM
3.1 GENERAL OPERATIONAL REQUIREMENTS FOR THE MCMIS
3.1.1 ONLINE ACCESS
3.1.2 PROCESSING REQUIREMENTS
3.1.3 REPORTING AND DOCUMENTATION REQUIREMENTS
3.1.4 OTHER REQUIREMENTS

3.2 ENROLLEE SERVICES
3.2.1 CONTRACTOR ENROLLMENT DATA
3.2.2 ENROLLEE PROCESSING REQUIREMENTS
3.2.3 CONTRACTOR ENROLLMENT VERIFICATION
3.2.4 ENROLLEE GRIEVANCE TRACKING SYSTEM
3.2.5 ENROLLEE REPORTING

3.3 PROVIDER SERVICES
3.3.1 PROVIDER INFORMATION AND PROCESSING REQUIREMENTS
3.3.2 PROVIDER CREDENTIALING
3.3.3 PROVIDER/ENROLLEE LINKAGE
3.3.4 PROVIDER MONITORING
3.3.5 REPORTING REQUIREMENTS

3.4 CLAIMS/ENCOUNTER PROCESSING
3.4.1 GENERAL REQUIREMENTS
3.4.2 COORDINATION OF BENEFITS
3.4.3 REPORTING REQUIREMENTS
3.4.4 REMITTANCE ADVICE AND CAPITATION LISTS

3.5 PRIOR AUTHORIZATION, REFERRAL AND UTILIZATION MANAGEMENT
3.5.1 FUNCTIONS AND CAPABILITIES
3.5.2 REPORTING REQUIREMENTS

3.6 FINANCIAL PROCESSING
3.7 QUALITY ASSURANCE
3.7.1 FUNCTIONS AND CAPABILITIES
3.7.2 REPORTING REQUIREMENTS

3.8 MANAGEMENT AND ADMINISTRATIVE REPORTING
3.8.1 GENERAL REQUIREMENTS
3.8.2 QUERY CAPABILITIES
3.8.3 REPORTING CAPABILITIES

3.9 ENCOUNTER DATA REPORTING
3.9.1 ENCOUNTER DATA REQUIREMENTS AND SUBMISSION
3.9.2 SUBMISSION OF TEST ENCOUNTER DATA
3.9.3 REMITTANCE ADVICE
3.9.4 SUBCONTRACTS AND ENCOUNTER DATA REPORTING FUNCTION
3.9.5 FUTURE ELECTRONIC ENCOUNTER SUBMISSION REQUIREMENTS

3.10 CRITICAL INCIDENT REPORTING
3.11 HEALTH INFORMATION TECHNOLOGY
3.11.1 GENERAL REQUIREMENTS


ARTICLE FOUR: PROVISION OF HEALTH CARE SERVICES
4.1 COVERED SERVICES
4.1.1 GENERAL PROVISIONS AND CONTRACTOR RESPONSIBILITIES
4.1.2 BENEFIT PACKAGE
4.1.3 SERVICES REMAINING IN FEE-FOR-SERVICE PROGRAM AND MAY NECESSITATE CONTRACTOR ASSISTANCE TO THE ENROLLEE TO ACCESS THE SERVICES
4.1.4 MEDICAID COVERED SERVICES NOT PROVIDED BY CONTRACTOR
4.1.5 INSTITUTIONAL FEE-FOR-SERVICE BENEFITS ? NO COORDINATION BY THE CONTRACTOR
4.1.6 (RESERVE FOR FUTURE USE)
4.1.7 SUPPLEMENTAL BENEFITS
4.1.8 CONTRACTOR AND DMAHS SERVICE EXCLUSIONS

4.2 SPECIAL PROGRAM REQUIREMENTS
4.2.1 EMERGENCY SERVICES
4.2.2 FAMILY PLANNING SERVICES AND SUPPLIES
4.2.3 WOMEN?S HEALTH SERVICES
4.2.4 PRESCRIBED DRUGS AND PHARMACY SERVICES
4.2.5 LABORATORY SERVICES
4.2.6 EPSDT SERVICES
4.2.7 IMMUNIZATIONS
4.2.8 CLINICAL TRIALS, INVESTIGATIONAL TREATMENT, EXPERIMENTAL TREATMENT
4.2.9 HEALTH PROMOTION AND EDUCATION PROGRAMS
4.2.10 MEDICAL HOME ? DEVELOPMENT, ESTABLISHMENT, AND ADMINISTRATION
4.2.11 ORTHODONTIC SERVICES
4.2.12 HOSPICE SERVICES

4.3 COORDINATION WITH ESSENTIAL COMMUNITY PROGRAMS
4.4 MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES FOR MLTSS MEMBERS AND CLIENTS OF DDD
4.4.1 GENERAL REQUIREMENTS
4.4.2 MLTSS AND DDD BEHAVIORAL HEALTH BENEFITS PACKAGE
4.4.3 MLTSS AND DDD BEHAVIORAL HEALTH NETWORK REQUIREMENTS
4.4.4 MLTSS AND DDD BEHAVIORAL HEALTH UTILIZATION MANGEMENT
4.4.5 COORDINATION WITH MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES

4.5 MEMBERS WITH SPECIAL NEEDS
4.5.1 GENERAL REQUIREMENTS
4.5.2 CHILDREN WITH SPECIAL HEALTH CARE NEEDS
4.5.3 CLIENTS OF THE DIVISION OF DEVELOPMENTAL DISABILITIES
4.5.4 PERSONS WITH HIV/AIDS


4.6 QUALITY MANAGEMENT SYSTEM
4.6.1 QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PLAN
4.6.2 QAPI ACTIVITIES
4.6.3 REFERRAL SYSTEMS
4.6.4 UTILIZATION MANAGEMENT
4.6.5 CARE MANAGEMENT
4.7 MONITORING AND EVALUATION
4.7.1 GENERAL PROVISIONS
4.7.2 EVALUATION AND REPORTING - CONTRACTOR RESPONSIBILITIES
4.7.3 MONITORING AND EVALUATION ? DEPARTMENT ACTIVITIES
4.7.4 INDEPENDENT EXTERNAL QUALITY REVIEW ORGANIZATION REVIEWS

4.8 PROVIDER NETWORK
4.8.1 GENERAL PROVISIONS
4.8.2 PRIMARY CARE PROVIDER REQUIREMENTS
4.8.3 PROVIDER NETWORK FILE REQUIREMENTS
4.8.4 PROVIDER DIRECTORY REQUIREMENTS
4.8.5 CREDENTIALING/RECREDENTIALING REQUIREMENTS/ISSUES
4.8.6 LABORATORY SERVICE PROVIDERS
4.8.7 SPECIALTY PROVIDERS AND CENTERS
4.8.8 PROVIDER NETWORK REQUIREMENTS
4.8.9 DENTAL PROVIDER NETWORK REQUIREMENTS
4.8.10 MLTSS NETWORK REQUIREMENTS
4.8.11 GOOD FAITH NEGOTIATIONS
4.8.12 PROVIDER NETWORK ANALYSIS

4.9 PROVIDER CONTRACTS AND SUBCONTRACTS
4.9.1 GENERAL PROVISIONS
4.9.2 CONTRACT SUBMISSION
4.9.3 PROVIDER CONTRACT AND SUBCONTRACT TERMINATION
4.9.4 PROHIBITION OF INTERFERENCE WITH CERTAIN MEDICAL COMMUNICATIONS
4.9.5 ANTIDISCRIMINATION
4.9.6 SUBCONTRACTS
4.9.7 ASSIGNMENTS

4.10 EXPERT WITNESS REQUIREMENTS AND COURT OBLIGATIONS
4.11 ADDITIONS, DELETIONS, AND/OR CHANGES
4.11.1 NOTIFYING DMAHS OF CHANGES TO REIMBURSEMENT RATES
4.11.2 SPECIFIC REQUIREMENTS FOR CHANGES TO POLICY, OPERATIONS, OR FUNCTIONS


ARTICLE FIVE: ENROLLEE SERVICES
5.1 GEOGRAPHIC REGIONS
5.2 AID CATEGORIES ELIGIBLE FOR CONTRACTOR ENROLLMENT
5.3 EXCLUSIONS
5.3.1 ENROLLMENT AND AUTO ASSIGNMENT EXCLUSIONS

5.4 ENROLLMENT OF MANAGED CARE ELIGIBLES
5.5 ENROLLMENT AND COVERAGE REQUIREMENTS
5.6 VERIFICATION OF ENROLLMENT
5.7 MEMBER SERVICES UNIT
5.8 ENROLLEE EDUCATION AND INFORMATION
5.8.1 GENERAL REQUIREMENTS
5.8.2 ENROLLEE NOTIFICATION/HANDBOOK
5.8.3 ANNUAL INFORMATION TO ENROLLEES
5.8.4 NOTIFICATION OF CHANGES IN SERVICES
5.8.5 ID CARD
5.8.6 ORIENTATION

5.9 PCP SELECTION AND ASSIGNMENT
5.9.1 INITIAL SELECTION/ASSIGNMENT
5.9.2 PCP CHANGES

5.10 DISENROLLMENT FROM CONTRACTOR?S PLAN
5.10.1 GENERAL PROVISIONS
5.10.2 DISENROLLMENT FROM THE CONTRACTOR?S PLAN AT THE ENROLLEE?S REQUEST
5.10.3 DISENROLLMENT FROM THE CONTRACTOR?S PLAN AT THE CONTRACTOR?S REQUEST AND REPORTING OF ENROLLEE NON-COMPLIANCE
5.10.4 TERMINATION

5.11 TELEPHONE ACCESS
5.12 APPOINTMENT AVAILABILITY
5.13 APPOINTMENT MONITORING PROCEDURES
5.14 CULTURAL AND LINGUISTIC NEEDS
5.15 ENROLLEE GRIEVANCES AND APPEALS
5.15.1 GENERAL REQUIREMENTS
5.15.2 NOTIFICATION TO ENROLLEES OF GRIEVANCE AND APPEAL PROCEDURES
5.15.3 GRIEVANCE AND APPEAL PROCEDURES
5.15.4 PROCESSING GRIEVANCES AND APPEALS
5.15.5 RECORDS MAINTENANCE

5.16 MARKETING
5.16.1 GENERAL PROVISIONS - CONTRACTOR?S RESPONSIBILITIES
5.16.2 STANDARDS FOR MARKETING REPRESENTATIVES


ARTICLE SIX: PROVIDER INFORMATION
6.1 GENERAL
6.2 PROVIDER PUBLICATIONS
6.3 PROVIDER EDUCATION AND TRAINING
6.4 PROVIDER TELEPHONE ACCESS
6.5 PROVIDER GRIEVANCES AND APPEALS

ARTICLE SEVEN: TERMS AND CONDITIONS (ENTIRE CONTRACT)
7.1 CONTRACT COMPONENTS
7.2 GENERAL PROVISIONS
7.3 STAFFING
7.4 RELATIONSHIPS WITH DEBARRED OR SUSPENDED PERSONS PROHIBITED
7.5 CONTRACTING OFFICER AND CONTRACTOR?S REPRESENTATIVE
7.6 AUTHORITY OF THE STATE
7.7 EQUAL OPPORTUNITY EMPLOYER
7.8 NONDISCRIMINATION REQUIREMENTS
7.9 INSPECTION RIGHTS
7.10 NOTICES/CONTRACT COMMUNICATION
7.11 TERM
7.11.1 CONTRACT DURATION AND EFFECTIVE DATE
7.11.2 AMENDMENT, EXTENSION, AND MODIFICATION

7.12 TERMINATION
7.13 CLOSEOUT REQUIREMENTS
7.14 MERGER/ACQUISITION REQUIREMENTS
7.15 SANCTIONS
7.16 LIQUIDATED DAMAGES PROVISIONS
7.16.1 GENERAL PROVISIONS
7.16.2 MANAGED CARE OPERATIONS, TERMS AND CONDITIONS, AND PAYMENT PROVISIONS
7.16.3 TIMELY REPORTING REQUIREMENTS
7.16.4 ACCURATE REPORTING REQUIREMENTS
7.16.5 TIMELY PAYMENTS TO PROVIDERS
7.16.6 CONDITIONS FOR TERMINATION OF LIQUIDATED DAMAGES
7.16.7 EPSDT & LEAD SCREENING PERFORMANCE STANDARDS
7.16.8 DEPARTMENT OF HEALTH AND HUMAN SERVICES CIVIL MONEY PENALTIES
7.16.8.1 FEDERAL STATUTES
7.16.8.2 FEDERAL PENALTIES

7.16.9 PROVIDER NETWORK COMPLIANCE STANDARDS
7.16.10 CARE MANAGEMENT COMPLIANCE STANDARDS

7.17 STATE SANCTIONS
7.18 APPEAL PROCESS
7.19 CONTRACTOR CERTIFICATIONS
7.19.1 GENERAL PROVISIONS
7.19.2 CERTIFICATION SUBMISSIONS
7.19.3 ENVIRONMENTAL COMPLIANCE
7.19.4 ENERGY CONSERVATION
7.19.5 INDEPENDENT CAPACITY OF CONTRACTOR
7.19.6 NO THIRD PARTY BENEFICIARIES
7.19.7 PROHIBITION ON USE OF FEDERAL FUNDS FOR LOBBYING
7.19.8 CERTIFICATION AND DISCLOSURE OF POLITICAL CONTRIBUTIONS ?COMPLIANCE WITH N.J.S.A. 19:44A-20.13 ET SEQ.

7.20 REQUIRED CERTIFICATE OF AUTHORITY
7.21 SET-OFF FOR STATE TAXES AND CHILD SUPPORT
7.22 CLAIMS
7.23 MEDICARE RISK CONTRACTOR
7.24 TRACKING AND REPORTING
7.25 FINANCIAL STATEMENTS
7.25.1 AUDITED FINANCIAL STATEMENTS
7.25.2 UNAUDITED FINANCIAL STATEMENTS (SAP)

7.26 FEDERAL APPROVAL AND FUNDING
7.27 CONFLICT OF INTEREST
7.28 RECORDS RETENTION
7.29 WAIVERS
7.30 CHANGE BY THE CONTRACTOR
7.31 INDEMNIFICATION
7.32 INVENTIONS
7.33 USE OF CONCEPTS
7.34 PREVAILING WAGE
7.35 DISCLOSURE STATEMENT
7.36 FRAUD, WASTE AND ABUSE
7.36.1 COMPLIANCE PLAN
7.36.2 AUDIT
7.36.3 PROVIDERS
7.36.4 SPECIAL INVESTIGATIONS UNIT
7.36.5 RECOVERIES AND OVERPAYMENTS
7.36.6 SANCTIONS
7.36.7 COMPLIANCE WITH SECTION 6032 OF THE FEDERAL DEFICIT REDUCTION ACT OF 2005

7.37 EQUALITY OF ACCESS AND TREATMENT/DUE PROCESS
7.38 CONFIDENTIALITY
7.39 SEVERABILITY
7.40 CONTRACTING OFFICER AND CONTRACTOR?S REPRESENTATIVE

ARTICLE EIGHT: FINANCIAL PROVISIONS
8.1 GENERAL INFORMATION
8.2 FINANCIAL REQUIREMENTS
8.2.1 COMPLIANCE WITH CERTAIN CONDITIONS
8.2.2 AUDIT REQUIREMENTS
8.2.3 COMPLIANCE WITH PAYMENT REQUIREMENTS

8.3 INSURANCE REQUIREMENTS
8.3.1 INSURANCE CANCELLATION AND/OR CHANGES
8.3.2 STOP-LOSS INSURANCE

8.4 MEDICAL LOSS RATIO
8.4.1 MEDICAL LOSS RATIO STANDARD AND REPORT
8.4.2 MEDICAL LOSS RATIO COMPLIANCE REMITTANCE

8.5 RATE GEOGRAPHIC DISTRICTS, PREMIUM GROUPS, AND SPECIAL PAYMENT PROVISIONS
8.5.1 RATE GEOGRAPHIC DISTRICTS
8.5.2 MAJOR PREMIUM GROUPS
8.5.2.1 NON-ABD CHILDREN, MEDICAID AND NJ FAMILYCARE A, B & C (<21 YEARS OF AGE)
8.5.2.2 NON-ABD, NJ FAMILYCARE D CHILDREN
8.5.2.3 NON-ABD MEDICAID, PREGNANT WOMEN, AND NJ FAMILYCARE A PARENTS/CARETAKERS
8.5.2.4 NON-ABD NJ FAMILYCARE ABP PARENTS/CARETAKER RELATIVES
8.5.2.5 NON-ABD NJ FAMILYCARE ABP ADULTS WITHOUT DEPENDENT CHILDREN
8.5.2.6 ABD WITHOUT MEDICARE
8.5.2.7 ABD WITH MEDICARE AND OTHER DUAL ELIGIBLES
8.5.2.8 MANAGED LONG TERM SERVICES AND SUPPORTS ELIGIBLES WITH MEDICARE
8.5.2.9 MANAGED LONG TERM SERVICES AND SUPPORTS ELIGIBLES WITHOUT MEDICARE
8.5.3 SUPPLEMENTAL PAYMENT PER PREGNANCY OUTCOME & NEWBORN INFANTS
8.5.4 PAYMENT FOR CERTAIN BLOOD CLOTTING FACTORS AND OTHER HIGH COST DRUGS
8.5.5 RECONCILIATION OF PAYMENTS
8.5.6 EPSDT INCENTIVE PAYMENT
8.5.7 PERFORMANCE-BASED CONTRACTING PROGRAM
8.5.8 MANAGED LONG TERM SERVICES AND SUPPORTS HOME AND COMMUNITY BASED SERVICES PERFORMANCE PAYMENT
8.5.9 PAYMENT/ADJUSTMENT TO THE CAPITATION RATES FOR THE HEALTH INSURANCE PROVIDERS FEE UNDER SECTION 9010 OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT OF 2010
8.5.10 PAYMENT FOR INCREASED ACCESS TO PHYSICIAN SERVICES
8.5.11 FINANCIAL PROVISIONS
8.5.12 PAYMENTS TO PERSONAL CARE ASSISTANT PROVIDERS

8.6 HEALTH BASED PAYMENT SYSTEM (HBPS)
8.7 THIRD PARTY LIABILITY
8.8 COMPENSATION/CAPITATION CONTRACTUAL REQUIREMENTS
8.9 CONTRACTOR ADVANCED PAYMENTS
8.10 FEDERALLY QUALIFIED HEALTH CENTERS
8.11 SCHOOL-BASED HEALTH SERVICE PROGRAMS
8.12 PROVIDER RECEIVABLES

ARTICLE NINE: MANAGED LONG TERM SERVICES AND SUPPORTS
9.1 GENERAL INFORMATION
9.2 MLTSS MANAGEMENT INFORMATION SYSTEM
9.2.1 CARE MANAGEMENT SYSTEM REQUIREMENTS
9.2.2 ELECTRONIC CARE MANAGEMENT RECORD STANDARDS
9.2.3 NJ CHOICE ASSESSMENT SYSTEM DATA

9.3 PROVISION OF MLTSS COVERED SERVICES
9.3.1 COORDINATION AND CONTINUITY OF CARE FOR FACILITY AND COMMUNITY ALTERNATIVE RESIDENTIAL SETTINGS
9.3.2 CONSIDERATION OF INSTITUTIONAL OR COMMUNITY BASED MLTSS: COST EFFECTIVENESS ANALYSIS
9.3.3 TRANSFER OF MLTSS MEMBERS BETWEEN PROVIDERS
9.3.4 TRANSFER OF PEDIATRIC MEMBERS TO AN ADULT SYSTEM OF CARE
9.3.5 UNABLE TO CONTACT
9.3.6 INACCESSIBLE

9.4 ENROLLEE SERVICES
9.4.1 GENERAL MLTSS REQUIREMENTS
9.4.2 VOLUNTARY WITHDRAWAL FROM MANAGED LONG TERM SERVICES AND SUPPORTS
9.4.3 DISENROLLMENT DUE TO MEMBER NON-COMPLIANCE WITH MLTSS CARE MANAGEMENT REQUIREMENTS

9.5 MLTSS CARE MANAGEMENT STANDARDS
9.5.1 GENERAL MLTSS REQUIREMENTS
9.5.2 MLTSS CARE MANAGEMENT STAFF QUALIFICATIONS
9.5.3 MLTSS TRAINING
9.5.4 CARE MANAGEMENT TRAINING
9.5.5 MLTSS CASELOAD MANAGEMENT

9.6 MLTSS CARE MANAGEMENT STANDARDS
9.6.1 CLINICAL ELIGIBILITY AND LEVEL OF CARE DETERMINATIONS
9.6.2 COMPLETING INITIAL PLAN OF CARE
9.6.3 CARE PLANNING: NEEDS ASSESSMENT AND OPTIONS COUNSELING
9.6.4 CARE PLANNING: PLAN OF CARE DEVELOPMENT AND SERVICE COORDINATION
9.6.5 PLAN OF CARE MONITORING AND REASSESSMENT STANDARDS
9.6.6 MLTSS CARE MANAGEMENT CASE CLOSURE STANDARDS

9.7 NURSING FACILITY PLACEMENT, TRANSITIONS, AND DIVERSIONS
9.7.1 NURSING FACILITY PLACEMENT
9.7.2 NURSING FACILITY TRANSITIONS AND MONEY FOLLOWS THE PERSON (MFP)
9.7.3 MFP PROCESS
9.7.4 MFP QUALITY ASSURANCE
9.7.5 NURSING FACILITY DIVERSION

9.8 PARTICIPANT DIRECTION AND PERSONAL PREFERENCE PROGRAM (PPP)
9.8.1 GENERAL MLTSS REQUIREMENTS
9.8.2 PARTICIPANT DIRECTION OPTION
9.8.3 REVOCATION OF PARTICIPANT DIRECTION
9.8.4 CHANGE IN SCOPE, DURATION OR AMOUNT OF PARTICIPANT DIRECTION SERVICES
9.8.5 CHANGES IN RATES AND IMPLEMENTATION OF REVISED RATES

9.9 BEHAVIORAL HEALTH STANDARDS
9.10 CRITICAL INCIDENT REPORTING
9.10.1 GENERAL MLTSS REQUIREMENTS
9.10.2 REPORTING AND MONITORING REQUIREMENTS
9.10.3 REPORTING SYSTEM

9.11 QUALITY MANAGEMENT AND PERFORMANCE IMPROVEMENT

APPENDICES
TABLE OF CONTENTS ? APPENDICES
SECTION A
A.4.0 Provision of Health Care Services
A.4.1 Provider Network File
A.4.1.2C Monthly Report of Managed Care Residents in IMD
A.4.3 Network Accessibility Analysis
A.5.5 Notification of Possible Incarceration Referral Form
A.7.0 Terms And Conditions
A.7.1 Certifications
A.7.1.A
A.7.1.B
A.7.1.C
A.7.1.D
A.7.1.E
A.7.1.F Quarterly Provider Network Certification Form
A.7.1.G Certification of Dental Network for the U.S. Department of Health and Human Services Form
A.7.2 Fraud, Waste, and Abuse
A.7.3
A.7.5
A.7.12
A.7.17
A.7.18
A.7.20 Federally Qualified Health Center Payments
A.8.0 Financial Provisions
A.8.1 Other Coverage Information
A.8.2 Tort/Accident Referral Form
A.8.3.A MCO PCP Rate Increase Invoice Template
A.9.4.2 MLTSS Voluntary Withdrawal Form
A.9.4.3 Participant Involuntary Disenrollment Form
A.9.6 Quarterly Report of Reductions in MLTSS Services
SECTION B
B.2.0 Conditions Precedent
B.2.1 Readiness Review
B.3.0 Managed Care Management Information Systems
B.3.1.2 State Monitoring Requirements
B.3.2 Data Files Resource Guide
B.4.0 Provision Of Health Care Services
B.4.1 Benefit Packages
B.4.2.4 MCO Drug Utilization Report
B.4.2.11 Orthodontic Services
B.4.4 Behavioral Health Services Dictionary
B.4.5 Head Start Programs
B.4.7 Local Health Departments
B.4.8 WIC Referral Forms
B.4.9 Mental Health/Substance Use Disorder Screening Tools
B.4.10 Centers of Excellence
B.4.11 Notification of Additions, Deletions, and/or Changes
B.4.12 Reserved
B.4.13 Statewide Family Centered HIV Care Network (Ryan White Part D)
B.4.14 New Jersey QAPI Standards
B.4.15 Hysterectomy and Sterilization Procedures and Consent Forms
B.4.16 Regional Child Abuse and Neglect Diagnostic and Treatment Centers
B.4.17 Special Child Health Services Network
B.5.0 Enrollee Services
B.5.1 Notification Forms
B.5.2 Cost-Sharing Requirements for NJ FamilyCare C and D Enrollees
B.7.0 Terms And Conditions
B.7.1 Physician Incentive Plan Provisions
B.7.2 Provider Contract/Subcontract Provisions
B.7.5 EPSDT Codes
B.7.13 FORM OF AGREEMENT CONCERNING CONTRACTUAL GUARANTY FOR HMO
B.7.35 Disclosure Statement Of Ownership And Control Interest, Related Business Transactions And Persons Convicted Of A Crime.
B.8.5.10 Payment For Increased Access To Physician Service
B.9.0 MLTSS Services Dictionary
B.9.3 Cost Effectiveness Policy Guidance: Exceptions Process
SECTION C
SECTION D
D.1 Contractor?s QAPI/Utilization Management Plans
D.2 Contractor?s Grievance Process
D.3 Contractor?s Provider Network
D.4 Contractor?s List of Subcontractors
D.5 Contractor?s Supplemental Benefits
D.6 Contractor?s Representative


New Jersey LTSS (DRAFT)

1

Claim Type

Code Mod Method/ Unit Amerigroup Healthfirst Horizon NJ Health UnitedHealthcare Amerigroup Healthfirst Horizon NJ Health UnitedHealthcare Amerigroup Healthfirst Horizon NJ Health UnitedHealthcare
Adult Family Care (GO)

Y7573

Adult Family Care S5140 Per Diem Foster care, adult; per diem

Assisted Living Residence - 1 day (GO)

Y9633, T2031

Assisted Living Services
(ALR - Assisted Living Residence)

T2031 Per Diem Assisted living, waiver; per diem

Comprehensivce Personal Care Home - 1 day (GO)

Y7574

Assisted Living Services
(CPCH - Comprehensive Personal Care
Home)

T2031 U1 Per Diem Assisted living, waiver; per diem

Assisted Living Program - 1 day (GO)
Y9634

Assisted Living Program
(ALP)

T2031 U2 Per Diem Assisted living, waiver; per diem

Behavioral Programs (TBI) H0004 ST 22, Y7564,
Y7566

H0004 15 minutes
Behavioral health counseling and therapy, per 15 minutes (Individual)

Behavioral Programs (TBI) H0004 ST 22, Y7564,
Y7566

H0005 HQ 15 minutes Behavioral health counseling and therapy, per 15 minutes (Group)

Caregiver/Participant Training (GO) Y9848, S5111, Y9849 Caregiver/ Participant Training S5111 One Visit per
day

Home care training, family; per session

S5120 15 minutes Chore services; per 15 minutes

S5121 Per Diem Chore services; per diem

G0515 96 15 minutes Habilitation, educational; waiver; per hour (Individual)

96153 96 15 minutes Habilitation, educational; waiver; per hour (Group)

T2033 Per Diem Residential care, not otherwise specified (NOS), waiver; per diem (e.g., Low Level
Supervision)

T2033 TF Per Diem Residential care, not otherwise specified (NOS), waiver; per diem (e.g., Moderate
Level Supervision)

T2033 TG Per Diem Residential care, not otherwise specified (NOS), waiver; per diem (e.g., High
Level Supervision)

T2038 Per Service Community transition, waiver; per service

T2038 U6 Per Service Administration
S5130 15 Minutes Individual Homemaker service, NOS; per 15 minutes

S5130 HQ 15 Minutes Group Homemaker service, NOS, per 15 minutes
S5130 U1 15 minutes Homemaker service, NOS, per 15 minutes. The code is to be used ONLY as a

continuity of care code for existing recipients of HBSC when the member requires
assistance with both ADLs and IADLs for a period of no longer than 180 days.
This code is being implemented to allow HBSC providers who are not accredited
as PCA providers to continue to provide services and be paid for a continuity of
care period of no longer than 180 days beginning July 1, 2014. This code will
expire 1/1/2015. THIS CODE EXPIRES 1/1/2015

S5130 U2 15 minutes Group Homemaker service, NOS, per 15 minutes. The code is to be used ONLY
as a continuity of care code for existing recipients of HBSC when the member
requires assistance with both ADLs and IADLs for a period of no longer than 180
days. This code is being implemented to allow HBSC providers who are not
accredited as PCA providers to continue to provide services and be paid for a
continuity of care period of no longer than 180 days beginning July 1, 2014. This
code will expire 1/1/2015. THIS CODE EXPIRES 1/1/2015

Home Delivered Meal Service (GO) S5170, Y9847 Home Delivered Meals S5170 Per Service -
One meal per

day

Home delivered meals, including preparation; per meal

Personal Emergency Response System Pill
Dispenser ? 1 Installation (GO)

S5160 22 Medication Dispensing Device
(Set Up)

T1505 Per Service Electronic medication compliance management device, includes all components
and accessories, not otherwise classified

Personal Emergency Response System Pill
Dispenser ? 1 Monthly Monitoring Fee (GO)

S5161 22 Medication Dispensing Device
(Monthly Monitoring)

S5185 Monthly Medication reminder service, nonface-to-face; per month

NA MLTSS PCA Current codes Codes per State Plan - Not a stand alone MLTSS benefit
T2002 per diem Nonemergency transportation; per diem; Not a stand alone MLTSS benefit.

T2003 Per Service Nonemergency transportation; encounter trip; Not a stand alone MLTSS
benefit.

Revenue Codes 0100, 0119, 0129, 0139, 0149,
0159, 0169

NA
Revenue Codes 0100, 0119, 0129, 0139, 0149, 0159, 0169.

SCNF - Revenue Codes 0100, 0119, 0129, 0139,
0149, 0159, 0169.

NA SCNF - Revenue Codes 0100, 0119, 0129, 0139, 0149, 0159, 0169.

HMO ReAuthorization Needed Provider Referral Needed? MLTSS Code DescriptionMLTSS Code

Community Transition Services (CRPD, GO) T2038 (CRPD), T2038,
T2038 HC (GO)

Community Transition Services

Behavior Management (TBI)

MLTSS Service

Chore Service

Cognitive Therapy

Former Code (s)

Chore Service (GO) S5120 52, Y9838, S5120
22, S5121, Y9837

Therapies through a CRS or Day Program ?
Cognitive Rehabilitative Therapy AND Therapies
through a CRS or Day Program - Cognitive
Rehabilitation Group Therapy (TBI)

97532 ST 22; T2012 HQ
ST

HMO Authorization Needed?

Community Residential Services
(CRS)

Non-Medical Transportation

Nursing Facility Services
(Custodial)

Home Based Supportive Care

Y9835, T2002, Y9834,
A0080

Transportation - Non Medical (GO)

NA

Former Waiver Service

Community Residential Services Low, Moderate and
High Level of Supervision (TBI)

Y7435, Y7436, Y7437

Y9845, T1022. Y9846,
Z1200, Z1205, Z1290,
Z1295, S5130 22, S5130
TV 22

Home Based Supportive Care (GO)



New Jersey LTSS (DRAFT)

2

Claim Type

Code Mod Method/ Unit Amerigroup Healthfirst Horizon NJ Health UnitedHealthcare Amerigroup Healthfirst Horizon NJ Health UnitedHealthcare Amerigroup Healthfirst Horizon NJ Health UnitedHealthcare
HMO ReAuthorization Needed Provider Referral Needed? MLTSS Code DescriptionMLTSS Code MLTSS ServiceFormer Code (s) HMO Authorization Needed?Former Waiver Service

97535 96 15 minutes Occupational Therapy, per diem (Individual) NOTE: For Free Standing Clinic or
ANY therapy service provided out of the home; EXISTING Codes should be
used. THE MODIFIER MUST be included.

97150 96 Per Diem Occupational Therapy, (Group) NOTE: For Free Standing Clinic or ANY therapy
service provided out of the home; EXISTING Codes should be used. THE
MODIFIER MUST be included.

97535 96 15 minutes Occupational Therapy (Individual) 15 minutes: Rehabilitation for MLTSS
members with TBI diagnosis. Free Standing Clinic or ANY therapy service
provided out of the home; EXISTING Codes should be used. THE MODIFIER
MUST be included on any claim where the service is for MLTSS members with
TBI diagnosis. One session per day.

97150 96 Per Diem Occupational Therapy: (Group), 15 minutes: Rehabilitation for MLTSS members
with TBI diagnosis. Free Standing Clinic or ANY therapy service provided out of
the home; EXISTING Codes should be used. THE MODIFIER MUST be
included on any claim where the service is for MLTSS members with TBI
diagnosis. One session per day.

Personal Emergency Response System ? 1
Installation (CRPD, GO)

S5160 (CRPD); S5160,
Y9839 (GO)

Personal Emergency Response System
(PERS: Set up)

S5160 Per Service Emergency response system; service fee, Installation

S5161 Per Month Emergency response system; service fee, per month - Standard Landline Unit

S5161 U1 Per Month Emergency response system; service fee, per month - Cellular Unit

S5161 U2 Per Month Emergency response system; service fee, per month - Cellular Unit with Fall
Detection

S5161 U3 Per Month Emergency response system; service fee, per month - Mobile Unit

97110 96 15 minutes Physical therapy; per diem (Individual - Maintenance Therapy) NOTE: For Free
Standing Clinic or ANY therapy service provided out of the home; EXISTING
Codes should be used. THE MODIFIER MUST be included. on any claim where
the service is for habilitative therapy.

S8990 96 15 minutes Physical therapy; per diem (Group - Maintenance Therapy) NOTE: For Free
Standing Clinic or ANY therapy service provided out of the home; EXISTING
Codes should be used. THE MODIFIER MUST be included on any claim where
the service is for habilitative therapy.

97110 96 15 minutes Physical Therapy: (Individual), 15 minutes: Rehabilitation for MLTSS members
with TBI diagnosis. Free Standing Clinic or ANY therapy service provided out of
the home; EXISTING Codes should be used. THE MODIFIER of U4 for
Individual and U5 for Group MUST be included on any claim where the service is
for MLTSS members with TBI diagnosis. One Session per day.

S8990 96 15 minutes Physical Therapy: (GROUP), 15 minutes, Rehabilitation for MLTSS members
with TBI diagnosis. Free Standing Clinic or ANY therapy service provided out of
the home; EXISTING Codes should be used. THE MODIFIER of U4 for
Individual and U5 for Group MUST be included on any claim where the service is
for MLTSS members with TBI Diagnosis. One Session per day

T1000 UA 15 minutes RN/LPN Private duty / independent nursing service(s) - licensed, up to 15
minutes

T1002 UA 15 minutes RN only Private duty / independent nursing service(s) - licensed, up to 15
minutes

T1003 UA 15 minutes LPN Only Private duty/independent nursing service(s); licensed, up to 15
minutes

S5165 Per Service Home modifications; per service

T1028 (Eval) Per Service Assessment of home, physical and family environment, to determine suitability to
meet patient's medical needs

T1005 15 minutes Respite care, in the home, per 15 minutes

S5151 Per Diem Unskilled respite care, not hospice; per diem

NF Respite REV 0663 DAILY Daily respite Care in a Nursing Facility

Social Adult Day Care (GO) Z1235, Y9853, S5102 Social Adult Day Care S5102 U3 Per Diem Day care services, adult; per diem

Respite
(Daily & Hourly)

Private Duty Nursing

Residential Modifications

Occupational Therapy
(Group & Individual)

Physical Therapy
(Group & Individual)

Personal Emergency Response System
(PERS: Monthly Monitoring)

Respite Care (TBI); Respite Care: 8 hour Day.
Respite Care : 8 hour night. Respite Care - Day
>8<12, Respite Care Night >8<12, Respite Care -
>12 <24, Respite Care ? Nursing Facility, Respite
Care ? ALF or AFC ? Per Diem (GO)

Y7456, Y7458, Y7463,
(TBI): Z1210, S9125,
Y9793, Z1215, Z1220,
Z1225, Z1230, Z1285,
Y9792, S5151 (GO)

PDN (Private Duty Nursing) - CRPD Z1710, Z1715, S9124,
Z1720, Z1725, Z1730,
Z1735, Z1740, Z1745

Therapies through a CRS or Day Program ?
Occupational - Individual and Group (TBI)

97535 ST (Indiv), S9129
HQ ST (Group)

Therapies through a CRS or Day Program ?
Physical (Group and Individual) (TBI)

S8990 ST (Indiv); S9131
HQ ST (Group)

Environmental Modifications (CRPD); (EAA)
Environmental Accessibility Adaptation (GO)

S5165, S5165 52
(CRPD); S5165, Y9795
(GO)

Personal Emergency Response System ? 1 Monthly
Monitoring Fee (CRPD, GO)

S5161 (CRPD); S5161,
Y9843 (GO)



New Jersey LTSS (DRAFT)

3

Claim Type

Code Mod Method/ Unit Amerigroup Healthfirst Horizon NJ Health UnitedHealthcare Amerigroup Healthfirst Horizon NJ Health UnitedHealthcare Amerigroup Healthfirst Horizon NJ Health UnitedHealthcare
HMO ReAuthorization Needed Provider Referral Needed? MLTSS Code DescriptionMLTSS Code MLTSS ServiceFormer Code (s) HMO Authorization Needed?Former Waiver Service

92507 96 Per Diem Speech therapy, per diem (Individual) NOTE: For Free Standing Clinic or ANY
therapy service provided out of the home; EXISTING Codes should be used.
THE MODIFIER MUST be included on any claim where the service is for
habilitative therapy.

92508 96 Per Diem Speech therap, per diem (Group) NOTE: For Free Standing Clinic or ANY
therapy service provided out of the home; EXISTING Codes should be used.
THE MODIFIER MUST be included on any claim where the service is for
habilitative therapy.

92507 96 Per Diem Speech Therapy: (Individual), 15 minutes: Rehabilitation for MLTSS members
with TBI diagnosis. Free Standing Clinic or ANY therapy service provided out of
the home; EXISTING Codes should be used. THE MODIFIER MUST be
included on any claim where the service is for MLTSS members with TBI
diagnosis. One Session per day.

92508 96 Per Diem Speech Therapy: (Individual), 15 minutes: Rehabilitation for MLTSS members
with TBI diagnosis. Free Standing Clinic or ANY therapy service provided out of
the home; EXISTING Codes should be used. THE MODIFIER MUST be
included on any claim where the service is for MLTSS members with TBI
diagnosis. One Session per day.

Structured Day Program (TBI) S5102 ST, S5109, S5101
ST

Structured Day Program S5100 15 minutes Day care services, adult; per 15 minutes

Supported Day Program (TBI) Y7443 Supported Day Services T2021 15 minutes Day habilitation, waiver; per 15 minutes

T2039 Per Service

T2039 U7
(Eval)

Per Service

Vehicle modifications, waiver; per service

Therapies through a CRS or Day Program ?
Speech Individual and Group (TBI)

Y7556 Speech, Language & Hearing Therapy
(Group & Individual)

Environmental Adaptations- Vehicle (GO) ; S5165, S5165 52, Y9795,
Y9854

Vehicle Modifications


Main Sheet