CurrentCareSourcePolicy N/A

Drug testing for substance use disorder (SUD) and MAT monitoring

Defines medical necessity, documentation, billing, and clinical use of presumptive and confirmatory drug testing for Arkansas Medicaid members in PASSE, including requirements for providers delivering medication assisted treatment (MAT). Affects Arkansas-licensed MAT providers and laboratories billing Medicaid.

Policy Summary

PayerCareSource

PolicyDrug testing for substance use disorder (SUD) and MAT monitoring

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2024

Next Review DateJul 17, 2024

Key ActionUse presumptive testing first and document clinical necessity for any definitive/confirmatory tests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$500annual lab review trigger (≥21)

8min OTP random UDTs/year

one code per datepresumptive CPT billing

initial + monthlylong-term detox UDTs

Coverage Criteria

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General medical necessity: Drug testing is medically necessary when ordered as part of initial assessment, ongoing monitoring, or recovery for substance use disorder (SUD) and when results will guide clinical care; testing must be justified by the member's clinical condition and the ordering provider's need for information.

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Preferred test types: Presumptive (qualitative) testing is encouraged as clinically appropriate; definitive/confirmatory testing is authorized when presumptive results are insufficient or to detect specific opioids/metabolites not identified by presumptive UDTs, with documentation supporting necessity.

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Use in treatment phases: Testing frequency should be higher early in treatment or during tapering and may decrease as member stabilizes; obtain an individualized baseline UDT prior to initiation or in early recovery; testing in OTPs requires initial toxicology plus 8 random UDTs per year; long-term detoxification requires initial plus monthly random UDTs; short-term detoxification requires an initial UDT.

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Not medically necessary

Tests considered not medically necessary / excluded

Not medically necessary conditions: Reflexive, routine, non-individualized, large arbitrary panels, testing required solely by third parties (e.g., pre-employment, court-ordered, school, military), forensic or administrative testing, blood testing outside the ED, hair/saliva/other body fluid testing for controlled substance monitoring, routine definitive testing following a negative presumptive result, and any testing without documentation of medical necessity are not medically necessary.

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Testing that is required by third parties is not covered. Examples include testing done for pre-employment purposes, court-ordered or other forensic/medico-legal testing (such as child custody), testing required by schools, athletics, or military service, testing required by a primary payor (county/state/federal agency), conditions of residence in facilities (for example, sober living or residential treatment), and other administrative purposes (for example, testing tied to a marriage license).

Also excluded are routine physical or medical examination testing and physician health program testing. In short, any testing that is mandated by a third party or performed for forensic/administrative purposes is considered not medically necessary and is excluded from coverage.

The policy excludes several categories of testing as not medically necessary. These include reflexive, routine, standard, or preprinted orders and testing that is not individualized (for example, ordering all assays available on a machine without clinical justification).

Large arbitrary or universal panels, routine use of definitive (confirmatory) testing immediately after a negative presumptive screen, and testing of hair, saliva, or other body fluids for controlled substance monitoring are specifically listed as non-covered. Blood drug testing performed outside the emergency department is also considered not medically necessary under this policy.

Coding and Billing

Presumptive drug testing CPT codesCPTCovered

80305	Drug testing, presumptive, any number of drug classes; performed by laboratory
80307	Drug testing, presumptive, definitive level (alternate code grouped in policy)

inv-06: Annual lab services review trigger — $500 per calendar year for members ≥21

Trigger amount>$500 per calendar year for laboratory services for members age ≥21

Applies toParticipating/In-Network providers (review of medical necessity required)

ExemptionLaboratory codes billed with appropriate MAT modifiers for opioid use disorder are excluded from the $500 review trigger

Reference guidanceSee Physician/Independent Lab/CRNA/Radiation Therapy Center Provider Manual (Arkansas DHS) for additional billing instructions

Provider Actions and Requirements

Prior Authorization

Medical necessity review threshold for labs

A review of medical necessity is required after laboratory services billed by in-network providers reach $500 per calendar year unless tests are billed with appropriate modifiers indicating MAT for opioid use disorder.

Threshold: $500 per calendar year for all laboratory services (in-network)
Exceptions: Tests billed with MAT-for-opioid-use-disorder modifiers

Note

Preferred testing sequence

Providers are encouraged to use presumptive drug testing methods as the first-line (preferred) approach when clinically appropriate. Confirmatory or definitive testing should be ordered only when indicated by unexpected presumptive results, to detect metabolites or specific opioids not identified by presumptive urine drug tests, or when results will materially affect clinical management. Do not perform routine definitive testing after a negative presumptive result or before discussing presumptive results with the member.

Preferred sequence: presumptive (initial) → confirmatory/definitive (when indicated)
Definitive testing use cases: unexpected results, unidentified specific opioids, or when clinical management requires metabolite-level analysis
Avoid routine definitive testing following negative presumptive tests

Documentation Required

Required clinical and order documentation

Orders and clinical records must document the medical necessity for all components of drug testing. At minimum, drug test orders and supporting documentation must include: type of test requested (presumptive or confirmatory) and drugs/drug classes to be tested; diagnosis (ICD-10) and pertinent supplemental diagnoses; clinical indication and phase of treatment; current prescribed medications (including OTC and illicit drugs of concern); days since last drug test with unexpected results history; member's current symptoms and how results will guide care; medications list; provider actions taken on recent unexpected results; results of pill counts if performed; service dates; and the physician's signed order with provider identification number(s). Copies of test results alone are insufficient. Reference facilities must retain the ordering physician's provider information in the member record for audit purposes.

Minimum order elements: test type, drugs/drug classes, ICD-10 diagnosis, clinical indication, signature and date of qualified provider, ordering physician PIN (and PCP PIN when applicable)
Documentation must include: H&P/assessment, phase of treatment, current medications, days since last unexpected result, member symptoms, plan for how results will guide care
All records pertinent to billing and test results must be retained; copies of results without the provider order do not support medical necessity

Denial Risk

Triggers for denial / Not medically necessary testing

The following testing practices are considered not medically necessary and may result in denial or recovery of payments: non-individualized or reflexive testing (routine, standard, or preprinted orders), large arbitrary panels or universal testing, testing solely because a machine can run the test, third-party–required testing (employment, school, legal, administrative, forensic, custody, licensure), routine definitive testing after negative presumptive results, blood testing outside of an ED without documented necessity, and testing types not addressed in this policy (including hair, saliva, or other fluids for controlled-substance monitoring) without documentation. Providers billing for testing are responsible for ensuring adherence to these limitations and for maintaining documentation for post-payment review and audits.

Examples of not medically necessary testing: reflexive/routine orders; large/arbitrary panels; universal or non-individualized testing
Third-party mandated testing not covered: pre-employment, random employment testing, school/athletics/military, court-ordered (except ED/forensic as clinically indicated), marriage license or administrative testing, physician health program screening
Other exclusions: routine definitive testing following a negative presumptive result; blood testing outside ED without justification; hair/saliva/other body fluid tests for controlled-substance monitoring without documented necessity

Background

Drug testing is an integral part of care for members with substance use disorder (SUD), supporting initial assessment, ongoing monitoring, and recovery. It is used to confirm medication adherence, to detect nonprescribed or illicit drug use, and to identify potential diversion when clinically indicated.

The policy emphasizes using presumptive (qualitative) testing first as the preferred method for screening, with definitive/confirmatory testing reserved for situations where presumptive results are insufficient, when specific opioids or metabolites need detection, or when documentation supports clinical necessity. Testing frequency should be individualized: more frequent screening is expected early in treatment or during tapering, with frequency reduced as a member stabilizes. Specific program requirements include obtaining a baseline individualized UDT prior to initiation and, for Opioid Treatment Programs (OTP), an initial toxicology plus 8 random UDTs per year.

Definitions

inv-12: Presumptive (Qualitative) Test

DefinitionPresumptive (Qualitative) Test: testing to determine the presence or absence of a drug or drug class; commonly used for rapid screening.

Common useUsed as initial/rapid screening in clinical settings to guide further testing

Billing notePresumptive drug testing CPT codes include 80305 and 80307 and may be billed one code per date of service

inv-13: Definitive (Confirmatory/Quantitative) Test

DefinitionDefinitive (Confirmatory/Quantitative) Test: a test determining the amount of a substance per unit volume or unit weight of specific drugs or metabolites; more specific and used to refine presumptive results.

Use caseAuthorized when presumptive tests are insufficient or to detect specific opioids/metabolites not identified by presumptive UDTs; documentation must support necessity

Clinical implicationDefinitive testing should be justified in the medical record prior to ordering following a presumptive test

inv-14: Medication Assisted Treatment (MAT) definition

DefinitionMedication Assisted Treatment (MAT): use of FDA‑approved medications in conjunction with counseling and behavioral therapies to treat substance use disorder.

Provider requirementsMAT providers must be licensed in Arkansas and follow SAMHSA guidelines at minimum; perform screening tests and initial evaluations including labs for communicable diseases, consent, treatment agreement, and PCSP.

Follow-upDuring continuing treatment (first year) provide at least one MAT office visit per month for medication and treatment management; maintenance may reduce frequency per guidance.

Level of Care Criteria

MAT / OTP / Detoxification — level of care criteria

Level of care criteria for admission, ongoing monitoring, and discharge in MAT/OTP/detoxification settings.

Initial assessment: Obtain history, perform medical and psychological assessment, and obtain an individualized baseline urine drug test (UDT) based on clinical presentation, prescribed medications, self-reported drugs of choice, and regional drug trends; discuss results with the member and agree on a plan of care.

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Continuing treatment (first year): Perform drug testing in conjunction with each monthly visit and have at least one follow-up MAT office visit per month for medication and treatment management.

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Maintenance and OTP specific requirements: Maintenance treatment frequency may decrease as member stabilizes per MAT guidance; federal OTP regulations require initial toxicology plus 8 random UDT screens per year per member.

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Detoxification: Short-term detoxification requires an initial UDT per member; long-term detoxification includes an initial and monthly random UDT(s) per member.

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Treatment Modalities

Medication Assisted Treatment (MAT) — treatment modality criteria

Requirements and expectations for providers delivering Medication Assisted Treatment (MAT).

MAT provider requirements: Providers of MAT must be licensed in Arkansas and authorized to provide services within the Arkansas Medicaid system, follow SAMHSA guidelines at minimum, perform screening tests accompanying prescribing, complete initial evaluation components (including lab screening for communicable diseases, consent forms, treatment agreement, and a person-centered service plan), identify a MAT team member to function as case manager, provide referrals or integrated counseling plans, and perform drug testing as indicated to guide care.

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Testing justification and documentation: Drug test orders must specify test type (presumptive or confirmatory), drug/drug classes to be tested, diagnosis (ICD) and supporting diagnoses, clinical indication, current medications, days since last test with unexpected results history, provider actions taken on unexpected results, and signature/date with ordering provider PIN (and referring PCP PIN if applicable); definitive testing must be clinically meaningful and documented.

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Clinical use of test results: Use test results to inform treatment interventions, medication management, and plans of care; providers should not test for substances when results would not affect clinical management.

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Visit Limits and Monitoring Frequency

inv-17: random urine drug tests for Opioid Treatment Programs (OTP) — minimum required random UDT screens per year

Minimum annual random UDTs for OTP8 random urine drug test screens per year (federal OTP requirement)

Initial requirementInitial toxicology required in OTP prior to ongoing testing

Long-term detoxificationRequires initial plus monthly random UDT(s) per member

Short-term detoxificationRequires an initial UDT per member

Policy Summary

PayerCareSource

PolicyDrug testing for substance use disorder (SUD) and MAT monitoring

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2024

Next Review DateJul 17, 2024

Key ActionUse presumptive testing first and document clinical necessity for any definitive/confirmatory tests.

SourceLink

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