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ANNEX A2
INITIATIVE-SPECIFIC ANNEX As
Initial the boxes below to identify the Initiatives for which your agency is renewing its contract.
Agency must meet eligibility and application requirements to qualify for Initiative participation. Only
those services initialed will signify the initiatives to be provided in this contract period.
Initial
Fee-for-Service Initiatives
Drug Court Network
Driving Under The Influence (DUII)
Mutual Agreement Program Department of Corrections (MAP DOC)
Mutual Agreement Program State Parole Board (MAP SPB)
Medication Assisted Treatment Initiative (MATI)
Recovery and Rebuilding Initiative (RRI)
Screening, Brief Intervention & Referral to Treatment (SBIRT)
South Jersey Initiative (SJI)
I understand and agree to deliver services under these initiatives according to the contract Document
Annex A2. I have reviewed these contract requirements with our agency staff and affirm that our
agency policies and procedures support adherence to these requirements. I understand that our
agency will be monitored by DMHAS for adherence to these contract requirements.
Agency Name: ______________________________
Federal ID: _________________________________
Signature
Date
Print Name
Title
DMHAS Initiative Specific Annex A2 – SFY 2015-2016
Department of Human Services
Division of Mental Health and Addiction Services
Revised:
Effective:
March, 2014
July 1, 2014
Page 1
Posted: March, 2014
ANNEX A2
DRUG COURT NETWORK
Drug Court Program Summary
Piloted in 1996 and implemented statewide in 2004, the mission of the Drug Courts (DC) is to stop
the abuse of alcohol and other drugs and related criminal activities. Drug Court programs are
rigorous, requiring intensive supervision based on frequent drug testing and court appearances, along
with tightly structured regimens of treatment and recovery services. This level of supervision permits
the program to actively support the recovery process and react swiftly to impose appropriate
therapeutic sanctions or to reinstate criminal proceedings when participants cannot comply with the
program. Approval to provide services to DC participants is predicated on an agency's ability and
agreement to adhere to the following:
Participating providers agree to cooperate with the monitoring requirements of DMHAS, the
Administrative Office of the Courts (AOC) and the vicinages of the New Jersey Superior Court
Drug Court Personnel, which includes site visits, on-site review of case files, billing/fiscal records
and interviews of staff and clients to insure compliance with Drug Court procedures.
Contract Specific Requirements
In addition to the General Service Requirements stated in the Division of Mental Health and Addiction
Services (DMHAS) Standard FFS Network Annex A, the Drug Court contractee shall comply with the
following Drug Court specific requirements:
1. No paid or volunteer staff involved in the criminal justice system has authority over or access to
any Drug Court client’s confidential information including, but not limited to, clinical reports,
records and information disclosed in individual, group, family sessions or community meetings.
2. DMHAS and the referring Drug Court shall be notified in writing of clients’ program admission
denials which includes referrals to a more suitable level of care.
3. All Drug Court primary counselors shall adhere to the Division of Consumer Affairs, State Board of
Marriage and Family Therapy Examiners Alcohol and Drug Counselor Committee regulations
regarding the practice of alcohol and drug counseling including the requirements for counselor
interns.
4. All Drug Court primary counselors and any clinical staff assigned to conduct substance use
DMHAS Initiative Specific Annex A2 – SFY 2015-2016
Department of Human Services
Division of Mental Health and Addiction Services
Revised:
Effective:
March, 2014
July 1, 2014
Page 2
Posted: March, 2014
ANNEX A2
evaluations shall receive training in ASAM and the completion and clinical justification of the LOCI.
Such training and staff competency in the area shall be evaluated annually and documented in the
staff’s personnel file.
5. All non-clinical staff who has contact with Drug Court clients shall receive an orientation on Drug
Court mandates.
6. Staff attendance is required at court staffing sessions and client court appearances.
7. The contractee shall maintain a Drug Court referral waiting list for those individuals who cannot be
served immediately; the waiting list shall be maintained for all levels of care that the contractee is
approved to provide services.
a. The contractee shall ensure that referrals from Drug Court vicinages and subsequent
admissions shall be based upon the order received.
b. The contractee shall notify drug courts and document circumstances under which the
waiting list order is not adhered to for a particular participant: such general reasons shall
be made part of the waiting list policy.
c. The contractee shall provide to the Drug Courts the status of the waiting list on a
monthly basis.
8. The contractee shall complete monthly Drug Court reports for residential programs and weekly
Drug Court reports for non-residential programs in accordance with vicinage specific
requirements.
9. The contractee shall notify the referring Drug Court and DMHAS regarding client nonadherence to
treatment and Drug Court program requirements within 2 hours of any relevant incident. If a client
absconds, it must be reported immediately.
10. Discharge planning shall begin at admission and include client’s probation officer so that housing
and continued care needs can be addressed throughout the course of treatment.
11. The Contractee shall include agency name, contact number and e-mail on all correspondence
sent to the referring Drug Court and to DMHAS.
DMHAS Initiative Specific Annex A2 – SFY 2015-2016
Department of Human Services
Division of Mental Health and Addiction Services
Revised:
Effective:
March, 2014
July 1, 2014
Page 3
Posted: March, 2014
ANNEX A2
12.
The contractee shall maintain in the client file documentation of case management efforts in
the acquisition of prescription insurance for individuals utilizing the reimbursable provision of
physical and psychotropic medication. Agencies are permitted to reimburse for 60 days of
psychotropic and physical medication per episode of treatment at the actual cost of
medication. This provision may be altered or revoked at the discretion of the Administrative
Office of the Courts (AOC) and the vicinages of the New Jersey Superior Court Drug Court
Personnel or the Division of Mental Health and Addiction Services. Requests for prescription
reimbursement are submitted to the Drug Court Initiative program manager.
DMHAS Initiative Specific Annex A2 – SFY 2015-2016
Department of Human Services
Division of Mental Health and Addiction Services
Revised:
Effective:
March, 2014
July 1, 2014
Page 4
Posted: March, 2014
ANNEX A2
DRIVING UNDER THE INFLUENCE INITIATIVE (DUII)
Driving Under the Influence Initiative Program Summary
Implemented in November 2005, the Driving Under the Influence initiative (DUII) supports treatment
services for individuals convicted of Driving Under the Influence and who meet financial and program
eligibility as set by the Division of Mental Health and Addiction Services (DMHAS).
Contract Specific Requirements
In addition to the General Service Requirements stated in the DMHAS FFS Standard Network
Agreement Annex A, the DUII Contractee shall comply with the following DUII requirements:
1. Affiliation and network requirements:
a. All treatment contractees shall be affiliated through the Affiliation Agreement Process as
defined in New Jersey Administrative Code 10:162-5 et seq. , New Jersey Statute 39:4-50
(NJ Statutes annotated version as per State Law Library).
i. Outpatient Contractees shall be affiliated with the referring County Intoxicated
Driver Resource Center (IDRC).
ii. All DMHAS licensed residential programs will be affiliated with the DMHAS
Intoxicated Driving Program (IDP).
b. All Affiliated Contractees shall comply with N.J.A.C. 10:162-5 et seq.
2. Initiative eligibility guidelines:
a. Clients shall have a DUI conviction on or after October 17, 2005.
b. Clients shall be a resident of New Jersey.
c. Clients shall have proof of income less than 350% of the Federal Poverty Level (FPL).
DMHAS Initiative Specific Annex A2 – SFY 2015-2016
Department of Human Services
Division of Mental Health and Addiction Services
Revised:
Effective:
March, 2014
July 1, 2014
Page 5
Posted: March, 2014
ANNEX A2
3. The following documents shall be reviewed as part of the assessment process and retained in
the client’s chart:
•
SI-AOD Screening Tool
•
Driving History Report/notes
•
Lifetime drug and alcohol driving offenses
•
Blood Alcohol Content Report
•
History of addiction treatment
•
Outside/Family information report
•
Underage driving/alcohol offenses
•
•
IDRC Interviewer notes
Records release
4. DUII Treatment Requirements: The treatment contractee agrees to schedule the client for an
intake/assessment within 30 days of referral from the IDRC. If the client cannot be scheduled
within 30 days, client will be directed back to the referring IDRC in order that another treatment
referral may be obtained. DUII clients should not be placed on a waiting list before treatment can
commence. All documentation shall be reported in NJSAMS.
5. Urine Drug Screens: The treatment contractee shall ensure that all clients will be randomly
screened for alcohol and other drug use. Results are to be documented in NJSAMS monthly
report.
6. Reporting for IDRC Clients: The treatment contractee shall utilize the NJSAMS ASI and LOCI
and all other reporting requirements of the NJSAMS IDRC reporting module in accordance with
N.J.A.C. 10:162-6
7. All DUII funded consumers must be connected to an IDRC/IDP for monitoring purposes. All DUII
funded consumers must have monthly reports completed in NJSAMS in order to ensure
IDRC/IDP monitoring.
8. The contractee shall meet agency criteria to participate in the co-occurring network and have
demonstrated readiness to provide integrated care for dually diagnosed client. New contractees
must submit a co-occurring application no later than 60 days following the execution of their new
FFS contract.
DMHAS Initiative Specific Annex A2 – SFY 2015-2016
Department of Human Services
Division of Mental Health and Addiction Services
Revised:
Effective:
March, 2014
July 1, 2014
Page 6
Posted: March, 2014
ANNEX A2
MUTUAL AGREEMENT PROGRAM –
DEPARTMENT OF CORRECTIONS (MAP DOC)
Mutual Agreement Program Department of Corrections Program Summary
The Mutual Agreement Program (MAP) was implemented in 1984 as a cooperative effort between the
New Jersey State Parole Board (SPB), Department of Corrections (DOC) and the Department of
Human Services, Division of Mental Health and Addiction Services (DHS DMHAS). The goal of the
MAP program is to afford the opportunity of community based substance use treatment as a special
condition of parole for the NJDOC inmates who otherwise might not achieve parole status.
MAP DOC agencies are licensed residential fee-for-service substance use treatment programs
located throughout the state of New Jersey. These facilities provide a highly structured environment,
which introduces intensive therapy for behavioral and psychological problems related to addiction.
Contract Specific Requirements
In addition to the General Service Requirements stated in the Division of Mental Health and Addiction
Services (DMHAS) Standard FFS Network Annex A, the Mutual Agreement Program Department of
Corrections (MAP DOC) network contractee shall comply with the following MAP DOC requirements:
1.
No paid or volunteer staff actively involved in the criminal justice system can have authority
over or access to any MAP DOC client’s confidential information including but not limited to,
clinical reports, records and information disclosed in individual, group and family sessions or
community meetings.
2.
Contractee shall identify and maintain at least one staff person to coordinate MAP DOC
services. This staff person shall act as a liaison with the DOC and DMHAS’ MAP Coordinator
regarding all MAP DOC issues and concerns.
3.
In addition to DMHAS Licensure Standards regarding Reportable Events, MAP DOC network
contractee shall ensure that their facility’s policy and procedures manual include and adhere to
the following:
DMHAS Initiative Specific Annex A2 – SFY 2015-2016
Department of Human Services
Division of Mental Health and Addiction Services
Revised:
Effective:
March, 2014
July 1, 2014
Page 7
Posted: March, 2014
ANNEX A2
a.
The manner by which immediate notification is made to DOC of any incidents which
require a parolee be discharged from the program and returned to the jurisdiction of the
Department of Corrections. Such incidents might include any disciplinary action that
requires the inmate be removed from the program, and should include how written
notification will be provided to the DOC as well as including a copy of the incident report
and discharge summary, as applicable.
b.
Written notification will be provided to the DOC including a copy of the incident report
regarding problematic client behaviors in any instance where a DOC client is found to
be in possession of illegal substances or items (e.g., drugs, paraphernalia, weapons,
etc.).
c.
4.
Internal agency policy regarding inmate walkaways or escapes utilizing components
from N.J.A.C. 10A:20-4.39.
The contractee shall provide weekly MAP DOC client rosters electronically to DMHAS’
Criminal Justice Unit MAP Coordinator and DOC evaluator by close of business each Friday.
The agency must also submit a daily roster to the DOC evaluator by 7am following each
business day.
5.
Contractee shall ensure bed availability for DOC referrals once admission confirmation is given
to DOC. Within 7 days of receiving a referral from DOC, contractee will provide written
confirmation to the Department of Corrections with a determination if a referral will be
accepted.
6.
DMHAS MAP DOC network contractee shall assist clients in obtaining prescribed medications
that are required beyond the two week supply provided by prisons at time of release.
7.
Contractee shall participate in meetings/trainings as requested by DMHAS.
DMHAS Initiative Specific Annex A2 – SFY 2015-2016
Department of Human Services
Division of Mental Health and Addiction Services
Revised:
Effective:
March, 2014
July 1, 2014
Page 8
Posted: March, 2014
ANNEX A2
MUTUAL AGREEMENT PROGRAM –
STATE PAROLE BOARD (MAP SPB)
Mutual Agreement Program State Parole Board Program Summary
The Mutual Agreement Program (MAP) was implemented in 1984 as a cooperative effort between the
New Jersey State Parole Board (SPB), Department of Corrections (DOC) and the Department of
Human Services, Division of Mental Health and Addiction Services (DHS DMHAS). The goal of the
MAP program is to provide the opportunity for substance use disorder treatment to SPB parolees as
required under special conditions of parole, for the purpose of reducing the likelihood of returning
back to criminal behavior.
MAP SPB agencies are licensed substance use treatment programs located throughout the state of
New Jersey. These facilities provide a highly structured environment that provides intensive therapy
for behavioral and psychological problems related to addiction.
Contract Specific Requirements
In addition to the General Service Requirements stated in the Division of Mental Health and Addiction
Services (DMHAS) Standard FFS Network Annex A, the Mutual Agreement Program State Parole
Board (MAP SPB) contractee shall comply with the following MAP SPB requirements:
1.
No paid or volunteer staff involved in the criminal justice system can have authority over or
access to any SPB client’s confidential information but not limited to, clinical reports, records
and information disclosed in individual, group and family sessions or community meetings.
2.
Contractee shall identify and maintain at least one staff person to coordinate MAP SPB
services. This staff person shall act as a liaison with SPB and DMHAS’ Criminal Justice Unit’s
MAP Coordinator regarding MAP SPB issues.
3.
In addition to DMHAS Licensure Standards regarding Reportable Events, MAP SPB
Network contractee shall ensure that their facility’s policy and procedures manual
include and adhere to the following:
DMHAS Initiative Specific Annex A2 – SFY 2015-2016
Department of Human Services
Division of Mental Health and Addiction Services
Revised:
Effective:
March, 2014
July 1, 2014
Page 9
Posted: March, 2014
ANNEX A2
a.
b.
The components of the September 26, 2013 New Jersey State Parole Board
memorandum regarding the Abscond Reporting Procedures. Such incidents might
include a parolee absconding or any disciplinary action that requires the parolee to be
removed from the program.
How problematic client behaviors will be reported to SPB in any instance where an SPB
client is found to be in possession of illegal substances or items (e.g., drugs,
paraphernalia, weapons, etc.) or when removal of a parolee from the program is
required.
4.
For Residential Programs only: Provide electronic rosters to the
DMHAS’ Criminal Justice Unit MAP Coordinator and SPB Coordinator by close of
business each Friday. Contractee will provide written electronic notification on all parolee
program arrivals as well a program discharges.
5.
Within 7 days of receiving a referral from SPB, contractee will provide written confirmation to
the SPB whether the referral will be accepted.
6.
Prescription Reimbursement: The contractee shall maintain in the client file documentation
of case management efforts in the acquisition of prescription insurance for individuals utilizing
the reimbursable provision of psychotropic medication. Contractee is permitted to reimburse
for 60 days of psychotropic medication per episode of treatment at the actual cost of
medication. This provision may be altered or revoked at the discretion of the State Parole
Board and the Division of Mental Health and Addiction Services. Requests for prescription
reimbursement are submitted to the MAP SPB program manager.
7.
Contractee shall participate in meetings/trainings as requested by DMHAS.
DMHAS Initiative Specific Annex A2 – SFY 2015-2016
Department of Human Services
Division of Mental Health and Addiction Services
Revised:
Effective:
March, 2014
July 1, 2014
Page 10
Posted: March, 2014
ANNEX A2
MEDICATION ASSISTED TREATMENT INITIATIVE (MATI)
Medication Assisted Treatment Initiative Program Summary
Through funding legislated through the Bloodborne Disease Harm Reduction Act, the Division of
Mental Health and Addiction Services (DMHAS) has developed the Medication Assisted Treatment
Initiative (MATI). This initiative funds medication assisted treatment for indigent New Jersey residents
with an opiate addiction, while also offering outreach, office-based services and case management,
as well as the opportunity for supportive housing, sub-acute enhanced medically managed
detoxification, authorizations for other treatment services, and an evaluation of the project.
In order for clients to attain services through the MATI, individuals must meet requirements set-forth
in both the MATI Eligibility Criteria and DMHAS Income Eligibility Policy. If a client requires another
level of care or support service not provided via the mobile unit or office-based program, the client
may be eligible for an authorization through the MATI FFS Network, which would enable a client to
receive services through one of the MATI Network Providers.
Contract Specific Requirements
In addition to the General Service Requirements stated in the Division of Mental Health and Addiction
Services (DMHAS) Standard FFS Network Annex A, the Medication Assisted Treatment Initiative
(MATI) contractee shall comply with the following MATI specific requirements:
1.
The contractee will provide treatment services in accordance with the MATI service
descriptions and comply with all State regulations/mandates.
2.
The contractee will accept MATI clients within 24 hours or provide an appropriate referral.
3.
The contractee will appoint appropriate staff to participate in monthly or bi-monthly consortium
meetings, as well as attend any meetings/trainings requested by DMHAS.
4.
The contractee agrees to coordinate with case management services provided by the mobile
van/office-based services.
DMHAS Initiative Specific Annex A2 – SFY 2015-2016
Department of Human Services
Division of Mental Health and Addiction Services
Revised:
Effective:
March, 2014
July 1, 2014
Page 11
Posted: March, 2014
ANNEX A2
5.
The contractee agrees to accept the physical exam completed at the mobile van/office-based
services to fulfill requirement for a physical exam at admission.
6.
The contractee shall maintain policies and procedures to ensure non-discrimination towards
clients who choose to utilize medication-assisted treatment to support their recovery.
7.
The contractee shall adhere to all prior authorization procedures established by DMHAS.
8.
The contractee shall meet agency criteria to participate in the co-occurring network and have
demonstrated readiness to provide integrated care for dually diagnosed client. New
contractees must submit a co-occurring application no later than 60 days following the
execution of their new FFS contract.
DMHAS Initiative Specific Annex A2 – SFY 2015-2016
Department of Human Services
Division of Mental Health and Addiction Services
Revised:
Effective:
March, 2014
July 1, 2014
Page 12
Posted: March, 2014
ANNEX A2
RECOVERY AND REBUILDING INITIATIVE
Recovery and Rebuilding Initiative Program Summary
The Recovery and Rebuilding Initiative (RRI) is funded through federal Supplemental Social Services
Block Grant (SSBG) resources that have been made available to the New Jersey Department of
Human Services to support its disaster recovery and response efforts in the aftermath of Superstorm
Sandy. The RRI is designed to increase access and capacity for substance use disorder treatment
services for consumers living in one of the ten significantly storm-impacted New Jersey counties
(Atlantic, Bergen, Cape May, Cumberland, Essex, Hudson, Middlesex, Monmouth, Ocean, and
Union) between the dates of October 28-30, 2012.
Participating RRI Treatment Network providers must be licensed by the NJ Department of Human
Services, Office of Licensure to provide co-located detoxification and short-term residential services
under the Standards for Licensure of Residential Substance Use Disorder Treatment Facilities at
N.J.A.C. 10:161 A. As RRI funding will be tracked and reported separately from other DMHAS
funding, each approved agency agrees to cooperate with all monitoring activities conducted by
DMHAS, including site visits, on-site review of case files, review of billing/fiscal records, interviews of
staff and consumers, and data collection and reporting requirements to ensure compliance with
DMHAS and to identify potential vulnerabilities in both compliance and transparency.
Contract-Specific Requirements
In addition to the General Service Requirements stated in the DMHAS Standard FFS Network Annex
A, the RRI Treatment Network contractee shall comply with the following initiative-specific
requirements:
1. Eligibility:
To be eligible for services available through the RRI, consumers must:
a. Be a United States citizen or legal resident;
b. Be 18 years of age or older;
c. Have been living in one of the ten storm-impacted counties between October 28-30, 2012;
d. Meet ASAM criteria for Level III.7, Level III.7D or Level III.DE care.
2. Proof of United States citizenship or legal residency:
Proof of United States citizenship or legal residency must be documented in the consumer’s
file upon admission. A copy of at least one of the following credentials displaying the name of
the consumer must be retained in the consumer’s file:
a. Current NJ digital driver license;
b. Current NJ digital non-driver ID card;
c. Current NJ digital boat license;
DMHAS Initiative Specific Annex A2 – SFY 2015-2016
Department of Human Services
Division of Mental Health and Addiction Services
Revised:
Effective:
March, 2014
July 1, 2014
Page 13
Posted: March, 2014
ANNEX A2
d. Active duty US military photo identification card;
e. Original or certified copy of civil birth certificate;
f. US Department of State birth certificate;
g. US Passport, current or expired less than three years;
h. Current US passport card;
i. Consular registration of birth abroad certificate;
j. Certificate of citizenship;
k. U.S. adoption papers;
l. Certificate of naturalization (Form N-550, N-570 or N-578);
m. Certificate of citizenship (Form N-560, N-561 or N-645);
n. Foreign passport with INS or USCIS verification and valid record of arrival/departure (Form
I-94);
o. Foreign passport with INS or USCIS verification and valid Form I-551 stamp;
p. Current alien registration card (new Form I-551) with expiration date and verification from
INS or USCIS;
q. Refugee travel document (Form I-571);
r. US re-entry permit (Form I-327);
s. Valid I-94 stamped “Refugee,” “Parolee,” “Asylee” or “Notice of Action” (Form I-797
approved petition) by INS or USCIS;
t. Valid I-94 with attached photo stamped “Processed for I-551…” by INS or USCIS.
3. Proof of Residence:
Proof of residence in a storm-impacted county must be documented in the consumer’s file at
the time of admission. A copy of at least one of the following credentials displaying the name
of the consumer and a valid street address (P.O. Boxes are not acceptable) must be retained
in the consumer’s file:
a. New Jersey driver’s license issued before October 28, 2012;
b. United States passport issued before October 28, 2012;
c. School records showing an address for the period between October 28-30, 2012;
d. Utility bill for services between October 28-30, 2012;
e. Credit card bill for the period between October 28-30, 2012;
f. Bank or credit union statement, with account numbers redacted, for services between
October 28-30, 2012;
g. 2012 state or federal tax return;
h. Lease or rental agreement effective between October 28-30, 2012;
i. Shelter records of housing between October 28-30, 2012;
j. Property tax bill, statement, record or receipt between October 28-30, 2012;
k. Signed attestation from a community social service provider, on agency letterhead, of the
consumer’s residence between October 28-30, 2012;
DMHAS Initiative Specific Annex A2 – SFY 2015-2016
Department of Human Services
Division of Mental Health and Addiction Services
Revised:
Effective:
March, 2014
July 1, 2014
Page 14
Posted: March, 2014
ANNEX A2
l. Signed attestation from a community social service provider, on agency letterhead, of the
consumer’s residence between October 28-30, 2012.
4. Alternative Proof of Residence:
a. If none of the credentials listed in 3, above, are available, the consumer may provide a
signed attestation of residence for the period October 28-30, 2012; which explains why no
other credential is available. The original signed attestation must be retained in the
consumer’s file.
5. Payer of Last Resort:
a. Federal funding for treatment services provided to RRI consumers must be accessed as
the payer of last resort. Participating treatment contractee must document the income
and program eligibility status of all consumers who may be eligible for the RRI using the
NJSAMS DASIE module;
b. RRI providers may only request authorization for services provided to eligible consumers
through the RRI when all funding options have been explored and/or exhausted and no
other funding is available;
c. Authorization or payment for services should be obtained from other payers, including
third-party commercial or public insurance/payer, if available;
d. Consumers receiving services under the RRI must sign an attestation that indicates one of
the following:
i. The consumer has no third party insurance coverage;
ii. The consumer has third party insurance coverage but services to be delivered
under the RRI are not a covered benefit;
iii. The consumer has third party insurance coverage and the services to be
delivered under the RRI are a covered benefit, but that coverage has been
exhausted;
iv. The consumer has third party insurance coverage and the services to be
delivered under the RRI are a covered benefit, but the carrier will not authorize
reimbursement for the service;
1. Should authorization for reimbursement by third party coverage be
provided following an appeal then the agency is required to notify the
program Manager and to void all FFS claims on a per diem basis;
2. Contractee may only request payment for enhancements under the RRI
when the Level of Care core service package is also funded through RRI
on the same day.
e. The attestation must be signed by the consumer and the staff member who verified the
information. The original must be retained in the consumer’s file;
DMHAS Initiative Specific Annex A2 – SFY 2015-2016
Department of Human Services
Division of Mental Health and Addiction Services
Revised:
Effective:
March, 2014
July 1, 2014
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Posted: March, 2014
ANNEX A2
f. Contractee may not utilize RRI funding, in whole or in part, to offset the reimbursement rate
of third party insurance;
g. In cases where consumers are programmatically eligible for FFS initiatives for which
funding is unavailable at the time of admission, contractee may then utilize RRI funding (if
eligibility criteria is met). Contractee is required to include a copy of the NJSAMS New
Client Limits screen indicating no new client admissions are available to other initiatives
with the DASIE in the treatment file to support the use of RRI funds;
h. Contractee must implement internal controls that result in assurances that all RRI funds are
properly authorized, and that program expenditures are reasonable, allowable and correct;
i. Per the Governor’s Executive Order No. 125, contractors are subject to penalties,
including suspension of funds, return of funds, and other actions as determined for noncompliance or illegitimate use of RRI funding.
6. Transportation:
a. Transportation is a reimbursable service under the RRI only when necessary to transfer a
consumer from a hospital emergency department and/or psychiatric emergency screening
center for admission to the RRI participating facility;
b. Approval to provide transportation services in the RRI initiative is based on the Program
Manager’s favorable review of the contractee transportation policy/s addressing driver/staff
ratio, response timeframes, monitoring of driver’s license status, safety and safe driver
competencies, use of subcontract services, etc. as applicable;
c. A contractee approved to provide RRI transportation shall establish affiliation agreements
with community-based hospital emergency departments and/or psychiatric emergency
screening centers, through which they agree to accept referrals of RRI consumers;
d. A signed, dated copy of the written affiliation agreements must be on file at the agency as
well as with the DMHAS Office of Care Management. At a minimum, the affiliation
agreement must:
i. Include the contractee’s policies and procedures for screening and approving
admission to the facility;
ii. Based upon bed availability at the time of screening, the contractee will transport
approved consumer from a hospital emergency department and/or psychiatric
emergency screening center to the treatment facility.
e. Transportation reimbursement is calculated based on the round-trip mileage provided for
an individual consumer admitted to a network provider directly from an affiliated emergency
room or screening center;
f. Contractee may not submit duplicate billing for multiple consumers transported during the
same service period;
DMHAS Initiative Specific Annex A2 – SFY 2015-2016
Department of Human Services
Division of Mental Health and Addiction Services
Revised:
Effective:
March, 2014
July 1, 2014
Page 16
Posted: March, 2014
ANNEX A2
g. RRI contractee is required to maintain a HIPAA compliant transportation log documenting
the date, destination, departure and arrival times, consumer NJSAMS number, and agency
staff (driver and passenger aide) for each trip claimed under the RRI. The provider shall
transmit the transportation logs electronically to the RRI Program Manager within five
business days of the end of each month.
7. Rosters:
a. RRI contractee is required to submit a HIPAA-compliant roster of all individuals receiving
RRI funded Medically Monitored Inpatient Detoxification Enhanced Level III.DE care to the
DMHAS RRI Program Manager within 5 business days of the end of each month.
i. Roster is to include: agency address and license number, consumer NJSAMS
ID#, LOC, admission date, dates of service;
ii. An additional notation should document which of the following criteria was met to
justify admission into this level of care: 1) co-occurring disorder (include
diagnosis); 2) pregnancy (provide approximate due date); 3) poly-addicted
persons, including those addicted to benzodiazepines; (provide diagnoses) 4)
may or may not be on opiate replacement therapy; 5) non–life-threatening
medical condition(s) that do not require the services of an acute care hospital
(provide diagnosis).
8. Coordination and collaboration with DMHAS and other Recovery and Rebuilding partners: RRI
treatment contractee shall participate in meetings, trainings, community events, and other
activities as requested by DMHAS as needed to support adherence to program accountability and
integrity, to promote awareness of services available under the RRI, and to improve coordination
of efforts among other service providers.
9. Co-occurring Network: The contractee shall meet agency criteria to participate in the co-occurring
network and have demonstrated readiness to provide integrated care for dually diagnosed client.
New contractees must submit a co-occurring application no later than 60 days following the
execution of their new FFS contract.
DMHAS Initiative Specific Annex A2 – SFY 2015-2016
Department of Human Services
Division of Mental Health and Addiction Services
Revised:
Effective:
March, 2014
July 1, 2014
Page 17
Posted: March, 2014
ANNEX A2
SCREENING, BRIEF INTERVENTION & REFERRAL TO TREATMENT
(SBIRT)
NJ SBIRT SPECIALTY TREATMENT NETWORK
NJ SBIRT Program Summary
Implemented in February 2013, the NJ Screening, Brief Intervention and Referral to Treatment (NJSBIRT) Project is a federal Substance Abuse and Mental Health Services Administration (SAMHSAfunded initiative to expand the existing substance use services continuum of care by making
evidence-based, risk identification and early intervention services available to reduce harmful
substance use and its associated negative health consequences.
The NJ SBIRT Project is a partnership between DMHAS, the Henry J. Austin Federally Qualified
Health Center (HJA), Trenton Health Team member organizations, and Rutgers University. As the
lead service partner, the HJA will implement SBIRT services in a mix of several primary care and
community health project sites located throughout the city of Trenton. SBIRT services will be fully
integrated into existing primary care and/or emergency care services at all project sites, affording
universal screening for substance use risk among all adult patients seeking medical care. All NJ
SBIRT Project sites will serve as treatment referral sources for those patients identified as needing
substance use assessment and/or treatment services.
Participating NJ SBIRT Specialty Treatment Network contractee must be licensed to provide services
in Mercer County by the NJ Department of Human Services, Office of Licensure, under the Standards
for Licensure of Outpatient Substance Abuse Treatment Facilities at NJAC 10:161 B, and agree to
cooperate with the monitoring requirements of DMHAS, including site visits, on-site review of case
files, review of billing/fiscal records, and interviews of staff and consumers to ensure compliance with
initiative-specific procedures.
Contract Specific Requirements
In addition to the General Service Requirements stated in the DMHAS Standard FFS Network Annex
A, the NJ SBIRT Specialty Treatment Network contractee shall comply with the following NJ SBIRT
specific requirements:
DMHAS Initiative Specific Annex A2 – SFY 2015-2016
Department of Human Services
Division of Mental Health and Addiction Services
Revised:
Effective:
March, 2014
July 1, 2014
Page 18
Posted: March, 2014
ANNEX A2
1. Network and Affiliation requirements:
a. All participating treatment contractee shall be affiliated with the Henry J. Austin Health
Center (HJA) through which they agree to accept referral of NJ SBIRT consumers from
any of the NJ SBIRT project sites located in the city of Trenton.
b. A signed, dated copy of the written affiliation agreement must be on file at the DMHAS,
Office of Care Management. At a minimum, the affiliation agreement must include the
specialty treatment provider agency’s policy and procedures for accepting a “warm
handoff” from the NJ SBIRT project sites.
c. All participating treatment contractee shall offer NJ SBIRT referred consumers: income
and program eligibility determinations; assessments; appropriate ASAM levels of
outpatient care; and enhancement packages to include clinical review services; and cooccurring services.
d. If a NJ SBIRT referred consumer is assessed as needing a level of care other than
outpatient or intensive outpatient, all participating treatment contractee shall offer NJ
SBIRT assessed consumers a secondary referral to another licensed substance use
provider for a more appropriate level of care, with notification of same to HJA through
NJSAMS.
e. It is recommended that participating treatment contractee schedule initial appointments
within 2 business days of the NJ SBIRT referral.
f. Under signed, patient consent, the participating treatment provider shall document the
disposition of all NJ SBIRT referred consumers in NJSAMS to facilitate follow-up by
HJA, including:
i. Consumers who do not attend scheduled assessment appointments;
ii. Consumers who are assessed and admitted to treatment at the participating
treatment provider agency; and
DMHAS Initiative Specific Annex A2 – SFY 2015-2016
Department of Human Services
Division of Mental Health and Addiction Services
Revised:
Effective:
March, 2014
July 1, 2014
Page 19
Posted: March, 2014
ANNEX A2
2. Consumers who are assessed and require a level of care not available at the participating
provider agency, and for whom the treatment provider makes a secondary referral.NJ SBIRT
Initiative consumer eligibility guidelines:
a. Consumers must:
i. Be referred from one of the NJ SBIRT Project sites in the city of Trenton
operated under the HJA administrative authority
ii. Be 18 years of age or older
iii. Meet ASAM criteria for Level I or Level II.1 outpatient care
b. Federal funding for treatment services provided to NJ SBIRT Project consumers may be
accessed as the payer of last resort. Participating treatment contractee must
document the income and program eligibility status of all referred NJ SBIRT consumers
using the NJSAMS DASIE Plus module. Authorization or payment for services should
be obtained from other payers when another payer is available.
c. NJ SBIRT Specialty Treatment Network contractee may only request authorization for
services provided to eligible consumers through the NJ SBIRT FFS Initiative when no
other payer is available. Payment for services authorized through the NJ SBIRT
Initiative shall be accepted as payment in full.
3. Participating treatment contractee shall participate in meetings/trainings as requested by
DMHAS.
DMHAS Initiative Specific Annex A2 – SFY 2015-2016
Department of Human Services
Division of Mental Health and Addiction Services
Revised:
Effective:
March, 2014
July 1, 2014
Page 20
Posted: March, 2014
ANNEX A2
SOUTH JERSEY INITIATIVE (SJI)
South Jersey Initiative Program Summary
Funded by DMHAS, the SJI began in 2001 to serve residents age 13-24 of Atlantic, Burlington, Cape
May, Camden, Cumberland, Gloucester, Ocean and Salem Counties. The program was initially
created to serve adolescent and young adults in the aforementioned counties until a residential
treatment facility could be built. The project evolved to a full continuum of care for residents of eight
southern counties between the ages of 13-24. On January 1, 2014 the initiative ceased serving the
13-17.99 year old population and is now solely dedicated to serving the 18-24 young adult population
in the eight southern counties.
Contract Specific Requirements
In addition to the General Service Requirements stated in the Division of Mental Health and Addiction
Services (DMHAS) Standard FFS Network Annex A, the South Jersey Initiative (SJI) contractee shall
comply with the following SJI specific requirements:
1.
The contractee shall provide treatment services for young adults aged 18 to 24 from Atlantic,
Burlington, Camden, Cape May, Cumberland, Gloucester, Ocean and Salem Counties.
2.
The contractee shall complete appropriate assessments on each client specific to their age
group:
a.
Addiction Severity Index (ASI) for ages 18 to 24
b.
All clients shall have an appropriate Level of Care Index (LOCI).
3.
Urine Drug Screens:
a. SJI contractee shall ensure that all clients will be screened weekly and randomly for
alcohol and other drug use.
b.
c.
d.
SJI contractee shall ensure that young adults will be screened upon return from off
grounds visits.
SJI contractee shall ensure that young adults with positive urine drug screens shall
receive additional individual counseling, with the focus on addressing the circumstances
behind the positive urine drug screens.
SJI contractee shall ensure that the adults treatment plan must be reviewed by the
multidisciplinary team with the treatment plan revised documenting targeted
DMHAS Initiative Specific Annex A2 – SFY 2015-2016
Department of Human Services
Division of Mental Health and Addiction Services
Revised:
Effective:
March, 2014
July 1, 2014
Page 21
Posted: March, 2014
ANNEX A2
4.
interventions.
Clinical Services:
a.
The SJI contractee shall ensure that progress notes include when applicable but are not
limited to:
 Referral(s) for other services
 case management related activities
5. The contractee shall meet agency criteria to participate in the co-occurring network and have
demonstrated readiness to provide integrated care for dually diagnosed client. New contractees must
submit a co-occurring application no later than 60 days following the execution of their new FFS
contract.
DMHAS Initiative Specific Annex A2 – SFY 2015-2016
Department of Human Services
Division of Mental Health and Addiction Services
Revised:
Effective:
March, 2014
July 1, 2014
Page 22
Posted: March, 2014