Effective Date: July 1, 2021

Purpose:

This policy provides guidelines for reimbursement for billing of outpatient care management services related to substance use disorders (SUD).

Scope:

Products included:

• Division of Developmental Disabilities (DDD)
• Managed Long Term Services & Supports (MLTSS) program.
• Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP)

Definitions:

• HCPCS Level II H0023: Behavioral health outreach service (planned approach to reach a targeted population)
• Modifier HF: Substance abuse program

Policy:

Effective July 1, 2021, Horizon NJ Health will consider for reimbursement care management services to support members 18 years of age and older who have a Substance Use Disorder (SUD) with complex physical or psychosocial needs.

In order to be reimbursed, services must be billed using HCPCS level II H0023 appended with modifier –HF. Each unit billed equates to fifteen (15) minutes. Up to two (2) hours or eight (8) units will be allowed per member every rolling thirty days. Claims must be billed by an SUD clinic (Independent Clinics- Drug and Alcohol) that is enrolled as a provider with the Division of Medical Assistance and Health Services (DMAHS), and is licensed by the Department of Health (DOH) to provide SUD treatment.

A diagnosis code of a SUD (excluding nicotine dependence or abuse) must be included on the claim. The member must be receiving SUD treatment in the community or have been recently discharged (within 6 months) from an inpatient or residential setting and seeking community SUD treatment. In addition, there needs to be support to address complex needs, including, but not limited to:

• Homelessness or at risk of homelessness;
• Diagnosis of a Serious Mental Illness (SMI), including but not limited to schizophrenia, bipolar disorder, major depressive disorder and PTSD; or
• Diagnosis of a chronic and serious physical health condition.

In order to be reimbursed for care management services, the member may not be receiving case management services (including, but not limited to, ICMS, PATH, CCBHC, CMO, PACT, CSS, or Mental Health Residential Services) concurrently.

Services must be rendered by a care manager, who, at minimum, possesses a bachelor’s degree in a behavioral health including, but not limited to, psychology, nursing, counseling or social work with two (2) years of addiction treatment experience (personal or professional).

The following documentation requirements must be included in the clinical treatment plan:

• An initial assessment that identifies one of the eligibility criteria for care management services:
  • Trauma or co-occurring mental illness
  • Chronic physical comorbidities that interfere with functioning
  • SUD needs (smoking cessation should be included, but does not qualify an individual for care management)
  • Peer, wellness, and recovery services
  • Family support services
  • Legal or housing services

• A person-centered care management plan that addresses all life domains (not limited to addiction treatment) that is signed by the care manager, supervising clinician and the member
• The care management plan must be outcome based and include measurable goals that are developed collaboratively with the member
• Time spent to support units billed

Procedure:

Horizon NJ Health will not consider for reimbursement care management services for members under eighteen (18) years of age.

Horizon NJ Health will not consider for reimbursement care management services in which HCPCS Level II H0023 is not appended with modifier –HF.

Horizon NJ Health will not consider for reimbursement care management service units that exceed two (2) hours or eight (8) total units every rolling 30 days.

Horizon NJ Health will not consider for reimbursement care management services claims that are not submitted by SUD Clinics (Independent Clinics- Drug and Alcohol).

Horizon NJ Health will not consider for reimbursement care management services claims that do not include a diagnosis code of an SUD.

Horizon NJ Health will not consider for reimbursement care management services in which there is not a complex physical or psychosocial need.

Horizon NJ Health will not consider for reimbursement care management services that are not supported by the medical records.

Resources:

New Jersey 1115 Substance Use Disorder (SUD) Demonstration

American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services

Limitations and Exclusions:

Notwithstanding the foregoing, all payment determinations are subject to all other applicable limitations, including, but not limited to, the following:

• Benefit Limitations;
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including, but not limited to, incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.