Effective Date: July 1, 2020

Purpose:
This policy provides reimbursement guidelines for billing DIR services.

Scope:
Products included:

• NJ FamilyCare
• Fully Integrated Dual Eligible (FIDE)-SNP
• Managed Long-Term Services and Supports (MLTSS)
• Division of Developmentally Disabled (DDD)

Definitions:

• DIR Services: Provides a foundation for understanding human development and the critical role of social-emotional development. DIR services can help to increase communication skills and improve attention, focus, social skills, and memory.

Policy:
In accordance with Section 1905(r) of the Social Security Act (42 U.S.C. § 1396(d) and the New Jersey Medicaid Managed Care Contract, for dates of service beginning on July 1, 2020 and thereafter, Horizon NJ Health shall reimburse eligible claims for DIR services for members under the age of 21.

The need for DIR services must be determined by a Qualified Healthcare Professional (QHP) capable of making a diagnosis of autism. In order to be reimbursed, the provider must be an eligible licensed professional as follows:

• Licensed Clinical Social Worker (LCSW)
• Licensed Professional Counselor (LPC)
• Psychologist
• Licensed Marriage and Family Therapist (LMFT)
• Board Certified Behavior Analyst (BCBA)
• Licensed Occupational Therapist (OT)
• Speech Language Pathologist (SLP)
• Licensed Physical Therapist (PT)

DIR services must be provided in the therapist’s office, a community setting or a child’s home.

Eligible providers may submit for DIR services with the appropriate procedure code below along with modifier –EP (Service provided as part of Medicaid early periodic screening diagnosis and treatment program). The claim should also include units based on the time the service rendered. Units bills higher than the below limitations will be denied.

Medical records for each DIR service must include sufficient documentation to support the service rendered, time spent and medical necessity.

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.

Procedure:
Horizon NJ Health shall deny claims for DIR services for members over 21 years old.

Horizon NJ Health shall deny claims billed for DIR services submitted without a supporting diagnosis code of autism.

Horizon NJ Health shall deny claims for DIR services not billed by one of the following allowed specialties: Licensed Clinical Social Worker (LCSW), Licensed Professional Counselor (LPC), Psychologist, Licensed Marriage and Family Therapist (LMFT), Board Certified Behavior Analyst (BCBA) or Licensed Occupational, Physical, and Speech Therapist.

Horizon NJ Health shall deny claims for DIR services that are performed in a location other than a therapist’s office, a community setting or a child’s home.

Horizon NJ Health shall deny units for DIR services that exceed the maximum units per day as noted under this policy.

Resources:
Section 1905(r) of the Social Security Act (42 U.S.C. § 1396(d) and federal regulation 42 C.F.R. § 441.50 et seq.

New Jersey Medicaid Managed Care Contract, Section 4.2.6. “EPSDT Services” under section B.7 “Autism Spectrum Disorder”

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

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

• 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.