MedicaidCoverageHigh impact
Newsletter Vol. 30, No.17
New Jersey Medicaid·NJ · Psychiatry, Pediatrics, Occupational Therapy +1 more·Provider Notice
Effective date
Jul 1, 2020
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid (NJFC) now covers Developmental, Individual Difference, Relationship-Based (DIR) therapy services for children under 21 diagnosed with Autism Spectrum Disorder (ICD-10 F84.0-F84.9). Billing teams must implement new CPT codes (96156EP-96171EP) with specific unit limits, verify provider credentials and DIR specialization training, and obtain prior authorization from MCOs or use single-case agreements for non-contracted providers.
Action Required
By July 1, 2020: (1) Billing team must add new CPT codes 96156EP-96171EP to billing system with corresponding 15-minute and 30-minute unit limits (96156EP=1 unit per diem; 96158EP=1 unit; 96159EP=30 units max; 96164EP=1 unit; 96165EP=22 units max; 96167EP=1 unit; 96168EP=14 units max; 96170EP=1 unit; 96171EP=14 units max). Note: These are suggested limits only and must be overridden when medically necessary. (2) Verify all DIR-providing clinicians hold required credentials (DIRFloortime® Advanced/Expert Practitioner, NJAIMH Level II/IV, DMAI Certificate, Certified Autism Specialist, ESDM Certified, or Level III/IV Infant Mental Health Specialist) and are NJFC Medicaid providers. (3) For providers contracted with MCOs: Request authorization from the child's managed care plan to provide and bill DIR services. (4) For non-contracted providers: Submit 'single case' provider agreement request to the MCO to ensure continuity of care and billing eligibility. (5) Update claim submission requirements to include ICD-10 diagnosis codes F84.0-F84.9 for all DIR service claims. (6) Establish workflow to confirm MCO authorization or single-case agreement before submitting claims; claims lacking proper authorization will be denied. (7) Train billing and clinical staff on code usage: 96156EP for assessment/reassessment/treatment plan development; 96158EP-96159EP for individual behavior treatment; 96164EP-96165EP for group sessions (2-8 patients, billed per child); 96167EP-96168EP for family guidance with child present; 96170EP-96171EP for family guidance without child present.