CurrentAetnaPolicy N/A

Pennsylvania — PA Act 106 certification and referral requirement for substance use treatment

Governs Pennsylvania-specific requirements under PA Act 106 for licensed physicians or psychologists to certify and refer individuals with alcohol or drug abuse/dependency for treatment in licensed facilities; applies to fully insured group plans written in Pennsylvania.

Policy Summary

PayerAetna

PolicyPennsylvania — PA Act 106 certification and referral requirement for substance use treatment

Policy CodePolicy N/A

Change TypeAdministrative (no material clinical changes)

Effective DateN/A

Next Review DateN/A

Key ActionLicensed physician or psychologist must provide written certification including length and type of care and refer the individual to a Pennsylvania Department of Health–licensed treatment facility.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 lawstate-specific statutory requirement

3 actionsclinician actions required

facility requiredlicensed facility required

Coverage Conditions (Pennsylvania Act 106)

PA Act 106 statutory coverage conditions

Covered when ALL of the following are met:

PA Act 106 requirements: (1) A licensed physician or psychologist certifies in writing that the person is suffering from alcohol/drug abuse or dependency; (2) The clinician refers the person for appropriate facility or outpatient alcoholism and drug abuse treatment; (3) The written certification includes the length and type of care; (4) Services are provided in facilities licensed by the Pennsylvania Department of Health to provide alcohol and other drug addiction treatment services; (5) The individual is covered under a fully insured group plan written in Pennsylvania.

All conditions required by statute; applies to fully insured group plans written in PA.

Services provided in facilities that are not licensed by the Pennsylvania Department of Health to specifically provide alcohol and other drug addiction treatment services do not meet the statutory requirements under PA Act 106. The statute requires that all covered services be delivered in facilities licensed by the Pennsylvania Department of Health to provide alcohol and other drug addiction treatment services for individuals covered under fully insured group plans written in Pennsylvania.

There is no separate "not applicable" carve-out in this policy: PA Act 106 mandates clinician certification, inclusion of the length and type of care, clinician referral, and treatment in Pennsylvania Department of Health–licensed facilities for individuals covered under fully insured group plans written in Pennsylvania.

Policy Summary

PayerAetna

PolicyPennsylvania — PA Act 106 certification and referral requirement for substance use treatment

Policy CodePolicy N/A

Change TypeAdministrative (no material clinical changes)

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Coding and Related Details

No codes specifiedmixed

No codes listed

Length and type of care — must be included in written certification

Required elementWritten certification must include the expected length and type of care.

Who provides itThe written certification must be completed by a licensed physician or psychologist.

PurposeDocuments the clinician’s assessment that the person is suffering from alcohol/drug abuse or dependency.

Connection to referralCertification must accompany referral to appropriate facility or outpatient alcoholism and drug abuse treatment.

Provider Certification, Referral, and Documentation Requirements

Prior Authorization

PA Act 106 — Certification and Referral Requirement

Under Pennsylvania Act 106, a licensed physician or psychologist must provide a written certification that the patient is suffering from alcohol or drug abuse or dependency and must refer the patient for appropriate facility or outpatient alcoholism and drug abuse treatment. The written certification must specify the type and expected length of care. Services must be delivered in facilities licensed by the Pennsylvania Department of Health to provide alcohol and other drug addiction treatment services. This requirement applies to individuals covered under fully insured group plans written in Pennsylvania.

Licensed clinician must provide written certification of alcohol/drug abuse or dependency
Certification must include type and length of care
Clinician must refer patient to appropriate facility or outpatient treatment
Treatment must occur in facilities licensed by the Pennsylvania Department of Health for alcohol and other drug addiction services
Applies to fully insured group plans written in Pennsylvania

Denial Risk

Noncompliance Risk

Failure to provide the required written certification and referral, or to use facilities not licensed by the Pennsylvania Department of Health for addiction treatment, may affect coverage under fully insured group plans written in Pennsylvania. Providers should follow these requirements to avoid claim denials or coverage disputes.

Noncompliance may lead to claim denials or coverage disputes
Use only Pennsylvania Department of Health–licensed addiction treatment facilities for covered services

Documentation Required

Required Documentation

Documentation must include a written certification from a licensed physician or psychologist stating the diagnosis of alcohol or drug abuse/dependency, the recommended type of treatment (facility-based or outpatient), and the anticipated length of care. Maintain and submit this documentation with claims or upon request to support coverage under fully insured group plans written in Pennsylvania.

Written certification: diagnosis, type of care, length of care
Referral details: facility or outpatient program name and licensing confirmation
Retain documentation to support claims and respond to coverage requests

Note

Provider Responsibilities

Providers must ensure referrals are to appropriately licensed facilities and that written certifications are completed before or at the time services are initiated to meet Act 106 requirements for fully insured group plans written in Pennsylvania.

Certify and refer prior to or at initiation of services when possible
Verify facility licensure with the Pennsylvania Department of Health

Key Definitions

Facility licensed by the Pennsylvania Department of Health — definition

DefinitionA facility licensed by the Pennsylvania Department of Health to specifically provide alcohol and other drug addiction treatment services.

ScopeAll services under PA Act 106 must be provided in these licensed facilities.

ApplicabilityRequirement applies to individuals covered under fully insured group plans written in Pennsylvania.

Licensed physician or psychologist — definition

Who qualifiesA licensed physician or psychologist authorized to certify in writing that a person is suffering from alcohol/drug abuse or dependency.

Required actionsMust certify in writing and refer the person for appropriate facility or outpatient alcoholism and drug abuse treatment.

Documentation contentCertification must state the person has alcohol/drug abuse or dependency and include length and type of care.

Level-of-Care / Service Setting Criteria

Permitted Treatment Modalities

Alcoholism and drug abuse treatment (facility or outpatient)

Licensed facility requirement: All services must be provided in facilities licensed by the Pennsylvania Department of Health to specifically provide alcohol and other drug addiction treatment services.

Applies to both facility and outpatient alcoholism and drug abuse treatment referenced by statute.

Background and Scope

PA Act 106 requires that a licensed physician or psychologist (1) certify in writing that the person is suffering from alcohol or drug abuse or dependency, (2) refer the person for appropriate facility or outpatient alcoholism and drug abuse treatment, and (3) include the length and type of care in the written certification. The law further requires that all services be provided in facilities licensed by the Pennsylvania Department of Health to specifically provide alcohol and other drug addiction treatment services; these conditions apply to individuals covered under fully insured group plans written in Pennsylvania.