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    v1.0.30
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyDelaware DHSS SUD Discharge Prior Auth | OpenPayer
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    CurrentDelaware Department of Health and Social ServicesPolicy DSAMH049

    DSAMH SUD Discharge UR

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    Governs DSAMH discharge reviews and final authorization decisions for substance use disorder treatment provided to Delaware residents age 18 or older who are uninsured or underinsured. Applies to DSAMH-contracted providers delivering ambulatory withdrawal management, residential detoxification, or residential substance use disorder services.

    Policy Summary
    PayerDelaware Department of Health and Social Services
    PolicyDSAMH SUD Discharge UR
    Policy CodePolicy DSAMH049
    Change TypeNo material change
    Effective DateApril 17, 2023
    Last ReviewMar 27, 2025
    Next Review DateNot specified
    Key ActionSubmit all discharge documentation to DSAMH_EEU_SUD@delaware.gov within one business day after discharge.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    1 business dayDischarge documentation submission
    7 daysOutpatient SUD aftercare
    7 daysMental health aftercare when needed
    2 business daysAuthorization or denial response

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    5Required discharge-plan elements

    Discharge Authorization and Payment Criteria

    Discharge Authorization and Payment Criteria

    Discharge authorization and payment require all applicable patient, provider, service, discharge-plan, review, and submission criteria below.

    ALL of the following

    • The patient is a Delaware resident who is 18 years of age or older and is uninsured or underinsured.

      A Delaware resident is an individual who is not eligible for an out-of-state Medicaid plan and either is domiciled in, maintains a place of abode in, and spends more than 183 days in Delaware, or possesses a valid Delaware-issued driver's license or non-driver identification card.

    • The provider is a DSAMH-contracted program providing 23-hour Ambulatory Withdrawal Management (ASAM 2), Ambulatory Withdrawal Management (ASAM 2), Residential Treatment (ASAM 3.1 or 3.5), and/or Residential Detox (ASAM 3.7) services.
    • The requested treatment meets medical necessity as defined by ASAM criteria for substance use disorder treatment and is subject to DSAMH utilization review authorization.
    • Complete discharge documentation is submitted to the DSAMH SUD UR email box at DSAMH_EEU_SUD@delaware.gov within one business day after discharge.within 1 business day after discharge

      Discharge documentation sent to another email box or faxed to the office will not be accepted. The subject line must include the word 'discharge.'

    • The discharge instructions include an aftercare appointment with an outpatient SUD provider that accepts State pay within seven days after discharge.within 7 days after discharge
    • The discharge instructions include an aftercare appointment with a mental health provider, when needed, within seven days after discharge.within 7 days after discharge
    • The discharge instructions include a relapse prevention plan.
    • The discharge instructions include community resources and emergency numbers.
    • The discharge instructions include the discharge diagnosis.
    • The discharge plan coordinates services to the individual's next level of care and addresses identified needs, including appointments, medications, access to medication, transportation, housing, and other health or social service needs, as applicable.
    • DSAMH SUD UR reviews all discharge documentation to determine the appropriateness of the discharge plan and uses the information obtained for the final authorization determination.
    • DSAMH SUD UR responds with an authorization or denial of the request within two business days of submission.within 2 business days of submission

    Denial Conditions and Appeals

    Payment is denied when discharge requirements are not met.

    ANY of the following results in denial of payment

    • The discharge plan or documentation is incomplete.
    • The discharge plan is inappropriate.
    • The discharge documentation is submitted late.
    • The documentation is submitted to an email address other than DSAMH_EEU_SUD@delaware.gov or is faxed to the office.
    • The discharge documentation does not support authorization under the applicable ASAM medical-necessity criteria.

    Key Eligibility and Timing Requirements

    Patient eligibility
    Minimum age18 years or older
    Covered populationDelaware residents who are uninsured or underinsured
    Applicable treatmentSubstance use disorder treatment subject to DSAMH authorization review
    Discharge documentation submission
    Submission deadlineWithin 1 business day after discharge
    Submission destinationDSAMH SUD UR email box: DSAMH_EEU_SUD@delaware.gov
    Subject lineInclude the word 'discharge' in the subject line

    Discharge Review and Authorization Workflow

    Note

    Applicable Providers and Services

    DSAMH-contracted programs serving Delaware residents age 18 or older who are uninsured or underinsured must follow this authorization process for covered SUD services.

    • 23-hour Ambulatory Withdrawal Management (ASAM 2)
    • Ambulatory Withdrawal Management (ASAM 2)
    • Residential Treatment (ASAM 3.1 and 3.5)
    • Residential Detox (ASAM 3.7)
    Documentation Required

    Submit Discharge Documentation

    Submit all discharge documentation to the DSAMH SUD UR email box within one business day after discharge. Do not submit documentation to another email box or by fax; those submissions will not be accepted.

    • Destination: DSAMH_EEU_SUD@delaware.gov
    • Deadline: within one (1) business day after discharge

    Policy Terms

    Authorization
    MeaningAgreement from DSAMH that a patient meets medical necessity as defined by ASAM criteria for substance use disorder treatment
    Payment determinationDSAMH will pay for the treatment
    Decision contextAuthorization is part of the review process for applicable substance use disorder treatment
    Delaware resident
    Medicaid statusThe individual is not eligible for an out-of-state Medicaid plan
    Delaware presenceThe individual is domiciled in a permanent location or maintains a place of abode in Delaware and spends more than 183 days in the State
    Identification alternative
    Policy Summary
    PayerDelaware Department of Health and Social Services
    PolicyDSAMH SUD Discharge UR
    Policy CodePolicy DSAMH049
    Change TypeNo material change
    Effective DateApril 17, 2023
    Last ReviewMar 27, 2025
    Next Review DateNot specified
    Key ActionSubmit all discharge documentation to DSAMH_EEU_SUD@delaware.gov within one business day after discharge.
    SourceLink
    On This Page
    Discharge Authorization and Payment CriteriaKey Eligibility and Timing RequirementsDischarge Review and Authorization WorkflowPolicy Terms
    Unaccepted submissionsDocumentation sent to another email box or faxed to the office will not be accepted
    Utilization review response
    Response deadlineWithin 2 business days of submission
    Reviewing entityDSAMH SUD Utilization Review
    Response typesAuthorization or denial of the request
    Outpatient SUD aftercare
    Appointment deadlineWithin 7 days of discharge
    Appointment typeAftercare appointment with an outpatient substance use disorder provider
    Provider requirementThe outpatient provider must accept State payment
    Mental health aftercare
    Appointment deadlineWithin 7 days of discharge when needed
    Appointment typeAftercare appointment with a mental health provider
    ApplicabilityRequired when mental health aftercare is needed
  1. Subject line must include the word “discharge”
    2. Documentation Required

    Include Required Discharge-Plan Elements

    Discharge instructions must include the required aftercare, clinical, and community-support information needed to coordinate the individual’s next level of care.

    • An aftercare appointment with an outpatient SUD provider who accepts State pay within seven (7) days of discharge
    • An aftercare appointment with a mental health provider, if needed, within seven (7) days of discharge
    • Relapse prevention plan
    • Community resources and emergency numbers
    • Discharge diagnosis
    Note

    DSAMH Discharge Review

    DSAMH SUD UR reviews all submitted discharge documentation and determines whether the discharge plan is appropriate. The information obtained from the discharge documentation is used for the final authorization.

    Prior Authorization

    Authorization or Denial Response

    DSAMH SUD UR will respond with an authorization or denial of the request within two business days of submission.

    • Response timeframe: within two (2) business days of submission
    • Response: authorization or denial of the request
    Denial Risk

    Discharge-Plan Denial Risk

    Incomplete, inappropriate, or late discharge plans will result in denial of payment from the State.

    • Ensure all required discharge-plan elements are included.
    • Submit documentation to the correct DSAMH SUD UR email box by the deadline.
    Note

    Appeal Denied Authorization

    For any denial of authorization, follow the next steps in the DSAMH003 Provider Appeals Policy.

    • Reference: DSAMH003 Provider Appeals Policy
    The individual possesses a valid Delaware-issued identification card, such as a driver's license or non-driver identification card
    Discharge plan
    PurposeA plan developed to coordinate an individual's services to the next level of care
    Care arrangementsIncludes information about appointments, medications, and access to medication
    Support needsIncludes transportation, housing, and other identified health or social service needs
    Utilization Review (UR)
    DefinitionReview of clinical information to determine authorization approval or denial
    Information reviewedClinical information and discharge documentation
    Decision evaluatedWhether authorization should be approved or denied