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    v1.0.31
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyBeacon Health Options SUD Prior Auth Update | Open…
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    CurrentBeacon-Health-OptionsPolicy N/A

    Coordination of Care Across Substance Use Disorder Conflicting Levels of Care

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    This provider alert governs authorization, care coordination, and claims adjudication when a participant receives conflicting substance use disorder levels of care concurrently. It applies to SUD providers and requires coordination, prompt authorization discharge, and new authorization submission when a participant returns to a lower level of care.

    Policy Summary
    PayerBeacon-Health-Options
    PolicyCoordination of Care Across Substance Use Disorder Conflicting Levels of Care
    Policy CodePolicy N/A
    Change TypeRevised and added requirements
    Effective DateMay 1, 2026
    Next Review DateN/A
    Key ActionCoordinate care with the participant and all other treating providers to ensure the participant is not receiving conflicting levels of care at the same time.
    SourceLink
    POLICY UPDATE CHANGES

    Claims adjudication now applies a level-of-care hierarchy in which the higher level of care is paid and conflicting lower-level services may be denied or retracted.

    Authorizations for lower levels of care are systematically terminated when an authorization for a higher level of care is received.

    4Levels in the SUD care hierarchy
    5SUD Residential codes ordered within the hierarchy
    Higher level

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Level of care paid when conflicting services overlap
    Lower levelConflicting level of care subject to denial or retraction

    Conflicting Level-of-Care Rules

    Conflicting Level-of-Care Rules

    Apply these authorization and claims rules when a participant receives, transitions between, or returns to different SUD levels of care.

    Authorization and care coordination

    • Providers must coordinate care with the participant and other treating providers to ensure the participant is not receiving conflicting levels of care at the same time, consistent with the service limitations across levels of care defined in COMAR 10.09.80.06B.
    • Providers must discharge authorizations promptly and accurately when participants transition between levels of care to prevent delays in authorization processing or inappropriate claim adjudication.
    • Effective May 1, 2026, receipt of an authorization for a higher level of care will systematically terminate the authorization for the lower level of care.
    • If a participant transitions from a lower level of care to a higher level of care and then returns to the lower level of care, the provider must submit a new authorization for the lower level of care after the higher-level episode ends.

    Level-of-care hierarchy and claims adjudication

    • Apply the level-of-care hierarchy from highest to lowest as follows: SUD Residential, PHP, IOP, and Outpatient Therapy.
    • Within SUD Residential, apply the hierarchy from highest to lowest as follows: W7375, W7370, W7350, W7330, and W7310.
    • When conflicting levels of care are identified, claims for the higher level of care will be paid.
    • Claims for conflicting services at a lower level of care will be denied or retracted if already paid.
    • The conflicting-claims rule applies to both current and past claims.

    SUD Level-of-Care Hierarchy

    SUD Residential hierarchy codesHCPCS
    W7375Highest SUD Residential level in the residential hierarchy
    W7370SUD Residential level, below W7375
    W7350SUD Residential level, below W7370
    W7330SUD Residential level, below W7350
    W7310Lowest SUD Residential level listed in the residential hierarchy
    Overall Level-of-Care Hierarchy
    1 — HighestSUD Residential
    2PHP
    3IOP
    4 — LowestOutpatient Therapy
    SUD Residential Code Hierarchy
    1 — HighestW7375
    2W7370
    3

    Required Provider Actions

    Documentation Required

    Coordinate concurrent care

    Coordinate care with the participant and all other treating providers to ensure the participant is not receiving conflicting levels of care at the same time.

    Prior Authorization

    Terminate conflicting lower-level authorization

    Lower-level authorizations are systematically terminated upon receipt of an authorization for a higher level of care. Review authorization status when a participant transitions to a higher level of care.

    Prior Authorization

    Obtain new authorization after step-down

    If a participant returns to a lower level of care after the higher-level episode ends, submit a new authorization for the lower level of care.

    Key Definitions

    Level-of-Care Hierarchy
    Highest levelSUD Residential
    Second levelPHP
    Third levelIOP
    Lowest levelOutpatient Therapy
    Conflicting Levels of Care
    ServicesServices delivered at different levels of care
    TimingDelivered during the same period
    Limitation
    Policy Summary
    PayerBeacon-Health-Options
    PolicyCoordination of Care Across Substance Use Disorder Conflicting Levels of Care
    Policy CodePolicy N/A
    Change TypeRevised and added requirements
    Effective DateMay 1, 2026
    Next Review DateN/A
    Key ActionCoordinate care with the participant and all other treating providers to ensure the participant is not receiving conflicting levels of care at the same time.
    SourceLink
    On This Page
    Conflicting Level-of-Care RulesSUD Level-of-Care HierarchyRequired Provider ActionsKey Definitions
    W7350
    4W7330
    5 — LowestW7310
    Documentation Required

    Discharge authorizations during transitions

    Discharge authorizations promptly and accurately when participants transition between levels of care. Timely discharge helps prevent delays in authorization processing or inappropriate claim adjudication.

    Denial Risk

    Avoid conflicting claims

    When conflicting levels of care are identified, claims for the higher level of care will be paid, while conflicting lower-level claims may be denied or retracted if already paid. This rule applies to both current and past claims.

    The services are not permitted to overlap under applicable service limitations, including COMAR 10.09.80.06B