ModifiedclearhealthalliancePolicy 8A-8

NC Medicaid Ambulatory Withdrawal Management With Extended On-Site Monitoring

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Defines NC Medicaid coverage, eligibility, and clinical criteria for Ambulatory Withdrawal Management with Extended On-Site Monitoring (ASAM Level 2 WM) for beneficiaries receiving services in a licensed outpatient setting.

Policy Summary

Payerclearhealthalliance

PolicyNC Medicaid Ambulatory Withdrawal Management With Extended On-Site Monitoring

Policy CodePolicy 8A-8

Change TypeMultiple material revisions and clarifications (admission criteria, assessment timeframe, provider accreditation, tribal equivalence)

Effective Date

Last ReviewJan 1, 2025

Next Review Date

Key ActionComplete a comprehensive clinical assessment within 3 calendar days of admission to determine ASAM level of care for discharge planning.

SourceLink

POLICY UPDATE CHANGES

Ambulatory Withdrawal Management with Extended On-Site Monitoring services must meet ASAM Level 2 WM admission criteria as defined in the ASAM Criteria, Third Edition, 2013.

Within three calendar days of admission, a comprehensive clinical assessment must be completed by a licensed professional to determine an ASAM level of care for discharge planning.

A beneficiary can receive the service from only one provider organization during any episode of care, and services may not be provided the same day as other SUD Withdrawal Management or Residential Services except on day of admission or discharge.

Providers must achieve national accreditation within one year of enrollment with NC Medicaid from a designated accrediting agency.

Policy language was updated to add federal Tribal equivalence or allowances in multiple provider qualification and documentation sections.

Removed utilization management language referencing prior approval and similar terms to comply with federal parity rules.

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ModifiedclearhealthalliancePolicy 8A-8

NC Medicaid Ambulatory Withdrawal Management With Extended On-Site Monitoring

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Policy Summary

Payerclearhealthalliance

PolicyNC Medicaid Ambulatory Withdrawal Management With Extended On-Site Monitoring

Policy CodePolicy 8A-8

Change TypeMultiple material revisions and clarifications (admission criteria, assessment timeframe, provider accreditation, tribal equivalence)

Effective Date

Last ReviewJan 1, 2025

Next Review Date

Key ActionComplete a comprehensive clinical assessment within 3 calendar days of admission to determine ASAM level of care for discharge planning.

SourceLink

POLICY UPDATE CHANGES

Ambulatory Withdrawal Management with Extended On-Site Monitoring services must meet ASAM Level 2 WM admission criteria as defined in the ASAM Criteria, Third Edition, 2013.

Within three calendar days of admission, a comprehensive clinical assessment must be completed by a licensed professional to determine an ASAM level of care for discharge planning.

Providers must achieve national accreditation within one year of enrollment with NC Medicaid from a designated accrediting agency.

Policy language was updated to add federal Tribal equivalence or allowances in multiple provider qualification and documentation sections.

Removed utilization management language referencing prior approval and similar terms to comply with federal parity rules.

Coverage Criteria for Ambulatory Withdrawal Management (ASAM Level 2 WM)

Specific Criteria Covered by Medicaid

Covered when ALL of the following are met

Diagnosis: Beneficiary has a substance use disorder (SUD) diagnosis as defined by the DSM-5 or subsequent editions.

DSM-5 required diagnostic reference.

ASAM admission criteria: Beneficiary meets ASAM Level 2 WM Ambulatory Withdrawal Management with Extended On-Site Monitoring admission criteria as defined in the ASAM Criteria, Third Edition (2013).

ASAM Level 2 WM applies for moderate withdrawal risk, without severe complications.

General Criteria Covered

Covered when ALL of the following are met

Individualized care: Procedure, product, or service is individualized, specific, consistent with symptoms or confirmed diagnosis, and not in excess of the beneficiary's needs.

Safety and effectiveness: Can be safely furnished and no equally effective and more conservative or less costly treatment is available statewide.

Not for convenience: Service is not primarily for the convenience of the beneficiary, caretaker, or provider.

Specific Criteria Covered by Medicaid

Covered when ALL of the following are met

Medicaid Specific Coverage Criteria: Beneficiary has a SUD diagnosis per DSM-5; and meets ASAM Level 2 WM Ambulatory Withdrawal Management with Extended On-Site Monitoring admission criteria as defined in ASAM Criteria, Third Edition, 2013.

Admission Criteria

Admission and assessment requirements

Admission assessment: Initial abbreviated assessment and physical exam by physician or physician extender at admission (pregnancy test as indicated); within 3 calendar days a comprehensive clinical assessment by a licensed professional must be completed to determine an ASAM level of care for discharge planning.3 days

Initial abbreviated assessment may be billed with Evaluation and Management codes separately.

Continued Stay and Discharge Criteria

Continued stay and discharge logic

Continued stay criteria: Continued stay if ANY: withdrawal symptoms have not been sufficiently resolved to discharge to a lower level of care or safe management in a less intensive environment; OR CIWA-Ar or other comparable standardized scoring has not increased or decreased.

Discharge criteria: Discharge if ANY: withdrawal signs and symptoms are sufficiently resolved for participation in self-directed recovery or ongoing treatment without further medical/nursing withdrawal management; OR signs/symptoms have failed to respond and intensified indicating need for transfer to a higher level of care; OR beneficiary is unable to complete Level 2 WM requiring more intensive services; OR beneficiary or legally responsible person requests discharge.

Not Covered Criteria

Not covered general and specific

General not covered: Not covered when ANY: beneficiary does not meet eligibility requirements in Section 2.0; beneficiary does not meet the criteria in Section 3.0; the procedure/product/service duplicates another provider's procedure/product/service; OR the procedure/product/service is experimental, investigational, or part of a clinical trial.

Specific not covered activities: Medicaid shall not cover activities including: transportation for beneficiary or family members; habilitation activities; recreational activities unless tied to planned social skill assistance; clinical/administrative supervision of two WM staff (covered as indirect cost); services not rendered; childcare or substitute caregiving; services teaching academic subjects or as substitute for education personnel; interventions not on the beneficiary's service plan; services to family members for problems not directly related to the beneficiary's needs; and payment for room and board.

Amended Date: January 1, 2025.

Program Requirements / Required Components

Service must include ALL of the following program components:

Program Required Components: Comprehensive clinical assessment within 3 calendar days of admission; initial assessment including addiction-focused history and physical exam (pregnancy test if indicated) at admission by physician or physician extender; nursing evaluation upon admission; individualized service plan; daily assessment of progress during withdrawal management and any treatment changes; on-site monitoring based on documented withdrawal severity and medical status; ability to conduct or arrange laboratory and toxicology tests (point-of-care allowed); beneficiary education on prescribed medications, interactions and side effects; medically necessary clinical services including individual therapy; involvement of family/significant others with informed consent; availability of specialized psychological/psychiatric consultation and supervision as indicated; crisis interventions when clinically necessary; 24-hour access to emergency medical consultation services; assistance accessing transportation if beneficiary lacks safe transportation; linkage and coordination with care management; affiliation with other ASAM levels of care for referrals; and discharge planning beginning at admission.

From Program Requirements (Section 6.3) and service description.

Staffing and Credentialing Requirements

Providers and staff must meet ALL of the following qualifications:

Provider enrollment and facility: Provider must meet Medicaid participation qualifications, have a signed DHHS Provider Administrative Participation Agreement, bill only within their licensed scope of practice, be credentialed and contracted by the DHHS designated contractor, become legally constituted to meet Provider Certification Medicaid Enrollment Agreement requirements, and provide services in a facility licensed under 10A NCAC 27G .3300 Outpatient Detoxification or a federal Tribal equivalent.

Section 6.0 and 6.1

Accreditation: Provider organization must achieve national accreditation with at least one designated accrediting agency within one year of enrollment as an NC Medicaid provider.within 1 year of enrollment

Section 6.1

Medical Director qualifications and responsibilities: Medical Director must be a licensed physician in good standing with the NC Medical Board, have at least one year of SUD treatment experience, be available for 24/7 emergency medical consultation (in-person or virtual), perform admission history and physical, determine SUD diagnosis per program eligibility, monitor the CSRS, develop service plans, evaluate withdrawal management methods, and monitor intoxication/withdrawal signs and symptoms.

None Apply.

Medicaid shall not cover the following activities: transportation for the beneficiary or family members; any habilitation activities; time spent in recreational activities unless tied to a planned social skill assistance activity; clinical and administrative supervision of two WM staff (covered as an indirect cost and part of the rate); services not rendered; childcare or substitute caregiving; services that substitute for education personnel or teach academic subjects; interventions not identified on the beneficiary's service plan; services to family members for problems not directly related to the beneficiary's needs; and payment for room and board.

Policy language referencing prior approvals, authorizations, reauthorizations, concurrent authorization, and other utilization management terms has been removed to comply with the Mental Health Parity and Addiction Equity Act and 42 CFR § 438.900; providers should follow current NC Medicaid guidance for any authorization requirements.

North Carolina Medicaid will not reimburse for conversion therapy.

Services are not covered when the beneficiary does not meet eligibility requirements in Section 2.0, does not meet the criteria in Section 3.0, when the procedure duplicates another provider's service, or when the procedure, product, or service is experimental, investigational, or part of a clinical trial. Specific exclusions also include the items listed under Section 4.2 (see exclusions for transportation, habilitation, childcare, unrendered services, room and board, and related items).

This document fragment does not list additional explicit 'not medically necessary' conditions beyond the general not-covered criteria in Section 4.1 (ineligibility, failure to meet Section 3.0 criteria, duplicate services, or experimental/ trial services). Historical edits noted removal of utilization management language but do not introduce new 'not medically necessary' items in this fragment.

Coding, Billing Codes, and Operational Key Data

Covered/Separate-billed servicesmixedCovered

Evaluation and Management CPT codes	Evaluation and Management CPT codes billed separately from the Ambulatory Withdrawal Management service
Comprehensive clinical assessment CPT codes	Comprehensive clinical assessment CPT codes billed separate from Ambulatory Withdrawal Management service
Individual therapy CPT codes	Individual therapy CPT codes billed separate from Ambulatory Withdrawal Management service
Laboratory and toxicology test codes (point-of-care allowable)	Laboratory and toxicology test codes (point-of-care allowable) billed separate from Ambulatory Withdrawal Management service

Covered HCPCS / H-codeHCPCSCovered

H0014 HF

H0014 HF, Billing Unit = 1 Unit = 15 Minutes.

Unlisted procedure or service guidancemixed

unlisted CPT/HCPCS

Use appropriate unlisted procedure or service code with special report when no specific CPT/HCPCS code exists; follow current CPT/HCPCS instructions for unlisted procedures and special report.

inv-18: Comprehensive clinical assessment timeframe — Within 3 calendar days of admission

RequirementComprehensive clinical assessment must be completed by a licensed professional within 3 calendar days of admission to determine ASAM level of care for discharge planning.

Related admission stepInitial abbreviated assessment and physical exam by physician or physician extender occurs at admission; information from that assessment is used in the comprehensive assessment.

Documentation noteRelevant diagnostic information obtained must be included in the treatment or service plan.

inv-19: Service order validity — Valid for 12 months

Validity periodA signed service order is valid for twelve (12) months.

Provider Responsibilities, Billing, and Documentation

Prior Authorization

EPSDT does not remove prior approval — follow NCTracks

If the service requires prior approval, EPSDT does not remove that requirement; providers must follow NCTracks guidance for prior approval when EPSDT is claimed. See NCTracks Provider Claims and Billing Assistance Guide and the EPSDT provider page for instructions.

EPSDT does not waive prior approval if the service requires prior approval.
Follow NCTracks Provider Claims and Billing Assistance Guide for prior approval procedures.

Prior Authorization

No prior approval required for this service

Medicaid shall not require prior approval for Ambulatory Withdrawal Management with Extended On‑site Monitoring; providers may proceed without submitting prior approval for this service per policy.

Prior Authorization

Background and Scope

Ambulatory Withdrawal Management with Extended On‑Site Monitoring (ASAM Level 2 WM) is an organized outpatient service providing medically supervised evaluation, withdrawal management, and referral services for beneficiaries at moderate risk of severe withdrawal who do not have severe physical or psychiatric complications. The service model includes an initial abbreviated assessment and physical exam at admission, nursing evaluation, daily monitoring of withdrawal signs and symptoms, on‑site monitoring guided by documented withdrawal severity, linkage to other ASAM levels of care, and discharge planning initiated at admission. The objective is a safe, comfortable withdrawal and timely transition to ongoing treatment.

Key Definitions

inv-39: CIWA-Ar — Clinical Institute Withdrawal Assessment of Alcohol Scale definition

DefinitionCIWA-Ar is a tool to assess an individual's alcohol withdrawal.

Use caseUsed to monitor severity of alcohol withdrawal signs and symptoms to inform continued stay or need for higher level of care.

Policy contextImprovement in CIWA‑Ar or comparable scoring is referenced in continued stay and discharge criteria.

inv-40: ASAM Criteria, Third Edition — definition and use

DefinitionThe ASAM Criteria, Third Edition is a comprehensive set of treatment standards using six dimensions for a biopsychosocial assessment and service planning for addictive, substance-related, and co-occurring conditions.

Role in policyASAM Criteria, Third Edition (2013) defines admission criteria for ASAM Level 2 WM used to determine coverage for Ambulatory Withdrawal Management with Extended On‑Site Monitoring.

Policy Revision History

2025-01-01RevisionLatest

Multiple substantive updates effective Jan 1, 2025: added comprehensive clinical assessment timing in Admission Criteria (3.2.3), clarified Tribal/IHS equivalence in provider qualifications and documentation, replaced 'active authorization period' with 'episode of care' in utilization management, and removed utilization management language referencing prior approvals to comply with Mental Health Parity regulations.

2024-10-01Original implementation

Policy 8A-8 initial implementation and publication of All Sections as the Ambulatory Withdrawal Management with Extended On-Site Monitoring coverage policy.

Policy Summary

Payerclearhealthalliance

PolicyNC Medicaid Ambulatory Withdrawal Management With Extended On-Site Monitoring

Policy CodePolicy 8A-8

Change TypeMultiple material revisions and clarifications (admission criteria, assessment timeframe, provider accreditation, tribal equivalence)

Effective Date

Last ReviewJan 1, 2025

Next Review Date

Key ActionComplete a comprehensive clinical assessment within 3 calendar days of admission to determine ASAM level of care for discharge planning.

SourceLink

On This Page

Physician extenders: Physician assistant or nurse practitioner in good standing with relevant board, with at least one year of SUD treatment experience; may evaluate, prescribe, and monitor medications, order labs/toxicology, provide education, coordinate care, perform admission assessments, monitor CSRS, develop service plans, and provide 24/7 emergency consultation coverage when delegated.

Section 6.2

Nursing staff: Registered nurses and licensed practical nurses in good standing with the NC Board of Nursing responsible for nursing evaluation on admission, monitoring CSRS when delegated, daily assessments during withdrawal management, monitoring signs and symptoms, preparing and dispensing medication with inventory records, and documenting nursing activities per state regulations.

Section 6.2

Clinical staff (LCAS/LCAS-A): Licensed Clinical Addictions Specialists (LCAS/LCAS-A) in good standing responsible for substance use–focused assessment, ASAM level determination, development and implementation of individualized person-centered service plans, ongoing assessment and reassessment, individual therapy, crisis interventions, involving family/significant others with consent, education, referrals, and required documentation.

Section 6.2

inv-20: Facility hours of operation — Minimum 8 hours/day Monday–Friday; minimum 4 hours/day Saturday–Sunday

Minimum weekday hoursFacility must be in operation a minimum of 8 hours per day, Monday through Friday.

Minimum weekend hoursFacility must be in operation a minimum of 4 hours per day on Saturday and Sunday.

Availability and staffingService must be available for admission seven days per week and program medical staff shall be available to provide 24-hour access for emergency medical consultation (in-person or virtual).

Language referencing prior approvals, authorizations, and utilization management has been removed to comply with Mental Health Parity regulations; providers should follow current NC Medicaid guidance (e.g., NCTracks) for any authorization-related instructions.

References to prior approval/authorization and utilization management were removed to comply with 42 CFR § 438.900 and MHPAEA.
Follow current NC Medicaid/NCTracks guidance for any remaining authorization requirements.

Billing Rule

Submit claims as Professional (CMS‑1500/837P)

Claims for Ambulatory Withdrawal Management with Extended On‑Site Monitoring must be submitted as professional claims using CMS‑1500/837P transaction format; the policy does not provide specific prior authorization submission instructions.

Claim type: Professional (CMS-1500/837P).
Follow NCTracks Provider Claims and Billing Assistance Guide and Medicaid bulletins for submission details.

Step Therapy

Conservative treatment and medical necessity requirement

Services must be individualized, medically necessary, consistent with the beneficiary's diagnosis and needs, and provided only when no equally effective, more conservative, or less costly statewide alternative is available.

Procedure, product, or service must be individualized and not in excess of the beneficiary's needs.
Must be safe and no equally effective, more conservative, or less costly statewide treatment should be available.

Step Therapy

One provider per episode; same‑day limits with other SUD services

A beneficiary may receive this service from only one provider organization during any episode of care; these services may not be provided the same day as other SUD Withdrawal Management or Residential Services except on day of admission or discharge.

One provider organization per episode of care.
Not allowed same day with other SUD withdrawal/residential services except admission or discharge day.

Note

—

(No additional provider action specified in source.)

Billing Rule

Code specificity and use of unlisted codes

Providers must report the most specific billing code that accurately describes the service and use current CPT/HCPCS/ICD editions; if no specific code exists use an appropriate unlisted procedure/service code with special report.

Report CPT/HCPCS and ICD-10-CM/PCS codes to the highest level of specificity and use the current editions.
If no specific code exists, report using the appropriate unlisted procedure or service code.

Prior Authorization

EPSDT and prior approval — under‑21 beneficiaries

When EPSDT is claimed for a beneficiary under 21, prior approval requirements still apply if the service requires prior approval; providers must consult NCTracks for EPSDT prior approval procedures.

EPSDT does not eliminate prior approval requirements.
Refer to NCTracks Provider Claims and Billing Assistance Guide and EPSDT provider page for details.

Documentation Required

Required clinical and medication documentation

Maintain complete service records documenting the nature and course of the beneficiary's progress; documentation must meet the DHHS Records Management and Documentation Manual and MAR/eMAR must meet 10A NCAC 27G .0209(c)(4) or tribal equivalent.

Service notes must satisfy DHHS Records Management and Documentation Manual requirements.
Medication administration records (MAR/eMAR) must meet 10A NCAC 27G .0209(c)(4) or federally recognized tribal equivalent.

Documentation Required

Signed service order required (valid 12 months; no backdating)

A signed service order by a physician, physician assistant, or nurse practitioner is required, must be signed and dated, cannot be backdated, is valid for 12 months, and must be in place on or before the first day the service is provided to bill Medicaid.

Service order must be completed and signed by physician/PA/NP.
Service order validity: 12 months and cannot be backdated; must be in place prior to or on first service day.

Billing Rule

Follow NCTracks guides and report codes to highest specificity

Follow the NCTracks Provider Claims and Billing Assistance Guide, Medicaid bulletins, fee schedules, and NC Medicaid clinical coverage policies when filing claims; report ICD-10-CM/PCS and procedure codes to the highest specificity supporting medical necessity and retain documentation of training and service records.

Follow NCTracks Provider Claims and Billing Assistance Guide and Medicaid bulletins for claims procedures.
Report ICD-10-CM/PCS and procedural codes to the highest level of specificity that supports medical necessity.

Billing Rule

Report ICD-10 and procedure codes to highest specificity and edition

Report ICD-10-CM/PCS and CPT/HCPCS procedure codes to the highest level of specificity that supports medical necessity and use the current code editions in effect at time of service.

Use current ICD-10 and CPT/HCPCS editions at time of service.
Report the most specific CPT/HCPCS or, if none exists, an appropriate unlisted code.

Note

Verify Medicaid enrollment and eligibility before service delivery

Verify each beneficiary's NC Medicaid enrollment and eligibility prior to delivering services; beneficiaries not enrolled or not eligible under their category may be ineligible for coverage.

Providers shall verify eligibility each time a service is rendered.
A beneficiary may have service restrictions by eligibility category that make them ineligible for this service.

Denial Risk

Denial triggers: eligibility, criteria, duplicates, experimental services

Coverage will be denied if the beneficiary is not enrolled or eligible, does not meet the criteria in Section 3.0, receives duplicate services, or if the procedure is experimental/investigational or part of a clinical trial.

Denial triggers include failure to meet Section 2.0 eligibility or Section 3.0 criteria.
Duplicate services or experimental/clinical trial procedures are not covered.

Denial Risk

Noncompliance may cause denials or recoupment

Noncompliance with NC Medicaid clinical coverage policies, NCTracks/manuals, or applicable laws/regulations (including 42 CFR Part 2) may result in claim denials, nonpayment, or recoupment.

Noncompliance with policies, manuals, or laws/regulations may lead to denial or recoupment.
Includes confidentiality/regulatory requirements such as 42 CFR Part 2.

Denial Risk

Coding specificity — risk of denials for nonspecific codes

Failure to report the most specific billing code that accurately and completely describes the service may trigger claim denials; providers must use current CPT/HCPCS and UB‑04/ICD guidance when coding.

Report the most specific billing code that accurately describes the procedure.
Use Current Procedural Terminology (CPT), HCPCS, and UB‑04 Data Specifications Manual and current editions.

Six dimensionsAcute intoxication/withdrawal potential; biomedical conditions; emotional/behavioral/cognitive conditions; readiness to change; relapse/continued use potential; recovery and living environment.

inv-41: Substance Use Disorder (SUD) diagnosis — Requirement per DSM-5 or subsequent editions

RequirementBeneficiary must have a substance use disorder (SUD) diagnosis as defined by the DSM‑5 or any subsequent editions to qualify for coverage.

DocumentationDiagnosis per DSM‑5 must be documented as part of eligibility and coverage criteria.

Policy linkageSUD diagnosis is a required element of the Specific Criteria Covered by Medicaid for ASAM Level 2 WM services.

inv-42: ASAM Level 2 WM — Admission must meet ASAM Level 2 WM criteria definition

Admission criteriaAdmission must meet ASAM Level 2 WM (Ambulatory Withdrawal Management with Extended On‑Site Monitoring) admission criteria as defined in the ASAM Criteria, Third Edition (2013).

Clinical profileApplies to beneficiaries at moderate risk of severe withdrawal who are free of severe physical or psychiatric complications and require medically supervised outpatient withdrawal management with on‑site monitoring and linkage to other care levels.

Use for discharge planningASAM level determined via comprehensive clinical assessment completed within 3 calendar days is used for discharge planning and level‑of‑care decisions.

inv-43: Ambulatory Withdrawal Management with Extended On‑Site Monitoring — service definition

Service definitionAn organized outpatient service provided by trained clinicians offering medically supervised evaluations, withdrawal management, on‑site monitoring based on documented severity, and referral/linkage to other ASAM levels of care.

Required componentsIncludes admission assessments, nursing evaluation, individualized service plan, daily assessments, lab/toxicology testing capability (point-of-care allowed), education, individual therapy as indicated, crisis interventions, 24‑hour emergency medical consultation access, and discharge planning beginning at admission.

Operational noteServices are delivered in regularly scheduled sessions under defined policies/protocols and must be available for admission seven days per week.

inv-44: Place of Service — Outpatient licensed facility

Place of serviceOutpatient licensed facility.

Policy referencePlace of service is identified in Section 6.0 (Provider(s) Eligible to Bill) and must be an outpatient licensed facility as defined in the policy.

Facility operationsFacility must meet hours of operation and staffing requirements (minimum daily hours, 24‑hour access to emergency consultation) to provide the service.