Effective Date: July 1, 2020

Purpose:
This policy provides reimbursement guidelines for billing self-help and peer support services.

Scope:
Products included:

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

Definitions:

• Procedure Code H0038: Self-help/peer services, per 15 minutes
• Modifier –HF: Substance abuse program

Policy:
In accordance with The New Jersey 1115 Substance Use Disorder (SUD) Waiver, for dates of service beginning on July 1, 2020 and thereafter, Horizon NJ Health shall reimburse eligible claims from Medicaid Substance Use Disorder (SUD) treatment providers for outpatient levels of care for self-help/peer services. Services must be rendered to those individuals in need of support to maintain stability in the community with a substance use disorder.

Eligible providers may submit for self-help/peer services rendered with HCPCS code H0038, modifier -HF and one (1) unit for every fifteen (15) minutes with the member, up to a maximum of sixteen (16) units per day, equal to four (4) hours. In order to be reimbursed, the claim must include an applicable substance disorder diagnosis code. The member must not already be enrolled in any service in which peer recovery services are already delivered. In order to be reimbursed, the provider must be an outpatient drug and alcohol clinic. This service shall only be reimbursed for members 18 years of age or older.

Medical records for each self-help/peer service must include sufficient documentation to support all diagnosis codes, time spent with the member 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 billed with HCPCS code H0038 without modifier –HF.

Horizon NJ Health shall deny claims for self-help/peer services that are not from outpatient drug and alcohol clinics.

Horizon NJ Health shall deny claims for self-help/peer services that do not have an appropriate substance disorder diagnosis code.

Horizon NJ Health shall deny units that exceed sixteen (16) units per day for HCPCS code H0038.

Resources:
The New Jersey 1115 Substance Use Disorder (SUD) Waiver

Center for Social Work Research, “Peer Specialist Training and Certification Programs: A National Overview”

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.