CurrentclearhealthalliancePolicy 8A-12

Substance Abuse Intensive Outpatient (SAIOP)

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This policy governs coverage, eligibility, and clinical criteria for Medicaid-covered Substance Abuse Intensive Outpatient Program (SAIOP) services (ASAM Level 2.1) for adolescents and adults in the NC Medicaid Program and applies to providers billing Medicaid.

Policy Summary

Payerclearhealthalliance

PolicySubstance Abuse Intensive Outpatient (SAIOP)

Policy CodePolicy 8A-12

Change TypeNo material changes

Effective Date

Last ReviewJan 1, 2026

Next Review Date

Key ActionComplete a comprehensive clinical assessment (CCA) or diagnostic assessment (DA) by a licensed professional and have a signed service order in place prior to or on the first day of service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

ASAM 2.1Required level of care for admission

Age 18+adult eligibility age threshold

Age 10-17adolescent eligibility age range

9-19 hrs/wkrequired weekly service range (adults)

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CurrentclearhealthalliancePolicy 8A-12

Substance Abuse Intensive Outpatient (SAIOP)

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Policy Summary

Payerclearhealthalliance

PolicySubstance Abuse Intensive Outpatient (SAIOP)

Policy CodePolicy 8A-12

Change TypeNo material changes

Effective Date

Last ReviewJan 1, 2026

Next Review Date

Key ActionComplete a comprehensive clinical assessment (CCA) or diagnostic assessment (DA) by a licensed professional and have a signed service order in place prior to or on the first day of service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

ASAM 2.1Required level of care for admission

Age 18+adult eligibility age threshold

Age 10-17adolescent eligibility age range

9-19 hrs/wkrequired weekly service range (adults)

6-19 hrs/wkrequired weekly service range (adolescents)

>=3 hrs/daybilling unit minimum

Coverage and Medical Necessity Criteria

Initial Coverage Criteria

Covered when ALL of the following are met:

Medicaid enrollment: Beneficiary is enrolled in the NC Medicaid Program and eligible for services.

See eligibility provisions for Medicaid enrollment and retroactive eligibility.

Age and diagnosis: Beneficiary is an adolescent aged 10-17 or an adult aged 18 and older with a primary substance use disorder diagnosis.

Adolescent and adult age ranges and SUD diagnosis requirement per policy.

ASAM level and service intensity: Services are ASAM, Third Edition, Level 2.1 and provide 9-19 hours/week of skilled treatment for adults or 6-19 hours/week for adolescents.9-19 hours (adults); 6-19 hours (adolescents)

Includes individual, group, family counseling, medication management, educational groups, and service coordination tailored to the Person-Centered Plan.

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

Per general criteria for covered services.

Safety and conservativeness: Service can be safely furnished and no equally effective, more conservative, or less costly statewide alternative exists.

Per general criteria for covered services.

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

Per general criteria for covered services.

Initial Admission Criteria

Covered when ALL of the following are met:

General medical necessity: Procedure/product/service is individualized, specific, consistent with symptoms or confirmed diagnosis, not in excess of beneficiary's needs, can be safely furnished, and no equally effective, more conservative or less costly statewide treatment is available; not primarily for convenience.

See General Criteria Covered.

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

DSM-5 SUD diagnostic requirement.

ASAM admission criteria: Beneficiary meets ASAM Level 2.1 SAIOP admission criteria as defined in the ASAM Criteria, Third Edition (2013).

ASAM Level 2.1 admission criteria required.

Assessment and service order:

Continued Stay and Discharge Criteria

Continued stay and discharge decisions — beneficiary meets continued stay if ANY one of the following applies:

Continued stay: (1) Beneficiary has achieved initial PCP goals and requires present level of care to meet additional goals; (2) Beneficiary is making some progress but has not achieved goals yet; (3) Beneficiary is not making progress or is regressing but has the capacity to resolve these problems; (4) Beneficiary is actively working toward goals and the PCP must be modified to identify more effective interventions.

Each of the six ASAM dimensions must be reviewed and documented.

Discharge: Beneficiary meets discharge if: (1) SUD signs and symptoms are resolved such that the beneficiary can participate in self-directed recovery or less intensive treatment; (2) Signs and symptoms have failed to respond and have intensified, indicating transfer to a more intensive level of care; or (3) Beneficiary or legally responsible person requests discharge.

Each of the six ASAM dimensions must be reviewed and documented for discharge decisions.

Coverage Criteria

Covered when program, provider, staffing, and assessment requirements are met

Provider qualifications: Provider must meet Medicaid participation qualifications, have a current signed DHHS Provider Administrative Participation Agreement, bill only within scope of practice, be employed by an organization meeting NC Medicaid provider qualification policies and applicable licensure rules, be credentialed/contracted by DHHS designated contractor, and achieve national accreditation within one year of enrollment.

Providers must be legally constituted and meet enrollment and credentialing requirements.

Licensure and facility: SAIOP services must be provided in a facility licensed under 10A NCAC 27G .4400 SAIOP licensure rules (tribal/IHS exceptions per federal law may apply).

Facility licensure requirement.

Staffing and supervision: Clinical Supervisor must be LCAS, CCS, or CSI, be licensed and in good standing; licensed clinical staff must be LCAS, LCSW, LCMHC, LMFT, or Licensed Psychologist and perform assessment, treatment, and coordination responsibilities; certified clinical staff (CADC, CADC-I, Registrant) must be licensed and coordinate with licensed staff; licensed staff must cover responsibilities when certified staff are unavailable.

Under the federal EPSDT Special Provision (42 U.S.C. § 1396d(r)), coverage limits and other policy restrictions may be exceeded for beneficiaries under age 21 when the provider's documentation demonstrates that the requested service is medically necessary to correct or ameliorate a health problem. Documentation must show how the service meets EPSDT criteria, including improving or maintaining the beneficiary’s health, preventing deterioration, or preventing development of additional health problems.

Services are not covered when the beneficiary fails to meet eligibility in Section 2.0 or the clinical criteria in Section 3.0; when the service duplicates another provider’s procedure, product, or service; or when the service is experimental, investigational, or part of a clinical trial. Specific non-covered activities include transportation, habilitation activities, recreational activities not tied to therapy, clinical/administrative supervision (as indirect cost), unrendered services, childcare, academic instruction, interventions not on the Person-Centered Plan, services to family members for issues not related to the beneficiary, and payment for room and board.

For beneficiaries under age 21, refer to Subsection 2.2.1 (EPSDT Special Provision) for exceptions to policy limitations. That subsection describes when service-level, scope, amount, duration, or frequency limits may be exceeded if provider documentation demonstrates the service is medically necessary to correct or ameliorate a health problem.

North Carolina Medicaid will not reimburse for conversion therapy. Providers must ensure services billed to Medicaid are within covered therapy types and do not include conversion therapy.

Services must be individualized, consistent with the beneficiary’s symptoms or confirmed diagnosis, not in excess of the beneficiary’s needs, and medically necessary. Services must be safely furnished and not primarily for the convenience of the beneficiary, caregiver, or provider; an equally effective, more conservative, or less costly statewide alternative must not be available.

In general, services are not covered when they fail to meet eligibility (Section 2.0) or the policy’s clinical criteria (Section 3.0), duplicate another provider’s service, or are experimental/investigational. Additionally, specific activities are excluded (see Section 4.2) such as transportation, habilitation, recreational activities not tied to therapy, supervision costs, childcare, academic instruction, interventions not on the PCP, services to family members for non-beneficiary issues, unrendered services, and room and board. Services that are not individualized, not consistent with diagnosis, excessive, unsafe, or primarily for convenience are similarly not considered medically necessary.

If provider documentation demonstrates that a proposed service for a beneficiary under 21 meets EPSDT criteria, certain policy limitations may be exceeded; otherwise services remain subject to the policy’s eligibility and clinical criteria. For questions about EPSDT exceptions or documentation standards, follow Subsection 2.2.1 and the general medical necessity requirements in Section 3.0.

Claims Codes, Units, and Billing Rules

Claim Types / Transactionsmixed

CMS-1500/837P	Professional claim transaction
UB-04/837I	Institutional claim transaction

Diagnosis and Procedure Code Systemsmixed

ICD-10-CM	Diagnosis coding to highest level of specificity
PCS	Procedural Coding System reporting to highest level of specificity

Procedure Codes and Unlisted Code Guidancemixed

CPT/HCPCS

Use current CPT and HCPCS; if no specific code exists, report the procedure, product or service using the appropriate unlisted procedure or service code

Coding systems and unlisted procedure guidancemixed

ICD-10-CM/PCS	Report to highest level of specificity using current edition
CPT	Use most specific CPT code; follow current CPT book instructions for Unlisted Procedure or Service and submit required special report
HCPCS	Use most specific HCPCS code; follow current HCPCS instructions for Unlisted Procedure or Service and submit required special report

ModifiersModifier

GT	Modifier to indicate service provided via interactive audio-visual telehealth

Billing unit

Billing unit definition1 unit = 1 event per day (minimum of 3 hours)

Unit granularityBilling reported per daily event rather than per hour or per session

Code source guidanceUse CPT/HCPCS/UB-04 Data Specifications to determine appropriate billing code that defines the unit

SAIOP billing unit minimum

SAIOP billing unit minimumSAIOP service is billed as a minimum three (3) hour event per day; 1 unit = 1 event/day (minimum 3 hours)

Authorization alignment

Provider Requirements, Documentation, and Billing Actions

Prior Authorization

Prior approval applies for beneficiaries under 21

If the service requires prior approval under this policy, that prior approval requirement still applies for beneficiaries under 21 years of age; the beneficiary's age does not waive prior approval.

Prior Authorization

No prior authorization required for SAIOP

Medicaid shall not require prior approval for SAIOP services; providers do not need to obtain prior authorization for SAIOP.

Billing Rule

Program Background

SAIOP (ASAM Level 2.1) is an intensive outpatient program for individuals with a primary substance use disorder that delivers individualized treatment including individual, group, and family counseling, medication management (including MAT), education, and service coordination tailored to a Person-Centered Plan. The program requires a comprehensive clinical assessment or diagnostic assessment by a licensed professional prior to service and meets specified staffing, scheduling, and program requirements to achieve the required weekly treatment intensity.

Key Definitions

ASAM Criteria, Third Edition — definition and role in assessment/service planning

DefinitionThe ASAM Criteria, Third Edition is a comprehensive set of treatment standards using six dimensions to create a holistic biopsychosocial assessment for service planning.

Six dimensionsAcute Intoxication/Withdrawal; Biomedical Conditions; Emotional/Behavioral/Cognitive Conditions; Readiness to Change; Relapse/Continued Use Potential; Recovery and Living Environment.

Role in SAIOPUsed to determine Level 2.1 admission eligibility and to guide individualized service planning and treatment intensity.

Medication Assisted Treatment (MAT) — definition

DefinitionMedication Assisted Treatment (MAT) is the use of FDA‑approved medications combined with counseling and behavioral therapies to provide a whole‑patient approach to treating substance use disorders.

Clinical tailoring

Policy Summary

Payerclearhealthalliance

PolicySubstance Abuse Intensive Outpatient (SAIOP)

Policy CodePolicy 8A-12

Change TypeNo material changes

Effective Date

Last ReviewJan 1, 2026

Next Review Date

Key ActionComplete a comprehensive clinical assessment (CCA) or diagnostic assessment (DA) by a licensed professional and have a signed service order in place prior to or on the first day of service.

SourceLink

On This Page

A comprehensive clinical assessment (CCA) or diagnostic assessment (DA) by a licensed professional must be completed prior to provision of service; a signed service order by an authorized professional must be in place prior to or on the first day of service and is valid for 12 months.

12 months validity for service order

CCA/DA and service order requirements; document diagnostic info in the Person-Centered Plan.

Staff qualification and supervisory responsibilities.

Staff-to-patient ratios: For adult SAIOP, at least one clinical staff per twelve or fewer adult beneficiaries for group sessions; for adolescent SAIOP, at least one clinical staff per six or fewer adolescent beneficiaries for group sessions.

Minimum clinical staff-to-beneficiary ratios.

Program schedule and intensity: SAIOP must be available in person at least five days per week (no more than two consecutive days without services) to achieve 9-19 hrs/week for adults and 6-19 hrs/week for adolescents. Schedule a minimum of three service days/week per beneficiary with minimum three hours per service day for adults and minimum two hours per service day for adolescents.9-19 hrs/week (adults); 6-19 hrs/week (adolescents); minimum 3 service days/week; adult = >=3 hours/service day; adolescent = >=2 hours/service day

Program frequency, minimum service days, and per-day minimums.

Assessments and level of care: A comprehensive clinical assessment (CCA), diagnostic assessment (DA), or reassessment by a licensed professional must be completed to determine ASAM level of care for discharge planning; relevant diagnostic information must be documented in the PCP. CCA/DA, toxicology testing, peer support, psychiatric and medical services may be billed separately from SAIOP.

Assessment and documentation requirements.

Crisis response and overdose preparedness: Providers must provide 24/7 crisis response (in person, telehealth, or telephone) for beneficiaries receiving SAIOP; programs must ensure onsite naloxone or other FDA-approved opioid antagonist and staff training on its use, with policies for use, storage, and education.

Crisis response availability and naloxone requirements.

Staff training: All staff must complete specified training prior to service delivery and additional components within required timeframes; annual continuing education is required. Training topics include crisis response, naloxone administration, harm reduction, SAIOP/ASAM 2.1 definition, ASAM criteria, trauma-informed care, co-occurring conditions, motivational interviewing, pregnancy and SUD, designated therapies, and population-specific training; document training activities.

Staff training and documentation requirements.

Providers and payers should ensure authorizations support the billed daily event length and any separately billed outpatient therapy

Utilization monitoringPHPs, PIHPs and provider agencies shall monitor utilization via service record reviews and internal audits of units billed

Claims submission and transaction types

Submit claims using the appropriate professional (CMS-1500/837P) or institutional (UB-04/837I) transactions and comply with NCTracks guidance, Medicaid bulletins, fee schedules, National Uniform Billing Guidelines (for institutional claims), and National Coding Guidelines.

Professional claims: CMS-1500 / 837P
Institutional claims: UB-04 / 837I (follow National Uniform Billing Guidelines)

Billing Rule

Align billing units with authorization (minimum 3 hours/day)

Report SAIOP as an event with a minimum of three (3) hours per day; ensure any authorization and documentation support the billed daily event length and any separately billed outpatient therapy.

Billing unit: 1 event/day = minimum 3 hours
Ensure authorization supports billed daily event length

Note

Conservative treatment and medical necessity requirement

Providers must ensure services are individualized, consistent with the beneficiary's diagnosis, medically necessary, not in excess of needs, safe to furnish, and provided only when no equally effective, more conservative, or less costly statewide alternative exists.

Document how the service is individualized and medically necessary
Confirm no more conservative statewide alternative is available

Note

Do not bill for conversion therapy

North Carolina Medicaid will not reimburse for conversion therapy; ensure provided services fall within covered therapy types.

Documentation Required

EPSDT documentation to exceed policy limits for <21

For beneficiaries under 21, provider documentation must demonstrate medical necessity to correct or ameliorate a health problem in order to exceed or override policy limitations under EPSDT.

Document how the requested service corrects, improves, or prevents worsening of a health problem per EPSDT (42 U.S.C. § 1396d(r))

Documentation Required

Complete CCA/DA and maintain assessment records

Complete a comprehensive clinical assessment (CCA) or diagnostic assessment (DA) by a licensed professional prior to providing SAIOP; document diagnostic information in the Person-Centered Plan (PCP) and update the assessment and PCP as changes occur. Service notes must meet DHHS Records Management and Documentation Manual requirements.

CCA/DA completed prior to service and used to determine ASAM level
Document diagnostic info and frequency/duration/intensity in the PCP
Update assessment and PCP with changes and ensure service notes meet DHHS manual

Documentation Required

Telehealth documentation and beneficiary attestation

For telehealth services, document a signed attestation of beneficiary choice and assess/document the beneficiary's behavioral, physical, and cognitive ability to participate, including SUD treatment and recovery needs and appropriateness of the recovery environment; ensure in-person services are available at least five days per week.

Signed attestation of beneficiary choice for telehealth
Document suitability for telehealth (behavioral/physical/cognitive and recovery environment)
Ensure in-person services are available ≥5 days/week

Documentation Required

Service order signature, dating, and timing requirements

Service orders must be signed and dated by an authorizing professional, indicate the date ordered, not be backdated, and be in place prior to or on the first day the service is initially provided; providers may not bill Medicaid without a valid service order.

Authorizing professionals: physician, PA, nurse practitioner, or licensed psychologist per scope of practice
Service order valid for billing only if not backdated and present prior to/on first day of service

Documentation Required

Service record and notes — required content and responsibility

Service records must document the nature and course of the beneficiary's progress in treatment; the staff member who provides the service is responsible for accurate documentation and service notes must meet DHHS Records Management and Documentation Manual requirements.

Document progress, interventions, and response in service notes
Provider staff are responsible for accuracy of billed service documentation

Billing Rule

Unlisted procedure/HCPCS billing and special report requirement

When using unlisted CPT or HCPCS codes, follow the current CPT/HCPCS instructions for Unlisted Procedure or Service and submit the required special report per the codebook guidance.

Follow CPT/HCPCS instructions and include required special report when billing unlisted codes

Note

Verify Medicaid eligibility at each service

Verify each Medicaid beneficiary's eligibility every time a service is rendered; failure to verify eligibility may result in ineligibility for coverage or denial of services.

Prior Authorization

Prior approval requirement remains for EPSDT beneficiaries

If a service requires prior approval under this policy, that requirement still applies for EPSDT beneficiaries under 21; lack of required prior approval can trigger denial.

Denial Risk

General denial triggers — eligibility, criteria, duplication, experimental

Coverage is not allowed and claims may be denied when the beneficiary does not meet Section 2.0 eligibility, does not meet Section 3.0 criteria, the service duplicates another provider's service, or the service is experimental, investigational, or part of a clinical trial.

Confirm eligibility per Section 2.0 and clinical criteria per Section 3.0 before billing
Do not bill duplicate services

Denial Risk

Documentation noncompliance may cause denial or nonpayment

Failure to meet documentation requirements consistent with this policy and the DHHS Records Management and Documentation Manual may result in nonpayment or denial of billed services.

Billing Rule

Coding specificity and current edition requirement

Report ICD-10-CM/PCS and procedure codes to the highest level of specificity and use the current editions in effect at the time of service; failure to do so could result in claim processing issues or denial.

Use current ICD-10-CM/PCS, CPT, and HCPCS editions and the most specific codes that support medical necessity

Medications are clinically driven and tailored to meet each beneficiary's needs.

Integration with SAIOPSAIOP programs shall support beneficiaries prescribed or who would benefit from MAT and coordinate care with the prescribing physician.

Telehealth — definition

DefinitionTelehealth is the use of two‑way real‑time interactive audio and video to provide and support health care services when participants are in different physical locations (per Clinical Coverage Policy 1‑H).

Documentation requirementWhen delivered via telehealth, document beneficiary choice and suitability for telehealth including behavioral, physical, and cognitive considerations.

Claims modifierInteractive audio‑visual telehealth services should be billed with the appropriate telehealth modifier (see coding/modifier guidance).

Comprehensive Clinical Assessment (CCA) / Diagnostic Assessment (DA) — assessment requirement definition

DefinitionA Comprehensive Clinical Assessment (CCA) or Diagnostic Assessment (DA) is an assessment completed by a licensed professional to determine ASAM level of care and to demonstrate medical necessity prior to provision of SAIOP services.

Use of equivalent assessmentsA substantially equivalent recent assessment may be used if it reflects current functioning and contains required elements per community practice standards and federal/state requirements.

DocumentationRelevant diagnostic information from the CCA/DA must be documented in the beneficiary's Person‑Centered Plan (PCP) and updated as changes occur.

ASAM Level 2.1 — ASAM-defined admission level required for SAIOP eligibility

DefinitionASAM Level 2.1 is the American Society of Addiction Medicine admission level for a Substance Abuse Intensive Outpatient Program (SAIOP), required for SAIOP eligibility.

Admission elementsBeneficiary must have a current SUD diagnosis per DSM‑5 and meet ASAM 2.1 admission criteria as defined in the ASAM Criteria, Third Edition.

Service intensity linkASAM 2.1 corresponds to the SAIOP program intensity described (weekly hours and service components) in the policy.

CCA/DA — comprehensive clinical assessment, diagnostic assessment, or reassessment

DefinitionCCA/DA refers to a comprehensive clinical assessment, diagnostic assessment, or reassessment completed by a licensed professional to determine ASAM level of care for admission or discharge planning.

Separate billable servicesCCA, DA, toxicology testing, peer support, and psychiatric/medical services may be billed separately from SAIOP.

Recording in PCPRelevant diagnostic information from the CCA/DA must be obtained and documented in the beneficiary's Person‑Centered Plan (PCP); update as changes/new strengths and barriers are observed.