Colorado SUD Treatment - Standard Authorization Request Form
Standard authorization form and required clinical information for requesting coverage of substance use disorder (SUD) treatment levels of care for Colorado Rocky Mountain Health Plans members (including RAE/PRIME/CHP+). Used by in-network and out-of-network providers to request authorization for ASAM levels of care.
No material clinical or coverage changes in this revision.
Policy summary and scope
This authorization request form is modeled on the ASAM criteria to standardize the six-dimension substance use disorder assessment and to capture required clinical data for Colorado Regional Accountable Entities (RAEs) and their partners. It is used to request admission and concurrent authorization for multiple ASAM levels of care (including outpatient, partial hospitalization, residential, withdrawal management, and medically monitored inpatient services) and to document special populations such as Special Connections for pregnant and parenting women. The form collects identifying/provider information, level of care requested, admission status and dates, ICD-10 diagnoses, substances and withdrawal measures (e.g., BAL, UDS, CIWA, COWS, SEWS, MINDS), vital signs when admitting to ASAM 3.2WM, 3.7, and 3.7WM, the six ASAM dimensions with brief narrative summaries, medication/MAT details, and any population-specific data required for authorization decisions.
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