CurrentOptumPolicy BH803 OH002026

New Jersey Medicaid Supplemental Clinical Criteria — Behavioral Health

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State-specific clinical criteria and coverage rules for behavioral health services under New Jersey Medicaid (NJ Family Care/Medicaid) for Optum-managed plans, addressing developmental services for Autism Spectrum Disorder (ASD), adult mental health rehabilitative services, provider qualifications, coding, and related clinical guidance.

Policy Summary

PayerOptum

PolicyNew Jersey Medicaid Supplemental Clinical Criteria — Behavioral Health

Policy CodePolicy BH803 OH002026

Change TypeNo material clinical or coverage changes

Effective DateFeb 1, 2026

Last ReviewFeb 1, 2026

Next Review Date

Key ActionVerify member eligibility and benefits and ensure a Qualified Healthcare Provider assesses the member and completes a treatment plan prior to initiating services.

SourceLink

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CurrentOptumPolicy BH803 OH002026

New Jersey Medicaid Supplemental Clinical Criteria — Behavioral Health

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Sign up for Optum Policy BH803 OH002026 alerts

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Policy Summary

PayerOptum

PolicyNew Jersey Medicaid Supplemental Clinical Criteria — Behavioral Health

Policy CodePolicy BH803 OH002026

Change TypeNo material clinical or coverage changes

Effective DateFeb 1, 2026

Last ReviewFeb 1, 2026

Next Review Date

Key ActionVerify member eligibility and benefits and ensure a Qualified Healthcare Provider assesses the member and completes a treatment plan prior to initiating services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

ASD <21ASD services for <21

5–30 hrs/wkDIR Floortime intensity

14–20 hrs/wkHome program target

96156–96171EPBilling CPTs listed

30 daysRehab plan due

Coverage Criteria

inv-01: Developmental Services — Medical Necessity Criteria

Developmental Services (DIR/DRBI/NDBI) are covered for NJ Family Care/Medicaid eligible children under age 21 diagnosed with ASD when medically necessary and assessed by a Qualified Healthcare Provider (QHP).

Eligibility and Diagnosis: Member is a New Jersey Family Care/Medicaid eligible child under age 21 with an ASD diagnosis (ICD-10 F84.0–F84.9).age <21; ICD-10 F84.x

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Assessment and Treatment Planning: A Qualified Healthcare Provider (QHP) must assess the child and complete a treatment plan prior to providing Developmental Services; treatment plan should document Functional Emotional Development, availability of natural supports, complexity of individual differences, safety considerations, and course of intervention modifiers.QHP assessment and treatment plan required

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Service Intensity, Home Program, and Duration: Service frequency and duration must be individualized based on functional emotional development and family capacity: professional services may range from up to 5 to 30 hours per week; DIR home program implementation by natural supports targeted at 14–20 hours per week; duration is often significant and rarely less than 12 months while goals are pursued.professional 5–30 hrs/week; home 14–20 hrs/week; duration commonly >=12 months

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Modality Selection: Developmental modalities covered under this benefit include DIR/Floortime, Developmental Relationship-Based Behavioral Interventions (DRBI) such as RDI, and Naturalistic Developmental Behavioral Interventions (NDBI) such as ESDM; modality should be selected based on the child's needs and credentialed provider availability.

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inv-02: Adult Mental Health Rehabilitative Services — Criteria

Adult Mental Health Rehabilitative (AMHR) Services are covered when criteria for admission, ongoing need, and applicable program levels are met.

Admission Criteria (summary): Member is age 18 or older with a diagnosed Serious Mental Illness that seriously impairs capacity to live independently with supports; referred by a licensed professional; does not require inpatient hospitalization or nursing home level care; able to evacuate residence within 3 minutes and manage basic medical needs; and services are medically necessary.age >=18; SMI with significant impairment; referral required; not medically unstable

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Levels of AMHR: AMHR includes Supervised Residence A+ (24/7 services), A (>=12 hrs/day), B (4–<12 hrs/day), C (>=1 hr/week but <4 hrs/day), and Family Care (Level D) with varying availability of community mental health rehabilitation services.

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Discharge Conditions: Discharge may occur for substantial, continuing, immediate threats to safety; behavior rendering the program noncompliant with agreements or law; repeated rule violations after written notice; attainment of maximum clinical benefit with an appropriate alternative living arrangement available; absence >30 days without intent to return; or refusal of necessary services when alternatives available.

inv-03: AMHR Admission

Covered when ALL of the following are met for AMHR (community residence) admission:

AMHR Admission Criteria: Member is 18 years or older AND has a diagnosed Serious Mental Illness that seriously impairs the member's capacity to live independently with appropriate supports AND is referred by a licensed professional AND does not have an acute medical condition requiring inpatient hospitalization, does not need nursing home level of care, is able to evacuate the residence within 3 minutes, and is capable of managing incontinence and other medical care needs AND services are medically necessary.

inv-04: Partial Care Admission

Covered when ALL of the following are met for Partial Care admission:

Partial Care Admission Criteria: Member demonstrates impaired functioning requiring critical skills training in at least one domain (personal self-care, interpersonal relationships, work, school, community living, or housing) on a continuing or intermittent basis for at least one year AND clinical evidence justifying partial care necessity is documented and confirmed by a psychiatrist or advanced practice nurse and the interdisciplinary treatment team AND the member requires psychiatric rehabilitation and active treatment of no less than 2 hours daily and no more than 25 hours weekly AND at the time of referral the member has at least one qualifying primary diagnosis (e.g., schizophrenia spectrum/psychotic disorders, major depressive disorder, bipolar disorder, delusional disorder, schizoaffective disorder, or other affective disorders).duration >=1 year; active treatment 2–25 hrs/day/week

When determining coverage, member-specific benefits and eligibility take precedence. Reviewers must first verify the member's eligibility, the member-specific benefit plan, and any applicable federal or state requirements before applying these Clinical Criteria. If a requested service or procedure is limited, excluded, defined differently, or conflicts with the member's benefit, the member's benefit supersedes these Clinical Criteria and coverage may be denied.

Members who have an acute medical condition requiring inpatient hospitalization or who require nursing home level of care are not eligible for admission to Adult Mental Health Rehabilitative (AMHR) community residence services. Admission also requires that the member be able to evacuate the residence within three minutes and be capable of managing incontinence and other basic medical care needs.

These Clinical Criteria are subordinate to any limits or exclusions in the member's specific benefit plan. If a benefit plan limits or excludes the requested service, or if there is a conflict between the Clinical Criteria and the member's benefit, the member-specific benefit limitation or exclusion overrides these criteria and will govern coverage decisions.

Discharge from AMHR or partial care is indicated when the member has achieved maximum clinical benefit from the services and an appropriate alternative living arrangement (not a shelter, motel, or hospital) is available and in the member's best clinical interest. Discharge may also occur for safety or behavioral reasons, prolonged absence without intent to return, or refusal of necessary services when an alternative living arrangement is available.

Coding and Diagnosis Codes

Developmental Services CPT codes and modifierCPTCovered

96156EP	Health behavior assessment or reassessment
96156EP26	Supervision/treatment plan modification
96158EP	Health behavior intervention, individual, face -to-face, initial 30 minutes
96159EP	Health behavior intervention, individual, face -to-face, each additional 15 minutes
96164EP	Health behavior intervention, group (2 or more patients), face -to-face, initial 30 minutes
96165EP	Health behavior intervention, group (2 or more patients), face -to-face, each additional 15 minutes
96167EP	Health behavior intervention, family (with the patient present), face -to-face, initial 30 minutes
96168EP	Health behavior intervention, family (with the patient present), face -to-face; each additional 15 minutes
96170EP	Health behavior intervention, family (without the patient present), face -to-face; initial 30 minutes
96171EP	Health behavior intervention, family (without the patient present), face -to-face; each additional 15 minutes

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Applicable Diagnosis CodesICD-10

F84.0–F84.9

ICD-10 codes for Autism Spectrum Disorder

Accepted Primary Diagnoses for Partial Care ReferralICD-10

Schizophrenia or other Psychotic Disorders	Primary allowable diagnosis listed for partial care referral
Major Depressive Disorder	Primary allowable diagnosis listed for partial care referral
Bipolar Disorder	Primary allowable diagnosis listed for partial care referral
Delusional Disorder	Primary allowable diagnosis listed for partial care referral
Schizoaffective Disorder	Primary allowable diagnosis listed for partial care referral
Affective Disorders	Primary allowable diagnosis listed for partial care referral

inv-12: DIR Floortime home program hours

Home program targetNatural supports (parents/family) are the primary deliverers and the goal is 14–20 hours per week of Floortime implemented at home.

Dependence on natural supportsSuccessful implementation depends on availability and capacity of natural supports; document factors (work, other children, stability) that affect feasibility.

Impact on professional hoursAn effective home program can reduce required professional service hours; frequency should be adjusted based on home program effectiveness.

inv-13: Professional service frequency (DIRFloortime)

Professional services rangeLeast intense: up to 5 hours/week; Most intense: up to 30 hours/week.

Provider Actions and Documentation Requirements

Prior Authorization

Verify benefits and complete QHP assessment and treatment plan (prior authorization pre-check)

Verify member eligibility and benefits with the member's specific plan prior to applying these Clinical Criteria. A Qualified Healthcare Provider (QHP) must assess the child and complete a treatment plan before providing Developmental Services; developmental services must be billed using the specified CPT codes with modifier EP for EPSDT when applicable.

Verify member-specific benefits and any federal/state regulatory requirements that supersede the Clinical Criteria.
QHP assessment and treatment plan required prior to initiating Developmental Services.
Bill developmental services using CPTs 96156EP–96171EP and Modifier EP for EPSDT, as applicable.

Note

Provide Partial Care with required active treatment intensity and delivery limits

Deliver Partial Care as individualized, structured, non-residential programming that provides active treatment and related services up to five hours per day, up to five days per week; ensure active treatment is initiated at intake and documented.

Background

Developmental Services for Autism Spectrum Disorder emphasize relationship-based, child-directed approaches such as DIR/Floortime and related developmental or developmental-relationship behavioral models (NDBI/DRBI). A Qualified Healthcare Provider (QHP) must assess the child and complete an individualized treatment plan before services begin. Service intensity is determined by clinical need and family capacity: professional DIR/Floortime services may range up to 5–30 hours per week, with a targeted home program implemented by natural supports of about 14–20 hours per week. These services are typically continued for at least 12 months and are billed using the specified CPT codes with the EPSDT EP modifier when applicable.

Definitions

inv-25: DIR / Floortime definition

DefinitionDIR (Developmental, Individual-differences, Relationship-based) is a framework to assess social-emotional development, individual differences, and the impact of relationships; Floortime is the common application of DIR.

Core featuresEmphasizes relationship-based, child-directed learning, functional emotional development, parent coaching, and play/passion-based interventions.

Natural supports roleDIR/Floortime relies on natural supports to implement an at-home Floortime program (target 14–20 hours/week).

inv-26: DRBI / NDBI definition

DefinitionDRBI (Developmental Relationship-Based Behavioral Interventions) describes a range of non-DIR developmental approaches (e.g., RDI); NDBI (Naturalistic Developmental Behavioral Interventions) are blended developmental-behavioral approaches (e.g., ESDM).

Examples

Level-of-Care Criteria

inv-29: Adult Mental Health Rehabilitative Services (AMHR)

AMHR (Adult Mental Health Rehabilitative Services) level-of-care determination and stay decisions are based on admission criteria, the program level selected, and ongoing medical necessity.

Admission Requirements: Member meets AMHR admission criteria: age >=18, diagnosed Serious Mental Illness impairing independent living, licensed professional referral, not requiring inpatient or nursing home-level care, able to evacuate residence within 3 minutes, capable of managing basic medical needs, and services are medically necessary.

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Program Levels and Service Availability: Select the AMHR level (Supervised Residence A+, A, B, C, or Family Care Level D) according to required hours of community mental health rehabilitation services and staffing availability.

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Discharge and Continued Stay Considerations: Continued stay requires ongoing medical necessity; discharge is indicated for any of the listed discharge conditions including safety threats, program noncompliance, repeated rule violations after notice, attainment of maximum clinical benefit with an alternative living arrangement available, absence >30 days without intent to return, or refusal of necessary services when alternatives exist.

Treatment Modalities

inv-31: DIR / DRBI / NDBI — modality criteria

Developmental treatment modalities covered under this benefit include DIR/Floortime, DRBI, and NDBI — selection should match the child's needs and provider credentials.

Developmental Modalities: Covered modalities: DIR/Floortime (relationship-based, child-directed, focus on social-emotional development and parent coaching), Developmental Relationship-Based Behavioral Interventions (DRBI) such as RDI, and Naturalistic Developmental Behavioral Interventions (NDBI) such as ESDM. Modality choice should be based on the child's functional emotional development, individual differences, and availability of credentialed providers.

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inv-32: Partial Care Core Services

Partial Care core services must align with individualized rehabilitation plans and support community integration through active treatment and skill development.

Core Services (summary): Core services include engagement and outreach, goal setting and skill development, illness management and recovery programming, psychoeducation, relapse prevention, dual disorder education, medication education (distinct from prescribing), wellness activities, cognitive/functional skill development (staff-to-consumer ratio not to exceed 1:12), pre-vocational services, therapeutic subcontract work (within line of sight of staff), goal-oriented verbal counseling, age-appropriate learning, social/leisure services, and psychiatric services.

Visit Limits and Frequency

inv-33: DIRFloortime professional services — maximum professional hours per week

Maximum professional hoursDIRFloortime professional services: up to 30 hours per week.

Least intense optionLeast intense professional services are up to 5 hours/week.

AdjustmentsProfessional hours should be reduced as the DIR home program becomes effective and based on child progress.

inv-34: DIRFloortime home program — recommended hours per week for natural supports

Recommended weekly hoursDIRFloortime home program recommended target: 14–20 hours per week delivered by natural supports.

Implementation dependencyGoal feasibility depends on availability, capacity, and stability of natural supports and family context.

Policy Summary

PayerOptum

PolicyNew Jersey Medicaid Supplemental Clinical Criteria — Behavioral Health

Policy CodePolicy BH803 OH002026

Change TypeNo material clinical or coverage changes

Effective DateFeb 1, 2026

Last ReviewFeb 1, 2026

Next Review Date

Key ActionVerify member eligibility and benefits and ensure a Qualified Healthcare Provider assesses the member and completes a treatment plan prior to initiating services.

SourceLink

On This Page

Adjust by home program

Actual professional hours may be substantially less when DIR home program effectively supports the child.

Frequency decision factorsFrequency should consider natural supports availability, child complexity, safety risks, and course-of-intervention modifiers.

inv-14: Duration of impaired functioning

Minimum duration criterionImpaired functioning must be present on a continuing and intermittent basis for at least one year.

Domains consideredDuration applies to impairment in domains such as self-care, interpersonal relationships, work, school, community living, or housing.

Documentation requirementClinical evidence documenting the continuing/intermittent impairment for ≥1 year must be in the record and confirmed by the interdisciplinary team.

inv-15: Partial care active treatment intensity

Daily/weekly intensityPartial Care requires active treatment of no less than 2 hours daily and no more than 25 hours weekly.

Service compositionActive treatment includes assessment, treatment, psychiatric rehabilitation, discharge planning, and a complementary schedule of services to maximize independence.

Delivery limitsPartial Care programming is non-residential, individualized, and available up to five hours per day for active treatment/pre-vocational services, limited to 5 days/week.

Provide integrated active treatment (assessment, treatment, psychiatric rehabilitation, discharge planning).
Limit active treatment/pre‑vocational/skill development to up to five hours per day, 5 days/week.
Document active treatment initiation at intake and align services to the individualized plan.

Step Therapy

Start with higher-frequency professional services when indicated and titrate by progress

Consider short-term higher-frequency professional services at treatment initiation and adjust frequency/duration based on clinical progress and the effectiveness of the DIR home program implemented by natural supports.

Initial intervention may benefit from short-term high-frequency professional services to launch parent-mediated care.
If limited progress occurs with lower-frequency professional services, increase professional service frequency rather than extending low‑intensity duration.
Adjust service frequency as the natural-supports DIR home program (target 14–20 hrs/week) is implemented.

Step Therapy

Create and regularly review individualized rehabilitation plan within 30 days

Develop, implement, monitor, and update an individualized rehabilitation plan no later than 30 days after admission; review and, if necessary, revise the plan within 3 months of development and every 3 months thereafter.

Staff must partner with the consumer to develop the individualized rehabilitation plan within 30 days of admission.
Review/revise the plan within 3 months of development and every 3 months thereafter, or upon consumer request.

Billing Rule

QHP assessment required; bill using specified CPTs and EP modifier

A QHP must perform the child assessment and complete the treatment plan prior to providing developmental therapy; bill developmental services using CPT procedure codes 96156EP through 96171EP with the EP modifier where EPSDT applies.

QHP assessment and documented treatment plan required before Developmental Services are provided.
Use CPTs 96156EP, 96156EP26, 96158EP, 96159EP, 96164EP, 96165EP, 96167EP, 96168EP, 96170EP, 96171EP and Modifier EP for EPSDT billing.

Documentation Required

Complete comprehensive and nursing assessments within 14 days and document team confirmation

Complete a written comprehensive rehabilitation needs assessment and a nursing assessment within 14 calendar days of admission; use the initial nursing assessment with the intake assessment to develop the comprehensive service plan. Ensure partial care necessity is confirmed and documented by a psychiatrist or advanced practice nurse and the interdisciplinary team.

Comprehensive rehabilitation needs assessment due by day 14 after admission.
Nursing assessment due within first 14 days; use it to develop the comprehensive service plan.
Psychiatrist or advanced practice nurse and interdisciplinary team must confirm and document partial care necessity in the record.

Note

Verify plan benefits and resolve member-specific benefit conflicts before services

Reference the member's benefit plan before authorizing services; if the requested service/procedure is limited, excluded, or conflicts with the member-specific benefit, the member's benefit supersedes these Clinical Criteria and coverage may be denied.

Identify member eligibility and member‑specific benefit limitations before initiating services.
If a service is limited/excluded or conflicts with the benefit, the benefit plan controls and may result in denial.

Denial Risk

Identify behavioral or compliance triggers that may lead to discharge

Monitor behaviors and compliance that may trigger discharge: discharge may occur for substantial, continuing, immediate threats to others' safety; behavior rendering the program noncompliant with agreements or law; repeated rule violations after written notice; absence >30 continuous days without intent to return; refusal of necessary services when alternatives are available; or when maximum clinical benefit has been reached and an appropriate alternative living arrangement exists.

Discharge may not be used on basis of safety threat if the person has been civilly committed.
Repeated rule violations require prior written notice and reflection in the resident services agreement.
Document absence >30 days without notice or refusal of necessary services as grounds for discharge when alternatives exist.

Includes RDI and Early Start Denver Model among other developmental models and infant mental health approaches.

Use under benefitThese approaches are included as allowable developmental interventions for ASD under the benefit.

inv-27: Active treatment definition

DefinitionActive treatment is a process initiated at intake for partial care that includes assessment, treatment, psychiatric rehabilitation, and discharge planning, with an integrated schedule of services to maximize independence and community living skills.

ComponentsIncludes assessment, comprehensive individualized rehabilitation plan, treatment implementation, monitoring, and discharge planning.

PurposeAims to promote community integration, achieve valued roles, and reduce unnecessary hospitalizations.

inv-28: Pre-vocational services definition

DefinitionPre-vocational services are interventions within partial care that help individuals acquire general work behaviors, attitudes, and skills needed for employment and related life domains (e.g., responding to criticism, decision making, managing symptoms).

ContextDelivered within structured partial care programming as part of skill development or therapeutic activities.

ObjectiveFocuses on general work readiness and transferable competencies rather than job-specific training.

inv-30: Partial Care / AMHR criteria grouping

Partial Care and AMHR overlap for community integration and active treatment; the following groups of criteria define Partial Care admission, required documentation, and core service expectations.

Partial Care Admission and Documentation: Member meets Partial Care admission criteria (impaired functioning >=1 year in relevant domains; documented necessity confirmed by psychiatrist or advanced practice nurse and interdisciplinary team; need for psychiatric rehabilitation and active treatment 2–25 hours/week; qualifying primary diagnosis) and the provider completes required assessments and documentation (comprehensive rehabilitation needs assessment within 14 days; individualized rehabilitation plan within 30 days and reviews every 3 months).

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Service Intensity and Delivery: Partial Care programs provide structured non-residential active treatment (up to five hours per day, up to 5 days/week) and must deliver services consistent with the individualized rehabilitation plan and medical necessity.

[[chunk 21]]

Core Service Expectations: Core services include engagement, goal setting, illness management and recovery, psychoeducation, relapse prevention, medication education, wellness activities, skill development, pre-vocational services, therapeutic subcontract work, goal-oriented counseling, age-appropriate learning, social/leisure services, and psychiatric services; medication evaluation and prescribing are separate from Partial Care reimbursement.

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Effect on professional careA robust home program can materially lower required professional service frequency.

inv-35: Partial Care Services — up to five hours of active treatment per day

Daily limitPartial Care Services provide up to five hours of active treatment or pre-vocational services per day (available on an hourly basis).

Weekly limitLimited to 5 days per week; active treatment intensity expectation is no less than 2 hours daily and no more than 25 hours weekly.

Program scopeNon-residential structured programming includes counseling, case management, psychoeducation, skill development, and psychiatric services.

inv-36: Nursing assessment/visits — nursing face-to-face every 90 days

Nursing visit frequencyA registered nurse or higher-level nursing professional shall provide face-to-face nursing visits every 90 days while the consumer resides in a supervised residence.

Initial nursing assessment timingA nursing assessment must be completed within the first 14 calendar days and used to develop the comprehensive service plan.

Purpose of visits90-day visits include assessment and review of clinical condition to ensure services align with the individualized rehabilitation plan; additional visits as needed based on consumer needs.