BH Admission and Concurrent Review Criteria for ASAM 3.5: Form

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Admission and Concurrent Review Criteria for ASAM 3.5 Behavioral Health Policy Updated Revision Effective: 10/1/2025 Policy Number: BH642POL

Approval Date: 8/14/2025

Line(s) of Business: Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Short term residential policy for substance use disorder treatment. In Massachusetts, this is referred to as Clinical Stabilization Services, or CSS.

Line of Business

Commercial:
Refer to criteria under the Policy section in this medical policy.

Medicaid – BeHealthy:
Medical necessity review is performed by the Massachusetts Behavioral Health Partnership (MBHP).

Medicare:
Refer to criteria under the Policy section in this medical policy.

Policy

I. Requirements for Admission to ASAM 3.5 LOC

II. For Medicare Advantage:

A. Per NCD 130.6: The Centers for Medicare & Medicaid Services recognize that there are similarities between the approach to treatment of drug abuse and alcohol detoxification and rehabilitation. However, the intensity and duration of treatment for drug abuse may vary (depending on the particular substance(s) of abuse, duration of use, and the patient’s medical and emotional condition) from the duration of treatment or intensity needed to treat alcoholism. AND

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B. When it is medically necessary for a patient to receive detoxification and/or rehabilitation for drug substance abuse as a hospital inpatient, coverage for care in that setting is available. C. American Society of Addiction Medicine (ASAM) Criteria is used to supplement this NCD to ensure consistency in making medically necessary determinations.

III. For Commercial and Medicare Advantage

A. HNE requires that providers utilize the admission criteria for Substance Abuse (SA) Level 3.5 outlined by the ASAM to ensure medical necessity.

Members should meet BOTH dimension 1 and 2 criteria, and one or more of dimension 3-6 criteria

1. Dimension 1: Alcohol Intoxication and /or Withdrawal Potential • Member is at minimal risk of severe withdrawal and does not require admission into a higher LOC for treatment and monitoring.
2. Dimension 2: Biomedical Conditions and Complications:
   • Member has none or is currently stable; member is receiving concurrent medical monitoring by their provider and does not require a higher level of care.
3. Dimension 3: Emotional/Behavioral/Cognitive Conditions and Complications:
   • Member demonstrates repeated inability to control impulses; or personality disorder requires structure to shape behavior. Other functional deficits require a 24-hour setting to teach coping skills.
4. Dimension 4: Readiness to Change:
   • Member has marked difficulty with, or opposition to, treatment with dangerous consequences. Or there is high severity in this dimension but no other dimensions.
5. Dimension 5: Relapse/Continued Use/Continued Problem potential:
   • Member has no recognition of the skills needed to prevent continued use, with imminently dangerous consequences.

6. Dimension 6: Recovery Environment:
   • Member’s environment is dangerous and member lacks skills to cope outside of a highly structured 24-hour setting.

   IV. Requirements for Continued Stay Criteria in ASAM 3.5 LOC
   A. The member meets the criteria for BOTH dimensions 1 and 2 of the ASAM criteria (listed above) for SA Level 3.5 and the criteria for one or more of dimensions 3-6.
   B. The member is an active participant in the treatment plan.
   C. The member is displaying evidence of clinical progress at ASAM 3.5 LOC, and there is an expectation that clinical progress will continue with continued ASAM 3.5 LOC.
   D. Member would not be expected to make equal or better clinical progress at a lower LOC.

   Policy Guidelines and Definitions

   Services Required

   Full therapeutic programming that must be provided seven days per week, 365 days per year, includes, but is not limited to the following;

7. Aftercare planning and coordination with primary care providers
8. Behavioral/health/medication education and planning

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3. Bio-psychosocial evaluation
4. Case and family consultation (For adults who give consent, the provider makes documented attempts to contact the parent, guardian, family members, and/or significant others within 24 hours of admission, unless clinically or legally contraindicated.)
5. Psychopharmacological consultation by referral
6. Medical history and physical examination
7. Nursing assessment and services
8. Peer support and other recovery-oriented services
9. Psychiatric consultation by referral
10. Three 30-minute face-to-face meetings per week for the purpose of individual care coordination/case management, review of the current treatment/recovery plan and aftercare planning.
11. Psychopharmacological consultation by referral
12. Medical history and physical examination
13. Nursing assessment and services.
14. Peer support and other recovery-oriented services
15. Psychiatric consultation by referral
16. Three 30-minute, face-to-face meetings per week for the purpose of individual care coordination/case management, review of the current treatment/recovery plan and aftercare planning.
17. At least one therapeutic group per day and at least 10 hours of therapeutic groups per week.
    Therapeutic groups must utilize evidence-based treatment models.
18. At least 15 psycho-educational groups per week on topics including, but no limited to: Substance Use Disorder education, relapse prevention and co-occurring disorders

19. At least three hours of individual counseling per week utilizing motivational interviewing, cognitive behavioral therapy, or other evidence-based practices.

    Documentation Required

    A. For reviews that occur at a Massachusetts facility between day of initial admit to Inpatient detox or ASAM 3.5 and day 13 of continuous treatment the provider must submit the Health New England Inpatient Detoxification Clinical Review Form – Concurrent Review section to provide updates on the member’s clinical status, the treatment plan and the aftercare plan. (Per CH258 Massachusetts mandate.) Providers outside of Massachusetts must submit the Health New England Inpatient Detoxification Clinical Review Form – Concurrent Review with documentation showing that the admission criteria for Substance Use Disorder Level 3.5 outlined by the ASAM that are listed in the previous section are still met and that the required services were provided.

    B. For MA CH258 providers- reviews that are scheduled for on or after day 14 of continuous days of ATS/ASAM 3.5 treatment, the provider must submit Health New England Inpatient Detoxification Clinical Review Form – Concurrent Review section with documentation showing that the admission criteria for Substance Use Disorder Level 3.5 outlined by the ASAM that are listed in the previous section are still met and that the required services were provided.

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C. In addition to completing the Concurrent Review section of the Health New England Inpatient Detoxification Clinical Review Form the provider may be required to attach documentation from the member’s chart. The additional documentation required for any particular review will be determined by the Health New England BH staff and may include, but is not limited to, the notes from all individual and group therapy sessions, psycho-educational groups, individual meetings for care coordination/case management, review of the current treatment/recovery plan and aftercare planning that were provided during the time period specified.

References

CMS National Coverage Determination, NCD 130.6, Treatment of Drug Abuse (Chemical Dependency). https://www.cms.gov/medicare-coverage-database/search.aspx

The ASAM Criteria, 3rd Edition, American Society of Addiction Medicine 3rd Edition (asam.org)

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 11/2022 Initial policy date 12/2023 Moved to new template 2/2024 • Line of Business section added • Added Description • Medicare Advantage added in policy section • Criteria for admission and continued stay unchanged.
7/2025 Reviewed with no changes

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
Health New England expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion

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that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.