Requirement for Designated Behavioral Health (BH) and Substance Use Disorder (SUD) Services
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Governs prior authorization and fiscal year limits for select 1115 behavioral health (BH) and substance use disorder (SUD) residential services provided to Alaska Medicaid beneficiaries beginning July 1, 2025. Affects providers submitting service authorizations to HMS Gainwell when services will exceed fiscal year limits.
State fiscal year limits will resume for select 1115 BH and SUD residential services beginning July 1, 2025; services up to the fiscal year limit do not require prior authorization but services exceeding the limit require submission of a service authorization to HMS Gainwell demonstrating medical necessity.
Coverage Criteria and Authorization Rules
Authorization and fiscal-year limit criteria
Covered when ALL of the following are met
Services up to the fiscal year limit do not require prior authorization; service authorization (SA) must be submitted to HMS Gainwell and demonstrate medical necessity for services that will exceed the fiscal year limits (effective July 1, 2025).
Comagine Health will continue to provide authorizations for certain psychiatric inpatient services and for Residential Psychiatric Treatment Center (RPTC) admissions and continued stay reviews. Specifically, Comagine Health remains responsible for authorizations of all inpatient psychiatric admissions and continued stays that exceed 3 days, and for RPTC admissions and continued stay reviews.
None explicitly stated in the document.
Coding and Fiscal Thresholds
| No codes listed |
Provider Requirements and Authorization Process
Prior Authorization Required
Beginning July 1, 2025, state fiscal year limits will resume for select 1115 behavioral health (BH) and substance use disorder (SUD) residential services. Medicaid beneficiaries may receive these services up to the fiscal year limit without prior authorization. Service authorization (SA) requests must be submitted to HMS Gainwell for any 1115 BH/SUD residential services that will exceed the fiscal year limits and must demonstrate medical necessity.
- Effective date: 2025-07-01
- Submit SA requests to HMS Gainwell for services that will exceed fiscal year limits
- SA must demonstrate medical necessity
Documentation and Submission Requirement
Providers must submit service authorization requests to HMS Gainwell for 1115 BH/SUD residential services that are expected to exceed the resumed fiscal year limits. Follow HMS Gainwell submission processes and include supporting documentation that demonstrates medical necessity for the continued stay or additional days beyond the fiscal year limit.
- Include clinical documentation supporting continued need
- Identify expected dates and level of service in the SA request
- Use applicable Provider Service Manual guidance for service definitions
Services Subject to Fiscal Year Limits and SA
1115 services that will require SA when exceeding fiscal year limits include (but are not limited to): Crisis Residential & Stabilization (after 7 days); Therapeutic Treatment Homes (after 90 days); Children's Residential Treatment Level 1 (after 90 days); Children's Residential Treatment Level 2 (after 90 days); Adult Mental Health Residential Treatment Level 1 (after 90 days); Adult Mental Health Residential Treatment Level 2 (after 180 days); ASAM 3.1, 3.3, 3.5 SUD Residential (after 90 days); ASAM 3.2, 3.7, 4.0 Withdrawal Management (after 14 days); ASAM 3.7, 4.0 SUD Residential (after 14 days). See the Alaska Behavioral Health and SUD Provider Service Manuals for full service definitions and limits.
- Crisis Residential & Stabilization: after 7 days
- Therapeutic Treatment Homes: after 90 days
- Children's Residential Treatment Level 1: after 90 days
- Children's Residential Treatment Level 2: after 90 days
- Adult Mental Health Residential Treatment Level 1: after 90 days
- Adult Mental Health Residential Treatment Level 2: after 180 days
- ASAM 3.1 SUD Residential: after 90 days
- ASAM 3.2 Withdrawal Management: after 14 days
- ASAM 3.3 SUD Residential: after 90 days
- ASAM 3.5 SUD Residential: after 90 days
- ASAM 3.7 SUD Residential: after 14 days
- ASAM 3.7 Withdrawal Management: after 14 days
- ASAM 4.0 SUD Residential: after 14 days
- ASAM 4.0 Withdrawal Management: after 14 days
Denial Risk for Insufficient Medical Necessity
SA requests that do not demonstrate medical necessity for services that exceed the fiscal year limits may be denied. Providers should ensure SA submissions include adequate clinical justification, supporting documentation, and adherence to the applicable Provider Service Manual criteria to reduce risk of denial.
- Denial risk if medical necessity is not demonstrated
- Follow Provider Service Manuals for criteria
- Comagine Health will continue to authorize RPTC admissions and inpatient psychiatric stays exceeding three days
Policy Background and Rationale
This policy reinstates state fiscal year limits for select 1115 behavioral health (BH) and substance use disorder (SUD) residential services effective July 1, 2025. Beneficiaries may receive designated 1115 services up to the fiscal year limits without prior authorization. If a beneficiary’s stay will exceed the applicable fiscal year day threshold for a designated service, providers must submit a service authorization (SA) request to HMS Gainwell that demonstrates medical necessity. Example service thresholds in the Provider Service Manuals include ASAM 3.1/3.3/3.5 residential after 90 days and ASAM 3.2/3.7/4.0 withdrawal management after 14 days; other service-specific thresholds are listed in the manuals. The change is intended to align utilization management with client need and ensure quality of care.
Definitions and Program References
Level-of-Care Criteria for Residential Services
ASAM and SUD Treatment Modalities
ASAM-level SUD residential and withdrawal management
Submit SA to HMS Gainwell demonstrating medical necessity when stay exceeds the specified day thresholds.
Designated 1115 BH and SUD Residential Service Limits
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