CurrentCareSourcePolicy N/A

Drug testing for substance use disorder (Arkansas PASSE)

Defines medical necessity, documentation, and coverage rules for presumptive and confirmatory drug testing for members in Arkansas PASSE, including requirements for MAT providers and laboratory standards. Applies to providers delivering SUD-related drug testing and MAT in the Arkansas Medicaid PASSE program.

Policy Summary

PayerCareSource

PolicyDrug testing for substance use disorder (Arkansas PASSE)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateNov 1, 2023

Next Review DateN/A

Key ActionFor in-network providers caring for members 21 and older, request a medical necessity review after cumulative testing reaches $500 unless MAT modifiers (X2 or X4) are used.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

80305,80307Presumptive UDT CPT codes referenced

$500Med necessity review threshold (in-network ≥21)

8Minimum random UDTs per year (OTP)

monthlyTesting frequency (first year MAT)

quarterlyTesting frequency (maintenance MAT)

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Coverage Criteria for Drug Testing and MAT

Covered drug testing conditions for MAT and OTP

Covered when ALL of the following are met

MAT program minimum components: MAT requires drug screening tests accompanying proper medication prescribing and a documented treatment plan including initial evaluation/diagnosis of OUD, lab screening for communicable diseases as appropriate, execution of a treatment agreement and consent forms, a person-centered service plan, identification of a MAT team member to function as case manager, and referrals or documented plans for counseling.

based on SAMHSA requirements; see chunks 6 and 11

Initial and continuing MAT testing frequency: Initial/early recovery: obtain an individualized baseline UDT and more frequent UDTs; Continuing (first year): at least one follow-up MAT office visit per month with drug testing at each monthly visit; Maintenance (subsequent years): at least one follow-up MAT office visit quarterly with drug testing at each quarterly visit.monthly then quarterly

see chunk 6 and chunk 11

OTP-specific testing: OTP maintenance: federal regulations require initial toxicology plus 8 random UDTs per year per member; short-term detoxification: one initial UDT per member; long-term detoxification: initial and monthly random UDT(s).8/year for OTP maintenance

see chunk 11

Individualized clinical indications

Covered when customized to clinical need

Individualized testing strategy: Testing should be individualized to the member's drugs of choice, clinical presentation, prescribed medications, regional drug trends, and detection windows; random-interval schedules are recommended over fixed-interval schedules to avoid predictable non-testing periods. The rationale for tests should focus on drugs most likely to be present and be at the lowest level that informs needed interventions.

see chunks 11 and 12

Testing that is not individualized or performed as routine, reflexive, or wholesale orders is not covered. Examples include reflexive testing, routine or preprinted orders, blanket or custom panels, and routine nonspecific or wholesale panels. Also excluded are large arbitrary panels, universal testing simply because a machine can run them, and use of testing as a condition of residence or program participation (for example, residential treatment facility, partial hospital, or sober living condition-of-residence testing).

Testing required by third parties or for administrative/forensic purposes is not covered. This includes pre-employment or employer-mandated random testing, court-ordered or forensic testing, school or military entry testing, physician health program testing, marriage license or other administrative-purpose testing, and testing where the primary pay source is other than Medicaid. Routine confirmatory testing following a negative presumptive result and blood testing performed outside the emergency department are also listed as not medically necessary.

Coding and Billing

Presumptive UDT CPT CodesCPT

80305	Presumptive drug testing (referenced)
80307	Presumptive drug testing (referenced)

Medical necessity review dollar threshold — $500

Medical necessity review threshold$500 cumulative testing for in-network providers age ≥21 triggers a medical necessity review unless billed with MAT modifiers X2 or X4

Applies to out-of-network providersA review of medical necessity is required for all testing for non-participating/out-of-network providers

Presumptive CPT codes referencedPresumptive drug testing CPT codes 80305 and 80307 are referenced in the medical necessity rule

Minimum random UDTs per year for OTP maintenance — 8

Minimum random UDTs per year (OTP maintenance)8 random urine drug tests per year required by federal OTP maintenance regulations

Short-term detoxification (OTP)

Provider Actions, Documentation & Prior Authorization

Documentation Required

Required documentation for drug test orders

Required documentation for drug test orders: Drug test orders must include at minimum the type of test to be performed (presumptive or confirmatory); the clinical indication for testing; all medications currently prescribed to the member (including OTCs); the ICD-10 diagnosis code(s) and any pertinent supplemental diagnoses supporting medical necessity for each test ordered; the drug(s) and drug classes to be tested; the ordering provider's signature, date, and individual provider identification number (PIN). If the member's PCP referred the client, the ordering physician must also include the PCP's individual PIN. Copies of test results without the provider's order are not sufficient documentation to support a claim. Independent/reference laboratory documentation must retain the ordering physician's provider information with the member's medical record for the medical necessity audit trail. All components of a requested drug-testing panel must be supported by medical necessity in the provider's documentation; documentation should explain the level of testing requested and include at minimum: phase of treatment (assessment, continuing, maintenance), current level of care (for example, ASAM level), member drug(s) of choice, days since last drug test when results are unexpected, current active symptoms prompting the test and how results will guide the plan of care, prior unexpected results (including recent tests and actions taken), results of any pill counts, and any clinical documentation if the member contests a presumptive result.

Type of test: presumptive or confirmatory
Clinical indication for testing
All current prescribed medications (including OTCs)

Background and Purpose

Drug testing is intended to support individualized clinical care: it assists with diagnosis, monitors adherence to prescribed medications, identifies nonprescribed or illicit substance use, and helps detect diversion in members with substance use disorder or at risk of misuse. The policy emphasizes that testing must be targeted to clinical need and not performed reflexively or to satisfy third‑party or administrative requirements; testing modalities not addressed in the policy (for example, hair or saliva for controlled substance monitoring) are treated as outside the scope and may be denied.

Definitions

MAT — Medication Assisted Treatment (MAT)

DefinitionMedication Assisted Treatment (MAT): Use of medications combined with counseling and behavioral therapies for the treatment of substance use disorders; MAT providers must be licensed in Arkansas and follow SAMHSA guidelines

Provider responsibilitiesMAT providers must perform drug screening, provide case management, coordinate counseling/referrals, document noncompliance, and maintain person-centered service plans

Reimbursement limitationMAT providers will not be reimbursed for prescribing FDA‑approved MAT medications for the practice of pain management

Presumptive vs Confirmatory testing

Presumptive (Qualitative) TestInitial screening tests to determine the presence of substances; may produce unexpected results and have cross-reactivity considerations

Confirmatory (Definitive/Quantitative) Test

Level of Care Criteria for MAT/OTP/Outpatient SUD Services

Treatment Modalities and Testing

MAT

Medication Assisted Treatment requirements: MAT providers must be licensed in Arkansas and follow SAMHSA guidelines; MAT requires drug screening accompanying proper medication prescribing, performance of case management, coordination of counseling/referrals or documented plans for integrated follow-up, documentation of noncompliance, and prohibition on reimbursement for prescribing MAT medications for pain management.

see chunks 6 and 4

Visit Frequency and Testing Limits

random UDTs for OTP maintenance — 8

Random UDTs per year (OTP maintenance)8 random UDTs per year (federal OTP maintenance requirement)

Short-term detoxificationOne initial UDT per member for short-term detoxification

Long-term detoxificationInitial and monthly random UDT(s) for long-term detoxification

follow-up MAT office visit with drug testing — 1 (per month, first year)

Follow-up MAT office visit (first year)At least one (1) follow-up MAT office visit per month with drug testing at each monthly visit during the first year

DocumentationVisits must include medication and treatment management and regular outreach to assist access to resources

Documentation Required

Testing frequency expectations

Testing frequency expectations: Drug testing must be individualized to the member based on the member's drug(s) of choice, clinical presentation, prescribed medications, and regional drug trends. Frequency is typically higher early in treatment or during tapering and should decrease as the member stabilizes. For MAT specifically, initial and early phases require more frequent testing: at least monthly follow-up with drug testing during the first year of continuing treatment, and quarterly drug testing during maintenance (subsequent years) with at least one follow-up MAT office visit quarterly. In opioid treatment programs (OTP), federal regulations require an initial toxicology plus eight random UDT screens per year for maintenance treatment; short-term detoxification typically requires one initial UDT; long-term detoxification requires an initial and monthly random UDT. Randomized schedules are preferred over fixed intervals to reduce predictability; providers should consider detection windows and potential cross-reactivity when selecting test frequency and analytes. Testing should be the lowest level necessary to inform treatment and prompt interventions when indicated.

Individualize frequency to member's history, prescribed meds, reported drugs of choice, and regional trends
More frequent testing early in treatment or during tapering; taper as member stabilizes
First year MAT: at least one follow-up visit per month with drug testing each month
Maintenance MAT: at least one follow-up visit quarterly with drug testing each quarter
OTP maintenance: initial toxicology plus 8 random UDTs/year
Short-term detox: one initial UDT; long-term detox: initial + monthly random UDTs
Prefer random-interval testing to fixed-interval schedules
Consider detection windows and cross-reactivity when planning testing