CurrentDelaware Department of Health and Social ServicesPolicy DSAMH048

DSAMH SUD Continued Stay UR Policy

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Governs DSAMH authorization reviews for continued SUD treatment days for Delaware residents age 18 or older who are uninsured or underinsured and receive covered services from DSAMH-contracted providers.

Policy Summary

PayerDelaware Department of Health and Social Services

PolicyDSAMH SUD Continued Stay UR Policy

Policy CodePolicy DSAMH048

Change TypeNo material clinical or coverage changes

Effective DateApr 17, 2023

Last ReviewApr 2, 2025

Next Review DateNot specified

Key ActionSubmit the CSR and clinical documentation by email to DSAMH_EEU_SUD@delaware.gov with “continued stay” in the subject line.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7 daysSubmission window

2 business daysDSAMH response timeframe

30 days

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CurrentDelaware Department of Health and Social ServicesPolicy DSAMH048

DSAMH SUD Continued Stay UR Policy

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Sign up for Delaware Department of Health and Social Services Policy DSAMH048 alerts

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Policy Summary

PayerDelaware Department of Health and Social Services

PolicyDSAMH SUD Continued Stay UR Policy

Policy CodePolicy DSAMH048

Change TypeNo material clinical or coverage changes

Effective DateApr 17, 2023

Last ReviewApr 2, 2025

Next Review DateNot specified

Key ActionSubmit the CSR and clinical documentation by email to DSAMH_EEU_SUD@delaware.gov with “continued stay” in the subject line.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7 daysSubmission window

2 business daysDSAMH response timeframe

30 days

Minimum review frequency

18+Minimum patient age

4Covered service categories

Continued Stay Coverage Criteria

SUD Continued Stay Authorization

Continued stay authorization requires all applicable conditions to be met.

Continued stay authorization

Eligible population and service: The patient is a Delaware resident age 18 or older, is uninsured or underinsured, and is receiving a covered SUD service from a DSAMH-contracted provider.Age 18 or older
Insurance verification: The provider submits evidence that the patient lacks applicable private or Medicaid coverage, or that the coverage does not cover the relevant SUD service.Before DSAMH review
Timely and proper submission: The CSR and supporting clinical documentation are submitted to the designated DSAMH SUD UR email address within the permitted submission window, with the required subject line and CSR designation.Up to 7 days before through 7 days after the last covered day
Submissions seven or more days after the last covered day are late and will not be accepted.
Complete CSR and clinical support: The CSR identifies the requested days and new start date and documents treatment progress, justification for continued treatment, and treatment goals; supporting records address medical necessity and progress since the last review.Each requested treatment day must meet medical necessity
DSAMH may authorize multiple days, but each day must be supported by facility documentation.
Continued medical necessity: The documentation demonstrates treatment progress and the need for continued treatment, including that treatment cannot be rendered at a lower level of care.Review at least every 30 days
Review frequency is based on level of care, treatment progress, and documentation provided by the SUD facility.

CSR and clinical documentation must be submitted to DSAMH_EEU_SUD@delaware.gov with “continued stay” in the subject line. Submissions sent to any other email address or faxed to the office will not be accepted.

CSR and clinical documentation must be submitted no more than seven days after the last covered day. Materials received seven or more days after the last covered day are considered late and will not be accepted; authorization will be denied, with no exceptions.

Submission and Documentation Requirements

Prior Authorization

Continued Stay Authorization Review

DSAMH conducts a continued stay review on the last covered day when additional treatment days are requested. Authorization is based solely on the SUD Continued Stay Request (CSR) form and clinical documentation submitted by the SUD facility, which must demonstrate treatment progress and the need for continued treatment.

DSAMH may authorize multiple days, but each treatment day must meet medical necessity based on the facility's documentation.
Reviews are completed at least every 30 days, with frequency based on level of care, treatment progress, and documentation provided.
DSAMH SUD UR responds with an authorization or denial within two business days of submission.

Prior Authorization

Required Submission Channel

Submit the CSR and all other clinical documentation to the DSAMH SUD UR email box. Submissions sent to another email box or faxed to the office will not be accepted.

Email: DSAMH_EEU_SUD@delaware.gov

Covered Service Categories

Applicable SUD Levels of Care

Coverage applies when all eligibility conditions are met for an applicable SUD treatment level of care.

Eligible SUD treatment admission: The patient is a Delaware resident age 18 or older, is uninsured or underinsured, and is receiving SUD treatment from a DSAMH-contracted provider at an applicable level of care.Age 18 or older

Applicable levels of care are Ambulatory Withdrawal Management (ASAM 2), 23-hour Ambulatory Withdrawal Management (ASAM 2), Residential Detoxification (ASAM 3.7), and Residential Treatment (ASAM 3.1 and 3.5).

Policy Purpose and Scope

This policy establishes an objective and consistent utilization review process for continued substance use disorder (SUD) treatment. DSAMH evaluates whether additional treatment days remain medically necessary under ASAM criteria, based on the facility’s Continued Stay Request (CSR) and supporting clinical documentation.

Key Definitions

Authorization

DefinitionThe agreement from DSAMH that a patient meets medical necessity for substance use disorder treatment and that DSAMH will pay for treatment.

Medical necessity standardMedical necessity is defined by ASAM criteria.

Payment responsibilityDSAMH will pay for treatment when the patient meets the applicable medical necessity criteria.

Days

DefinitionDays means calendar days.

Counting methodCalendar days are used for counting days under the policy.

Exception

Policy Summary

PayerDelaware Department of Health and Social Services

PolicyDSAMH SUD Continued Stay UR Policy

Policy CodePolicy DSAMH048

Change TypeNo material clinical or coverage changes

Effective DateApr 17, 2023

Last ReviewApr 2, 2025

Next Review DateNot specified

Key ActionSubmit the CSR and clinical documentation by email to DSAMH_EEU_SUD@delaware.gov with “continued stay” in the subject line.

SourceLink

On This Page

Include the words continued stay in the subject line.

Documentation Required

Required Continued Stay Documentation

The CSR and supporting clinical documentation must establish the patient's residential status, insurance status, treatment progress, and continued-treatment needs.

Documentation of Delaware residential status for SUD treatment admission.
EOB, proof of insurance verification, or proof of lack of insurance at referral.
Documentation that treatment cannot be provided at a lower level of care.
Treatment goals; progress and group notes since the last review; and documentation of psychoeducation and community resources, if available.
Documentation of a relapse-prevention plan; toxicology laboratory results since the last review, if available; and a medication administration record when medications changed since the last review.
Discharge planning documentation; collateral information regarding outpatient providers, family, or the support system; and COWS and/or CIWA-Ar scores since the last review, if available.

Documentation Required

CSR Content Requirements

The CSR form must clearly identify the requested continuation and support the request with clinical information demonstrating the need for treatment.

Number of days requested.
New start date for the CSR.
CSR indicated as the type of authorization requested.
Documentation of treatment progress, justification for continued treatment, and treatment goals.

Denial Risk

Late CSR Submission

CSR and supporting clinical documentation may be submitted up to seven days before or up to seven days after the last covered day. Material submitted seven or more days after the last covered day is late and will not be accepted.

Late submission results in a denial of authorization for failure to submit the CSR for review.
No exceptions will be made.

Denial Risk

Incomplete CSR

An incomplete CSR will result in a denial of authorization. The form must include every required CSR element and the supporting clinical information needed for review.

Missing the number of days requested, new CSR start date, or authorization type identified as CSR makes the submission incomplete.
The CSR must also include treatment progress, justification for continued treatment, and treatment goals.

Unsupported block type: denial_risk should be replaced?

Denial Risk

Missing Insurance Status Evidence

Before DSAMH reviews the CSR and clinical documentation, the treating SUD provider must submit evidence that the patient lacks applicable coverage or that the coverage does not cover the requested treatment.

Provide evidence that the patient is not covered by private insurance, out-of-state Medicaid, or Delaware Medicaid; or that the policy does not cover SUD Ambulatory Withdrawal Management, 23-hour Ambulatory Withdrawal Management, Residential Detox, and/or Residential services.
Acceptable evidence includes an EOB, proof of insurance verification, or proof of lack of insurance at the time of referral.
This evidence is required before DSAMH reviews the CSR and other clinical documentation for authorization.

Calendar days apply unless otherwise specified.

Delaware Resident

DefinitionAn individual who is not eligible for an out-of-state Medicaid plan and meets the applicable Delaware residency criteria.

Physical 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.

IdentificationThe individual possesses a valid Delaware-issued identification card, such as a driver's license or non-driver identification card.

Utilization Review (UR)

DefinitionUtilization Review (UR) means the review of clinical information to determine authorization approval or denial.

Information reviewedClinical information is reviewed during UR.

DeterminationThe review determines whether authorization is approved or denied.