MedicaidCoverageHigh impact
Newsletter Vol. 27, No.07
New Jersey Medicaid·NJ · Psychiatry·Provider Notice
Effective date
Nov 1, 2016
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid (NJFC/FFS) now covers Community Support Services (CSS) as a carved-out mental health benefit for eligible consumers with serious mental illness who are discharged from psychiatric hospitals or in supportive housing. Providers must enroll in the NJFC FFS program, submit CSS-specific forms (Enrollment/Admission, IRP, CRNA) to an Interim Management Entity for utilization management review, and use Special Program Codes (SPCs 19-26, 39) to identify CSS initiatives in the eligibility system. Claims with service dates on or after November 1, 2016 are eligible for FFS payment if the consumer meets strict eligibility criteria and an Individualized Rehabilitation Plan (IRP) is submitted within 60 days of admission.
Action Required
By November 1, 2016 (retroactive): (1) Billing team must enroll all mental health providers in NJFC FFS CSS program via www.njmmis.com using the Community Support Services application; DMHAS must approve provider participation. (2) Update billing system to recognize eight CSS Special Program Codes (SPCs): 19 (Generic), 20 (RIST), 21 (DD/MI), 23 (MESH), 24 (Forensically Involved), 25 (ESH), 26 (RIST MESH), 39 (At Risk) and ensure SPC is added to consumer Medicaid eligibility records upon CSS admission. (3) Clinical and billing staff must establish process to submit three required forms to IME-CSS Utilization Management within specified timeframes: CSS Enrollment/Admission Form (with SPC), Community Support Rehabilitative Needs Assessment (CRNA) within 14 days of admission, and Individualized Rehabilitation Plan (IRP) within 60 days of admission; all forms must include separate CSS Fax Cover sheet. (4) Implement documentation verification that consumers meet ALL three CSS eligibility requirements: (A) diagnosis of SMI from specified ICD-10 list, (B) require active rehabilitation/support for community integration, (C) meet at least one of three criteria (risk of hospitalization, deteriorating functioning, inadequate resources). (5) Update billing workflows to ensure CSS is billed as FFS carved-out benefit for managed care-enrolled consumers on same date of service. (6) Configure system to exclude CSS consumers from concurrent billing of PACT, CCBHC, AMHR-MH group home, or targeted case management services. Failure to properly enroll, submit required forms timely, use correct SPCs, or verify eligibility will result in claim denials and potential audit findings.