CurrentCareSourcePolicy Drug Testing-AR PASSE-MM-1332

Drug Testing

Defines medical necessity, documentation, allowed and disallowed drug testing methods, frequency expectations for MAT/OTP, provider/lab requirements, and billing rules for presumptive and definitive drug testing for Arkansas PASSE members.

Policy Summary

PayerCareSource

PolicyDrug Testing

Policy CodePolicy Drug Testing-AR PASSE-MM-1332

Change TypeAnnual review/administrative updates

Effective DateOct 1, 2025

Next Review DateMay 31, 2026

Key ActionInclude type of test (presumptive or confirmatory), drug/drug class, ICD diagnosis, current medications, clinical indication, signature and date of qualified provider and ordering physician's PIN (and PCP PIN if referred); maintain records for audits.

SourceLink

POLICY UPDATE CHANGES

Annual review with updated references and background noted on 06/18/2025.

Previous revisions on 08/02/2023 and 07/17/2024 noted; updates included references and deleted modifiers from II.A.

3Testing code groups highlighted (presumptive, validity, definitive guidance)

8OTP random UDTs per year (maintenance)

500Annual lab services $ threshold for in-network members >=21

Coverage Summary

Billing, Lab & Provider Requirements

Billing and Lab Requirements

ALL of the following

Specimen validity billing: Providers performing validity testing on urine specimens shall not separately bill for validity testing (urinary pH, specific gravity, creatinine, nitrates, oxidants, or other tests)
Record retention by labs: Independent labs must retain physician's order, test results, and all records pertinent to billing
Accreditation/documentation: Documentation of FDA-approved complexity level for instrumented equipment and/or CLIA Certificate or high complexity lab accreditation may be required
In-network medical necessity review threshold: Participating/in-network providers: medical necessity review required after reaching $500 per calendar year for all laboratory services for members 21+ unless codes billed with appropriate modifiers to indicate MAT for OUD$500 per calendar year
Applies to members aged 21 and older
Out-of-network review: Non-participating/out-of-network providers: medical necessity review required for all testing

Actionable Callouts

Background, Evidence and Definitions

Presumptive (qualitative) drug tests rapidly detect the presence or absence of a drug or drug class and are commonly used for routine monitoring because they are fast, accessible, and cost-effective. Definitive (confirmatory/quantitative) tests are more specific assays that identify and often quantify particular drugs or metabolites; they are used when presumptive results are insufficient to guide clinical care, to resolve unexpected or conflicting results, or to support clinical or legal decisions. Clinical use of drug testing should be driven by the patientcentered treatment plan and documented clinical indications: order the minimum panel and frequency necessary to manage care, interpret results in context, and document how results affect treatment. Providers must also maintain laboratory accreditation and records (including physician orders, test results, and documentation of result review and follow-up) to support medical necessity and billing.

Ethical and effective testing aligns with SAMHSA, CMS/CLIA, FDA, and ASAM guidance and with peer-reviewed evidence: presumptive tests are appropriate for routine screening and frequent monitoring, while definitive assays are justified when specificity or quantification is clinically meaningful. Ordering providers should document the clinical rationale for each definitive assay performed and ensure that laboratories are appropriately certified and that records are retained per regulatory and payer requirements.

Key sources supporting this policy include guidance from the Substance Abuse and Mental Health Services Administration (SAMHSA), federal laboratory regulations under CMS/CLIA, FDA device and assay guidance, the American Society of Addiction Medicine (ASAM) practice guidelines, and peer-reviewed studies on test performance and clinical utility. These sources collectively recommend: use presumptive testing for routine monitoring, reserve definitive testing for clinical questions requiring higher specificity or quantification, document medical necessity for confirmatory assays, and ensure testing is performed by accredited laboratories with retained records. See the References section of this policy for the full citation list.

Term	Definition
{"text":"Presumptive (Qualitative) Test"},{"text":"Testing of a specimen to determine the presence or absence of a drug or drug class; commonly used for rapid screening and routine monitoring."}
{"text":"Definitive (Confirmatory/Quantitative) Test"},{"text":"A specific assay that identifies and often quantifies particular drugs or metabolites; used to confirm presumptive results or when quantification/specificity is clinically necessary."}
{"text":"Medication Assisted Treatment (MAT)"},{"text":"Use of FDA-approved medications in conjunction with counseling and behavioral therapies to treat substance use disorder."}
{"text":"Extension of Benefits"},{"text":"A review of medical necessity and authorization to exceed an annual maximum benefit."}

Revision History

06/18/2025annual review

Annual review with updated references and background; Approved at Committee (not material).

10/01/2025policy effective

Policy approved at Committee; effective date as listed in header.

05/31/2026policy archivedLatest

Policy archived per header (no longer active).

08/02/2023annual review

Administrative/annual review updates: updated references and other administrative changes noted.

07/17/2024administrative update

Administrative/annual updates: II.A. updated references and approved at Committee.