SFY 20223Effective 070121Revised 033121Clinical Review15ServiceRateUnit of serviceTypeBilling CodeDayMonthYearBilling CodeDayMonthYearBilling CodeDayMonthYearAnnual client limitClinician identifi ID: 857040
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1 DMHAS MATI SFY 2022-3Effective 07/01/21R
DMHAS MATI SFY 2022-3Effective 07/01/21Revised 03/31/21 Clinical Review 15 ServiceRateUnit of serviceTypeBilling CodeDayMonthYearBilling CodeDayMonthYearBilling CodeDayMonthYearAnnual client limitClinician identified Urine Drug Screen - Presumptive Testing $ 8.00 Oral Swab $ 8.00 serviceClinicalZSWBn/aZSWBn/aZSWBn/an/a Mantoux Tuberculin Test $ 10.00 serviceClinicaln/an/a Continuing Care LOCI $ 25.00 20 minutesClinicalZLOCIn/aZLOCIn/aZLOCIn/an/a Limit Clinical Review Enhancements$75.00$75.00$99.00 Co-occurring Clinical Services 15 ServiceRateUnit of serviceTypeBilling CodeDayMonthYearBilling CodeDayMonth Case Management - COOC $ 12.00 15 minutesCo-occurringT2022 HFn/aT2022 HFn/aT2022 HFfixed Comprehensive Intake Evaluation $ 150.49 serviceCo-occurringn/an/an/a Crisis Intervention - Individual $ 13.00 15 minutesCo-occurringS9484 HFS9484 HFn/aS9484 HFfixed Family Therapy $ 102.55 60 minutesCo-occurring90847 HF90847 HFn/a90847 HFfixed Individual Therapy $ 61.39 30 minutesCo-occurring90832 HF Individual Therapy $ 81.23 45 - 50 minutesCo-occurring90834 HF90834 HFn/a90834 HFfixed Group Therapy $ 24.75 90 minCo-occurring90853 HF90853 HFn/a90853 HFfixed Clinical Consultation $ 25.00 15 minutesCo-occurringn/afixed Limit Co-occurring Clinical Services Enhancement $246.49$527.50$150.49Medically Assisted Treatment Initiative (MATI) Fee for Service Enhancement Authorization Parameters E
2 ncounter entry required before expiratio
ncounter entry required before expiration of authorization (days) - IWM, STR & LTR Limits HWH Limits Ambulatory Limits IWM, STR & LTR Limits HWH Limits Ambulatory Limits DMHAS MATI SFY 2022-3Effective 07/01/21Revised 03/31/21 Medically Assisted Treatment Initiative (MATI) Fee for Service Enhancement Authorization Parameters 15 ServiceRateUnit of serviceTypeBilling CodeDayMonthYearBilling CodeDayMonthYearBilling CodeDayMonthYearAnnual client limitClinician identified Medication Monitoring $ 40.88 15 minutes CO Med 90862 HF 90862 HFn/a90862 HFn/an/afixed Limit Co-occurring Medication Monitoring Service Enhancement $0.00$81.76$81.76 Psychiatric Evaluation 15 ServiceRateUnit of serviceTypeBilling CodeDayMonthYearBilling CodeDayMonthYearBilling CodeDayMonthYearAnnual client limitClinician identified Psychiatric Evaluation $ 394.35 servicePsych Evalfixed Limit Co-occurring Pyschiatric Evaluation Service Enhancement $394.35$1,577.40$394.35$1,577.40$394.35$1,577.40$1,577.40 HWH Limits Ambulatory Limits Encounter entry required before expiration of authorization (days) - Encounter entry required before expiration of authorization (days) - IWM, STR & LTR Limits Co-occurring Med Monitoring Services Enhancement IWM, STR & LTR Limits HWH Limits Ambulatory Limits DMHAS MATI SFY 2022-3Effective 07/01/21Revised 03/31/21 Medically Assisted Treatment Initiative (MATI) Fee for Service Enhancement Authorization Parameters 15 ServiceRateUnit of serviceType
3 Billing CodeDayMonthYearBilling CodeDayM
Billing CodeDayMonthYearBilling CodeDayMonthYearBilling CodeDayMonthYearAnnual client limitClinician identified Comprehensive Metabolic Panel $ 9.45 serviceMAT-Lab Srvcn/an/an/an/a Transferase, Alanine Amino Panel (ALT) $ 2.70 serviceMAT-Lab Srvcn/an/an/an/a Transferase, Aspartate Amino Panel (AST) $ 2.70 serviceMAT-Lab Srvcn/an/an/an/a Bilirubin Panel $ 2.70 serviceMAT-Lab Srvcn/an/an/an/a Mantoux Tuberculin Test $ 10.00 serviceMAT-Lab Srvcn/an/an/an/a Hepatic Function Panel $ 6.30 serviceMAT-Lab Srvcn/an/an/an/a Complete Blood Count $ 4.50 serviceMAT-Lab Srvcn/an/an/an/a Quantitative Syphilis Test $ 2.70 serviceMAT-Lab Srvcn/an/an/an/a Urine Drug Screen - Presumptive Testing $ 8.00 serviceMAT-Lab SrvcH0003 HFn/aH0003 HFn/aH0003 HFn/an/a Urine Preg Test Visual Color Comp $ 2.70 serviceMAT-Lab Srvc Limit Laboratory Services Enhancements$37.35$37.35$37.35 IWM, STR & LTR Limits Encounter entry required before expiration of authorization (days) - Medication Assisted - Laboratory Services HWH Limits Ambulatory Limits DMHAS MATI SFY 2022-3Effective 07/01/21Revised 03/31/21 Medically Assisted Treatment Initiative (MATI) Fee for Service Enhancement Authorization Parameters 15 ServiceRateUnit of serviceTypeBilling CodeDayMonthYearBilling CodeDayMonthYearBilling CodeDayMonthYearAnnual client limitClinician identified Medication Monitoring - MAT $ 40.88 15 minutesMAT IS-MZ3
4 353n/aZ3353n/aZ3353n/an/a Methadone Main
353n/aZ3353n/aZ3353n/an/a Methadone Maintenance $ 3.83 MAT IS-MH0020 HFn/aH0020 HFn/aH0020 HFn/an/a Physician visit - new patient (10 min) $ 22.17 10 minutesMAT IS-M Physician visit - new patient (20 min) $ 46.67 20 minutesMAT IS-M Physician visit - new patient (30 min) $ 55.03 30 minutesMAT IS-M Physician visit - new patient (45 min) $ 83.08 45 minutesMAT IS-M Physician visit - new patient (60 min) $ 104.04 60 minutesMAT IS-M Physician visit - established patient (10 min) $ 46.67 10 minutesMAT IS-M Physician visit - established patient (15 min) $ 73.44 15 minutesMAT IS-M Physician visit - established patient (25 min) $ 107.87 25 minutesMAT IS-M Physician visit - established patient (40 min) $ 144.92 40 minutesMAT IS-M Urine Drug Screen - Presumptive Testing $ 8.00 serviceMAT IS-MH0003HFH0003HFH0003HF Limit Med Assist-Induction/Stabilization Methadone Enhancements $278.42$278.42$196.66 15 ServiceRateUnit of serviceTypeBilling CodeDayMonthYearBilling CodeDayMonthYearBilling CodeDayMonthYearAnnual client limitClinician identified Medication Monitoring - MAT $ 40.88 15 minutesMAT- MMZ3353n/aZ3353n/aZ3353n/an/a Methadone Maintenance $ 3.83 MAT- MMH0020 HFn/aH0020 HFn/aH0020 HFn/an/a Physician visit - new patient (10 min) $ 22.17 10 minutesMAT- MM Physician visit - new patient (20 min) $ 46.67 20 minutesMAT- MM Physician visit - established patient (10 min) $
5 46.67 10 minutesMAT- MM Physician visit
46.67 10 minutesMAT- MM Physician visit - established patient (15 min) $ 73.44 15 minutesMAT- MM Urine Drug Screen - Presumptive Testing $ 8.00 serviceMAT- MMH0003HFH0003HFH0003HF Encounter entry required before expiration of authorization (days) - Encounter entry required before expiration of authorization (days) - Medication Assisted - Methadone Maintenance Medication Assisted - Induction/Stabilization Methadone IWM, STR & LTR Limits HWH Limits Ambulatory Limits IWM, STR & LTR Limits HWH Limits Ambulatory Limits DMHAS MATI SFY 2022-3Effective 07/01/21Revised 03/31/21 Medically Assisted Treatment Initiative (MATI) Fee for Service Enhancement Authorization Parameters Limit Medication Assisted-Methadone Maintenance Enhancements $278.42$278.42$196.66 DMHAS MATI SFY 2022-3Effective 07/01/21Revised 03/31/21 Medically Assisted Treatment Initiative (MATI) Fee for Service Enhancement Authorization Parameters 15 ServiceRateUnit of serviceTypeBilling CodeDayMonthYearBilling CodeDayMonthYearBilling CodeDayMonthYearAnnual client limitClinician identified Cognitive Behavioral Motivational Therapy $ 25.00 1 hour groupMAT IS-SxZMTHZMTHZMTH Medication Monitoring - MAT $ 40.88 15 minutesMAT IS-SxZ3353n/aZ3353n/aZ3353n/an/a Buprenorphine/Naloxone Maint. (2mg/0.5mg) $ 7.25 MAT IS-SxZM05n/aZM05n/aZM05n/an/a Buprenorphine/Naloxone Maint. (8mg/2mg) $ 9.84 MAT IS-SxZM2Gn/aZM2Gn/aZM2Gn/an/a Buprenorphine Maintenance (8mg) $
6 11.38 MAT IS-SxZM8Gn/aZM8Gn/aZM8Gn/a
11.38 MAT IS-SxZM8Gn/aZM8Gn/aZM8Gn/an/a Physician visit - new patient (10 min) $ 22.17 10 minutesMAT IS-Sx Physician visit - new patient (20 min) $ 46.67 20 minutesMAT IS-Sx Physician visit - new patient (30 min) $ 55.03 30 minutesMAT IS-Sx Physician visit - new patient (45 min) $ 83.08 45 minutesMAT IS-Sx Physician visit - new patient (60 min) $ 104.04 60 minutesMAT IS-Sx Physician visit - established patient (10 min) $ 46.67 10 minutesMAT IS-Sx Physician visit - established patient (15 min) $ 73.44 15 minutesMAT IS-Sx Physician visit - established patient (25 min) $ 107.87 25 minutesMAT IS-Sx Physician visit - established patient (40 min) $ 144.92 40 minutesMAT IS-Sx Urine Drug Screen - Presumptive Testing $ 8.00 serviceMAT IS-SxH0003HFH0003HFH0003HF Limit Med Assist-Inductions/Stabilization Suboxone Enhancements $1,529.12$1,529.12$1,447.36 Encounter entry required before expiration of authorization (days) - IWM, STR & LTR Limits Medication Assisted - Induction/Stabilization Buprenorphine HWH Limits Ambulatory Limits DMHAS MATI SFY 2022-3Effective 07/01/21Revised 03/31/21 Medically Assisted Treatment Initiative (MATI) Fee for Service Enhancement Authorization Parameters 15 ServiceRateUnit of serviceTypeBilling CodeDayMonthYearBilling CodeDayMonthYearBilling CodeDayMonthYearAnnual client limitClinician identified Medication Monitoring - MAT $ 40.88 15 minutesMAT - SxMZ3353n/aZ3353
7 n/aZ3353n/an/a Buprenorphine/Naloxone Ma
n/aZ3353n/an/a Buprenorphine/Naloxone Maint. (2mg/0.5mg) $ 7.25 MAT - SxMZM05n/aZM05n/aZM05n/an/a Buprenorphine/Naloxone Maint. (8mg/2mg) $ 9.84 MAT - SxMZM2Gn/aZM2Gn/aZM2Gn/an/a Buprenorphine Maintenance (8mg) $ 11.38 MAT - SxMZM8Gn/aZM8Gn/aZM8Gn/an/a Physician visit - new patient (10 min) $ 22.17 10 minutesMAT - SxM Physician visit - new patient (20 min) $ 46.67 20 minutesMAT - SxM Physician visit - established patient (10 min) $ 46.67 10 minutesMAT - SxM Physician visit - established patient (15 min) $ 73.44 15 minutesMAT - SxM Urine Drug Screen - Presumptive Testing $ 8.00 serviceMAT - SxMH0003HFH0003HFH0003HF Limit Medication Assisted-Suboxone Maintenance Enhancements $1,529.12$1,529.12$1,447.36 Encounter entry required before expiration of authorization (days) - Medication Assisted - Buprenorphine IWM, STR & LTR Limits HWH Limits Ambulatory Limits DMHAS MATI SFY 2022-3Effective 07/01/21Revised 03/31/21 Medically Assisted Treatment Initiative (MATI) Fee for Service Enhancement Authorization Parameters Recovery Support 15 ServiceRateUnit of serviceTypeBilling CodeDayMonthYearBilling CodeDayMonthYearBilling CodeDayMonthYearAnnual client limitClinician identified Recovery Mentor $ 10.00 15 minutesRecovery Sup ZRMENZRMENZRMEN Case Management -Recovery Support $ 12.00 15 minutesRecovery Sup T2022 HFn/aT2022 HFn/aT2022 HFn/an/a Transition - Discharge $ - serviceRecovery
8 Sup ZDISZDISZDIS Transition - Admission
Sup ZDISZDISZDIS Transition - Admission $ - serviceRecovery Sup ZADMZADMZADM Transportation - staff time $ 8.00 Recovery Sup ZTRAVZTRAVZTRAV Transportation - mileage $ 0.31 a mileRecovery Sup ZMILZMILZMIL Court Liaison $ 6.50 15 minutesRecovery Sup ZCTLIZCTLIZCTLI Limit Recovery Support Enhancements $192.00$192.00$192.00 Medical Services 15 ServiceRateUnit of serviceTypeBilling CodeDayMonthYearBilling CodeDayMonthYearBilling CodeDayMonthYearAnnual client limitClinician identified Physician visit - new patient (10 min) $ 22.17 10 minutesMedical Srvcsn/an/an/a Physician visit - new patient (20 min) $ 46.67 20 minutesMedical Srvcsn/an/an/a Physician visit - new patient (30 min) $ 55.03 30 minutesMedical Srvcsn/an/an/a Physician visit - new patient (45 min) $ 83.08 45 minutesMedical Srvcsn/an/an/a Physician visit - new patient (60 min) $ 104.04 60 minutesMedical Srvcsn/an/an/a Physician visit - established patient (10 min) $ 46.67 10 minutesMedical Srvcsn/an/an/a Physician visit - established patient (15 min) $ 73.44 15 minutesMedical Srvcsn/an/an/a Physician visit - established patient (25 min) $ 107.87 25 minutesMedical Srvcsn/an/an/a Physician visit - established patient (40 min) $ 144.92 40 minutesMedical Srvcsn/an/an/a Limit Medical Services Enhancements$0.00$300.00$300.00 IWM, STR & LTR Limits Encounter entry required before expiration of authorization (days) -
9 Encounter entry required before expirati
Encounter entry required before expiration of authorization (days) - IWM, STR & LTR Limits HWH Limits Ambulatory Limits HWH Limits Ambulatory Limits DMHAS MATI SFY 2022-3Effective 07/01/21Revised 03/31/21 Medically Assisted Treatment Initiative (MATI) Fee for Service Enhancement Authorization Parameters Vivitrol - Pre-Induction 15 ServiceRateUnit of serviceTypeBilling CodeDayMonthYearBilling CodeDayMonthYearBilling CodeDayMonthYearAnnual client limitClinician identified Case Management - Vivitrol $ 12.00 15 minutes Vivitrol T2022 HF 4 4 n/a T2022 HF 4 4 n/a T2022 HF 4 4 n/a n/a open Urine Preg Test Visual Color Comp $ 2.70 1 test Vivitrol 81025 1 1 6 81025 1 1 6 81025 1 1 6 n/a open Physician visit - new patient (20 min) $ 46.67 20 minutes Vivitrol 99202 0 0 0 99202 1 n/a n/a 99202 1 n/a n/a n/a open Limit Vivitrol - Pre-Induction Enhancements$50.70$97.37$97.37 15 ServiceRateUnit of serviceTypeBilling CodeDayMonthYearBilling CodeDayMonthYearBilling CodeDayMonthYearAnnual client limitClinician identified Case Management - Vivitrol $ 12.00 15 minutes Vivitrol T2022 HF 2 2 n/a T2022 HF 2 2 n/a T2022 HF 2 2 n/a n/a open Urine Preg Test Visual Color Comp $ 2.70 1 test Vivitrol 81025 1 1 6 81025 1 1 6 81025 1 1 6 n/a open Physician visit - established patient (10 min) $ 46.67 10 minutes Vivitrol 99212 0 0 0 99212 1 n/a n/a 99212 1 n/a n/a n/a open Vivitrol Medication and Injection $ 1,076.27 injection Vivi
10 trol ZVIV 1 1 6 ZVIV 1 1 6 ZVIV 1 1 6 n/
trol ZVIV 1 1 6 ZVIV 1 1 6 ZVIV 1 1 6 n/a open Limit Vivitrol - On-going Induction Enhancements $1,102.97$1,149.64$1,149.64 Encounter entry required before expiration of authorization (days) - Vivitrol - On-going Induction Encounter entry required before expiration of authorization (days) - IWM, STR & LTR Limits HWH Limits Ambulatory Limits IWM, STR & LTR Limits HWH Limits Ambulatory Limits DMHAS MATI SFY 2022-3Effective 07/01/21Revised 03/31/21 Medically Assisted Treatment Initiative (MATI) Fee for Service Enhancement Authorization Parameters Vivitrol - Liver Function Test 15 ServiceRateUnit of serviceTypeBilling CodeDayMonthYearBilling CodeDayMonthYearBilling CodeDayMonthYearAnnual client limitClinician identified Comprehensive Metabolic Panel $ 9.45 service Vivitrol 80053 1 1 n/a 80053 1 1 n/a 80053 1 1 n/a n/a open Transferase, Alanine Amino Panel (ALT) $ 2.70 service Vivitrol 84460 1 1 n/a 84460 1 1 n/a 84460 1 1 n/a n/a open Transferase, Aspartate Amino Panel (AST) $ 2.70 service Vivitrol 84450 1 1 n/a 84450 1 1 n/a 84450 1 1 n/a n/a open Bilirubin Panel $ 2.70 service Vivitrol 82247 1 1 n/a 82247 1 1 n/a 82247 1 1 n/a n/a open Hepatic Function Panel $ 6.30 service Vivitrol 80076 1 1 n/a 80076 1 1 n/a 80076 1 1 n/a n/a open Limit Vivitrol - Liver Function Test Enhancement $9.45$9.45$9.45 IWM, STR & LTR Limits Encounter entry required before expiration of authorization (days) - HWH Limits Ambulatory