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ANNEX A
Standard Fee-For-Service Network Agreement
Agencies must meet eligibility and application requirements to qualify for Network participation.
I understand and agree to deliver services according to the Standard Fee-For-Service Network
Agreement Annex A requirements. I have reviewed these contract requirements with 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:
_______________________________
PRINT NAME:
TITLE:
DATE:
FFS Contract Annex A – SFY 2014
Department of Human Services
Division of Mental Health and Addiction Services
Revised
Effective:
May, 2013
May 1, 2013
Page 1
Posted:
May, 2013
ANNEX A
Standard Fee-For-Service Network Agreement
Contracting Agency Specifications:
1.
Terms and conditions of this agreement are in addition to parameters outlined in the
Department of Human Services (DHS) Standard Language Document.
2.
Participation in the substance abuse treatment fee-for-service networks is limited to New
Jersey licensed substance abuse facilities and qualifying recovery support service providers.
3.
DMHAS cannot exceed its budget authority and will not allow authorizations above available
resources. DMHAS reserves the right to suspend new authorizations in a Network at any time
if projected expenditures are expected to exceed budget Authority.
4.
DMHAS encourages the agency to utilize Evidence Based Practices that are well supported by
research evidence with outcomes that are reliable, valid, and provide transparency to ensure
that techniques and procedures will provide the best possible interventions or treatments.
5.
Participating network contractees must attend training as required by DMHAS.
6.
Depending on funding source and service population, geographic limits may be placed on
network contractees.
7.
Contractee network participation and exclusion as well as ability to amend business rules of
networks may occur based on:
a.
b.
c.
d.
e.
8.
Available resources/effective use of resources;
Limits on client lengths of stay in treatment;
Right to expand and contract network allocations;
Client eligibility for each network; and
Intent to meet identified special client’s needs.
Acceptance into the network does not ensure client referrals.
Contracting Agency Terms and Conditions:
The New Jersey Department of Human Services (DHS), Division of Mental Health and Addiction
Services (DMHAS) agrees under this Agreement to provide reimbursement for substance abuse
treatment and/or recovery support services rendered to clients who meet DMHAS income and
eligibility requirements under the following terms and conditions:
I.
Fiscal
1.
The contractee shall ensure that these funds are utilized for the provision of services to clients
who meet criteria for DMHAS publicly-funded services as outlined in the DMHAS Income
Eligibility Policy TS-2-22-2010.
FFS Contract Annex A – SFY 2014
Department of Human Services
Division of Mental Health and Addiction Services
Revised
Effective:
May, 2013
May 1, 2013
Page 2
Posted:
May, 2013
ANNEX A
Standard Fee-For-Service Network Agreement
a.
The contractee shall not discharge clients in order to receive alternate clients at higher
reimbursement rate.
b.
The contractee shall use the Division of Addiction Services Income Eligibility
(DMHASIE) module to determine client eligibility for both fiscal and programmatic
criteria. This does not apply to Drug Court, MAP SPB and MAP DOC clients.
c.
The contractee shall ensure that a signed copy of the DMHASIE is maintained in each
individual client’s file.
d.
The contractee shall ensure that funds made available under this agreement will not be
used to supplant other funding.
e.
The contractee shall ensure that attempts are made to obtain reimbursement from the
client’s health insurance company and ensure that there is no other payer, public or
private, for the patient before and when utilizing DMHAS funding. This does not apply to
the Drug Court MAP SPB and MAP DOC Network.
f.
The contractee shall ensure that when a client has other health insurance, such benefits
must be used first and to the fullest extent before utilizing DMHAS funding. This does
not apply to the Drug Court MAP SPB and MAP DOC Network.
g.
DMHAS funding may not be utilized for insurance co-pays.
2.
The contractee cannot bill Medicaid or the Substance Abuse Initiative (SAI) for the same
service provided on the same day under this contract.
3.
The contractee shall have a Client Sliding Fee Scale policy and procedure approved by the
Board. The sliding fee scale must start at “zero.” A copy of the Client Sliding Fee Scale Policy
and Procedure, including the Fee Schedule, must be submitted to DMHAS for approval as part
of the contract application. Note that in the Drug Court and MAP initiatives, client fees are not
allowable.
4.
The contractee shall ensure that revenues collected from client fees and other payors are
reported in a format prescribed by DMHAS.
5.
Reimbursement schedules are subject to revision by DMHAS. Contractees affected by
changes in reimbursement schedules will be notified 30 days before change is effective.
6.
The contractee shall submit all requests for reimbursement to the DMHAS fiscal agent, per the
fiscal agent’s guidelines.
7.
The contractee shall report all information in the electronic format acceptable to DMHAS fiscal
agent in order to receive payment.
FFS Contract Annex A – SFY 2014
Department of Human Services
Division of Mental Health and Addiction Services
Revised
Effective:
May, 2013
May 1, 2013
Page 3
Posted:
May, 2013
ANNEX A
Standard Fee-For-Service Network Agreement
8.
The contractee intending to subcontract out any of the required deliverables outlined in the
Initiative-Specific Annex A or Service Descriptions shall obtain prior written approval from the
DMHAS Director and supply the following information:
a.
b.
c.
9.
Name of Subcontractor;
Deliverables to be provided; and
Reimbursement rate/unit of service.
Agencies may appeal a termination action by DMHAS by submitting a Level 1-Request for an
Informal Conflict Resolution document to DMHAS within 7 working days of receiving written
notification by DMHAS of the termination action. Any Level 1 appeal documents received after
the 7 working days deadline will not be reviewed and the termination action will be finalized.
Agencies may only appeal the termination action if it is alleged that DMHAS has violated
a statutory, regulatory, policy or procedure in determination. Agencies must cite the
specific violation in its appeal submission. Once DMHAS has received the Level 1
document a determination will be made within 7 working days to uphold or overturn the
termination action and agencies will be advised in writing of the final disposition for this appeal.
If upon review of a Level 1 document submission the termination action is upheld by DMHAS,
agencies may submit a Level 2-Appeal of Informal Conflict Resolution Recommendation
document to the DHS Office of Contract Policy and Management within 7 working days of
receiving the written communication from DMHAS that the termination action has been upheld.
Please be advised that during the appeal process agencies will remain suspended from
participating in the out of compliance Initiative the suspension will become termination unless
the termination action is overturned by either level of appeal. Agencies will still be permitted to
request authorization for services in Initiatives for which they are in compliance.
Upon termination of Initiative participation, the agency will not be able to receive initial
authorizations for new clients or continuing authorizations for existing clients. The agency may
submit claims against existing authorizations for existing clients. The agency may not
discharge existing clients from treatment due to lack of funding.
II.
Utilization Rate Performance Criteria
1.
Contractees serving clients through SJI, DUII, and MATI initiatives shall maintain minimum
“utilization rates” as established by DMHAS for residential services and for ambulatory
services for each quarterly reporting period of the contract term. Agencies should be
continuously reviewing their service utilization figures to ensure compliance with this contract
performance requirement. DMHAS will review each agency’s “utilization rate” after the end of
each quarterly reporting period. DMHAS will review utilization rate performance by level of
care, agency and site for each quarter and identify those sites below the target thresholds.
Corrective action steps will be initiated as follows for identified and continuing
underperformance:
FFS Contract Annex A – SFY 2014
Department of Human Services
Division of Mental Health and Addiction Services
Revised
Effective:
May, 2013
May 1, 2013
Page 4
Posted:
May, 2013
ANNEX A
Standard Fee-For-Service Network Agreement
a.
First Quarter: agency sites below the target thresholds will be notified that they are on
probation.
b.
Second Quarter: new admissions will be suspended for agency sites that remain below
the target thresholds for a second quarter.
c.
Third Quarter: network participation will be terminated for agency sites that remain
below the target threshold for a third quarter.
2.
Agency site utilization performance will be monitored quarterly across contract cycles. Agency
site network participation may be terminated for continuing underperformance identified in the
previous contract cycle.
III.
General Service Requirements
1.
Treatment services requiring a facility license shall be provided in accordance with DMHAS
Licensure Standards.
2.
All treatment and recovery support services rendered under this contract shall be provided in
accordance with the DMHAS Service Descriptions as described in Annex A1 and A3.
3.
All providers contracted for the SJI, DUII, MATI, and Drug Court Initiatives will be required to
maintain an affiliation agreement with 211 to ensure a warm hand-off for clients who access
services via the 211 addictions hotline. New admissions under these initiatives will be
suspended for contractees that do not meet this requirement.
4.
The contractee shall maintain affiliation agreements with primary healthcare providers.
5.
The contractee contracted for the SJI, DUII, and MATI Initiatives shall meet agency criteria to
participate in the co-occurring network and have demonstrated readiness to provide integrated
care for dually diagnosed client by December 31, 2012. New admissions under these
initiatives will be suspended for contractees that do not meet this requirement.
a. The contractee shall be co-occurring capable and provide at a minimum:
 Assessments and treatment or
 Must be able to screen, refer and provide linkages to a co-occurring capable agency.
6.
The contractee shall accommodate any and all clients who take legitimately prescribed
medications including medications for the treatment of opioid dependence who are referred to
or present for admission at the agency.
7.
The contractee shall maintain the following information on file and make it available to DMHAS
upon request:
FFS Contract Annex A – SFY 2014
Department of Human Services
Division of Mental Health and Addiction Services
Revised
Effective:
May, 2013
May 1, 2013
Page 5
Posted:
May, 2013
ANNEX A
Standard Fee-For-Service Network Agreement
a. criteria for admission and a description of the admission process;
b. description of waiting list management practices and;
c. criteria for client discharge and description of the discharge planning process.
8.
The contractee shall maintain an adequate client record system available for review by
DMHAS that shall include: (a) adequate support documentation for first-and third-party
billings, including client co-pays and Medicaid and SAI reimbursement; and (b) a
comprehensive treatment or service plan, including client reporting and evaluations, as
required by licensure or service descriptions.
a.
The contractee shall conduct full criminal background checks for all employee staff,
volunteers, interns, and any other staff scheduled to routinely work for the contractee.
b.
Programs serving adolescents shall conduct full criminal background checks supported
by fingerprints for all employees, staff, volunteers, interns, and any other staff scheduled
to routinely work for the contractee.
c.
The contractee shall ensure that all individuals admitted to treatment services are
properly assessed and meet criteria for admission, continued stay, and discharge per
the American Society of Addiction Medicine (ASAM) Patient Placement Criteria II
Revised (ASAM-PPC IIR). Appropriate assessment must be completed on each client
using the NJ-SAMS Addiction Severity Index (ASI), DSM IV Diagnoses (all 5 axes), and
Level of Care Indicator (LOCI). All referrals to treatment levels must be made utilizing
the ASAM-PPC IIR.
9.
The contractee shall ensure that all individuals admitted to recovery support services are
properly assessed for substance use disorders by an appropriately licensed clinician.
10.
The contractee shall ensure that clients screened as “at risk” for co-occurring disorders (COD)
shall receive a complete mental health assessment. If the screening contractee is not qualified
to provide COD services, it is the contractee’s responsibility to facilitate a referral for this
service and coordinate ongoing care.
11.
The contractee shall coordinate with other services and resources to include continuing care
and services for pregnant, postpartum and parenting women.
12.
The contractee shall provide all services under this agreement in a smoke-free environment.
FFS Contract Annex A – SFY 2014
Department of Human Services
Division of Mental Health and Addiction Services
Revised
Effective:
May, 2013
May 1, 2013
Page 6
Posted:
May, 2013
ANNEX A
Standard Fee-For-Service Network Agreement
13.
14.
The contractee shall have a policy that meets the standards prescribed by the 42 CFR Part II,
dated June 9, 1987 and the Health Insurance Portability and Accountability Act of 1996
(HIPAA) which includes but is not limited to:
a.
Client records must be maintained for a minimum of 10 years in accordance with
N.J.S.A. 26:8-5 et seq. and disposed of in the manner prescribed.
b.
All employees shall receive on an annual basis education on confidentiality and the
Health Insurance Portability and Accountability Act of 1996 (HIPAA) Requirements.
c.
All employees shall be advised that disciplinary action may occur upon inappropriate
disclosure
The contractee shall ensure that all program staff are qualified to perform their assigned job
duties in accordance with applicable New Jersey professional licensing regulations and are
knowledgeable in the area of services rendered. Copies of staff credentials, including
licenses, certifications, and training records must be maintained in the staff personnel files.
Submission of Staff Information for FFS Contract:
DMHAS has implemented a web-based application for the electronic collection and
maintenance of clinical and medical staff credential information. The agency is responsible
for maintaining updated information of clinical and medical staff working at each licensed site
in the web-based Clinician Roster information System (CRIS). DMHAS staff will review CRIS
reports to ensure compliance with licensing requirements.
15.
Supervisors shall ensure compliance withTitle 45, Chapter 6 Clinical Supervision in the New
Jersey Office of the Attorney General, Division of Consumer Affairs, State Board of Marriage
and Family Therapy Examiners Alcohol and Drug Counselor Committee, Statutes and
Regulations.
16.
The contractee shall maintain an average ratio of substance abuse counselors to clients on the
basis of each program’s daily census, as follows:

Outpatient
1:35

Intensive Outpatient
1:24

Partial Care
1:12

Outpatient Detoxification
1:24

Hospital Detoxification
1:20

Short-term Residential
1:8

Long-term Residential
1:12

Halfway House
1:20

Opioid Treatment Program
1:35
FFS Contract Annex A – SFY 2014
Department of Human Services
Division of Mental Health and Addiction Services
Revised
Effective:
May, 2013
May 1, 2013
Page 7
Posted:
May, 2013
ANNEX A
Standard Fee-For-Service Network Agreement
IV.
Treatment Service Requirements
1.
The contractee providing treatment services shall maintain comprehensive and accessible
client records which document services provided directly and indirectly to the client and his/her
family support system. Every client treatment service file must contain:
2.
a.
Documentation of patient assessment using the ASI, DSM-IV, and documentation of
client placement according to ASAM-PPC IIR using the LOCI;
b.
Household income assessment using the DMHASIE;
c.
For residential services, physical examination/medical assessment including TB testing
as required;
d.
A multidisciplinary team shall review the treatment plan, treatment plan review and the
client’s progress at least every 90 days;
e.
Clinical counseling and progress notes;
f.
Acknowledgment of HIV counseling and testing or refusal for testing, signed by client;
g.
Attendance sheet signed by client;
h.
Discharge plan; including provision and planning for recovery support services;
i.
NJ-SAMS admission and discharge reports;
j.
Signed consent(s) to allow transfer of the NJ-SAMS client record access for all clients
who were referred for continuing care to another substance abuse treatment contractee
and;
k.
Urine Drug Screen results.
Treatment service contractees shall submit claims through the DMHAS Fiscal Agent.
Reimbursement for services will be based on DMHAS Fee-For-Service Length of Stay
Guidelines. In circumstances where it is clinically determined that a client needs additional
treatment and the length of stay will exceed DMHAS’ Benefit Package Guidelines, an
extension request shall be submitted. The contractee shall submit all Extension Requests
according to the DMHAS Extension Request Policy Effective July 1, 2010.
FFS Contract Annex A – SFY 2014
Department of Human Services
Division of Mental Health and Addiction Services
Revised
Effective:
May, 2013
May 1, 2013
Page 8
Posted:
May, 2013
ANNEX A
Standard Fee-For-Service Network Agreement
3.
Licensed treatment contractees shall offer all clients HIV counseling and testing. Testing must
be offered at the time of admission and every six (6) months thereafter. HIV testing will not be
required for admission to treatment; clients have the right to refuse it, but they should be
strongly encouraged to be tested. It will be required that all clients receive pre-test counseling.
Testing or refusal by a client to be tested shall be documented in the client record.
4.
All clients testing positive for HIV, or self-reported as HIV positive, must receive an initial
referral for appropriate HIV medical treatment, and should be referred at least quarterly for a
follow-up consultation. It is the responsibility of the Medical Director or the Executive Director,
in the case where a program does not have a Medical Director, to ensure that clients receive
medical care for their HIV disease at an Early Intervention Program (EIP), HIV Care Center or
by a qualified physician selected by the client.
5.
The contractee shall ensure that clients found to be unemployed and under employed at intake
will be offered a referral for vocational testing to the Division of Vocational Rehabilitation
(DVR) or other appropriate agency. Client records must document referral, testing and followup.
FFS Contract Annex A – SFY 2014
Department of Human Services
Division of Mental Health and Addiction Services
Revised
Effective:
May, 2013
May 1, 2013
Page 9
Posted:
May, 2013