Urine Drug Screening (UDS) standard benefit — Coverage Criteria
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Governance of urine drug screening benefit for iCare members, including automatic allowance of six UDS per year, rules for prior authorization (PA), and criteria for additional (overage) testing; applies to providers submitting UDS requests for members under the integrated home care services standard benefit.
No material clinical or coverage changes in this revision.
Coverage Criteria
Covered criteria
Covered when criteria below are met:
No clinicals or order needed for the initial 6 UDS; retro authorization accepted up to 14 days after first UDS.
Definitive tests in applicable tiers may be submitted for 1-year intervals; presumptive overages require clinicals, order and COT screening per policy.
Request must be timely (within 14 days of treatment start); overage requests require documentation as specified.
Overages beyond the automatic 6 presumptive UDS per year standard benefit require submission and review for medical necessity. For members whose risk tier places them in the highest category (Presumptive, tier 4), the policy explicitly states that any tests in excess of the 6-per-year benefit "must be submitted and reviewed for medical necessity." Providers should include all required documentation when requesting additional testing so the medical review can assess necessity against the member’s risk level.
Requests for UDS that are not accompanied by supporting clinical documentation—particularly for members who are not enrolled in Chronic Opioid Therapy (COT) or Alcohol and Other Drug Abuse (AODA) treatment—should be submitted with clinic notes, a signed order, and any COT-specific screening information as applicable. The policy indicates that overages are "TBD with clinicals, order and COT screen" for lower risk tiers and that higher-risk and presumptive overage requests require supporting clinicals and an order for medical review.
Covered Indications
COT and AODA treatment criteria
Covered when ALL of the following are met:
Definitive testing frequencies and submission intervals are tier-specific; definitive tests may be requested for up to 1-year intervals where allowed.
If member is not in COT or AODA, overage requests must include clinicals for medical review; late submissions (beyond 14 days after first UDS) risk denial.
Frequency Limits
Coding and References
| L36037 | LCD Urine Drug Testing (referenced) |
Provider Actions & Requirements
Prior authorization required for standard benefit and overages
A prior authorization (PA) form must be submitted to obtain the standard benefit of 6 UDS per year; the PA must be submitted annually to renew this benefit. Retro authorization requests are accepted up to 14 days after the first UDS; PA for presumptive overages and for definitive tests may be submitted for up to 1-year intervals.
- Submit PA form on the iCare website to access the 6-per-year standard benefit.
- PA must be renewed annually.
- Retro authorization allowed within 14 days of the first UDS.
- PA for presumptive over the 6-benefit level and for definitive testing may be submitted for 1-year intervals.
Risk-tiered testing guidance for COT
Follow the policy's risk-tiered guidance for Chronic Opioid Therapy (COT): lower-risk tiers have less frequent definitive testing while higher-risk tiers require more frequent definitive tests and may require orders/supporting documents. Tier 4 specifically requires a signed order and supporting documentation and subjects overages to medical necessity review.
- Definitive testing frequency increases with higher COT risk tiers (examples: Tier 1 = 1–2/yr; Tier 3 = up to 12/yr; Tier 4 = requires order and supporting documents).
- Presumptive testing: initial 6-per-year is standard; overages depend on tier and require clinicals/order for tiers with stricter requirements.
Required supporting documentation for overage requests
When requesting UDS above the standard 6-per-year benefit, include the specific number of tests requested and the timeframe, supporting physician notes demonstrating ongoing need, and a signed MD order; if the member is not in COT or AODA, submit clinical documentation for medical review.
- State the amount of UDS requested and the time period those tests cover.
- Attach the doctor’s clinical notes that support ongoing need for additional testing.
- Include a signed MD order for the overage request.
- If the member is not in COT or AODA, provide clinicals for medical review.
Timely submission requirement (14-day retro window)
All requests for UDS beyond the standard 6 must be submitted within 14 days of the first UDS to be considered timely; submissions received after this 14-day retro window risk denial or will be subject to review for timeliness and medical necessity.
- Retro authorization and overage requests must be filed within 14 days of the first UDS.
- Late submissions may be denied as untimely.
Ordering Requirements
Ordering requirements: PA form for standard benefit; signed MD order for overages
For the initial standard 6 UDS benefit, submit only the PA form (no clinical notes or signed order required). For any overage beyond the 6-per-year benefit, include a signed MD order and the supporting clinical documentation described above.
- Initial standard benefit (6 UDS): submit PA form on the iCare website; no clinicals or order needed.
- Overages: include signed MD order and supporting doctor's notes detailing ongoing need and amount/timeframe requested.
Definitions
Not Covered
Definitive and presumptive tests submitted beyond the 6-per-year standard benefit are not automatically covered; the policy requires that these overages be submitted and reviewed for medical necessity. In the highest-risk presumptive tier (tier 4), overages "must be submitted and reviewed for medical necessity," and definitive testing in that tier also "requires order and supporting documents." Requests lacking the required PA, signed order, or clinical documentation are therefore subject to denial as not medically necessary.
Background
Urine drug screening is used to monitor patients on Chronic Opioid Therapy (COT) and those in Alcohol and Other Drug Abuse (AODA) treatment. The policy provides risk-tiered guidance for both definitive and presumptive testing: lower risk tiers have fewer recommended definitive tests while higher risk tiers recommend more frequent definitive testing and may impose documentation requirements. Across tiers, members receive a baseline of 6 presumptive UDS per calendar year upon submission of the prior authorization form; additional testing is allowed only when supported by the required clinical documentation, orders, and medical necessity review.
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