CurrentMontana Department of Public Health & Human ServicesPolicy 535

SUD Clinically Managed Low-Intensity Residential (ASAM 3.1) — Adult and Adolescent

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Defines coverage, provider and service requirements, medical necessity criteria, and utilization management for ASAM 3.1 clinically managed low-intensity residential substance use disorder services for adults and adolescents under Montana Medicaid.

Policy Summary

PayerMontana Department of Public Health & Human Services

PolicySUD Clinically Managed Low-Intensity Residential (ASAM 3.1) — Adult and Adolescent

Policy CodePolicy 535

Change TypeNo material change

Effective DateOct 1, 2022

Next Review Date

Key ActionObtain prior authorization before initiating ASAM 3.1 services; the department or UR Contractor may authorize up to 90 days with continued stay review required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=5 hrs/wkMinimum professionally directed treatment time required

>=2Service components required/week

90 daysMax authorization

30 days

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CurrentMontana Department of Public Health & Human ServicesPolicy 535

SUD Clinically Managed Low-Intensity Residential (ASAM 3.1) — Adult and Adolescent

Customize your policy alerts

Sign up for Montana Department of Public Health & Human Services Policy 535 alerts

Get alerted when Policy 535 changes without checking for updates manually.

Monitor payer policy activity

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Policy Summary

PayerMontana Department of Public Health & Human Services

PolicySUD Clinically Managed Low-Intensity Residential (ASAM 3.1) — Adult and Adolescent

Policy CodePolicy 535

Change TypeNo material change

Effective DateOct 1, 2022

Next Review Date

Key ActionObtain prior authorization before initiating ASAM 3.1 services; the department or UR Contractor may authorize up to 90 days with continued stay review required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=5 hrs/wkMinimum professionally directed treatment time required

>=2Service components required/week

90 daysMax authorization

30 days

Coverage and Medical Necessity for ASAM 3.1

Medical necessity and coverage criteria for ASAM 3.1

Covered when ALL of the following are met:

Admission and severity criteria: Member must meet the moderate or severe SUD criteria as described in this manual and meet the ASAM diagnostic and dimensional admission criteria for ASAM 3.1 level of care.moderate or severe SUD

Source: Medical Necessity Criteria (chunk 3)

Provider and program requirements: Services must be provided by a state-approved substance use disorder program licensed to provide ASAM 3.1 and by an interdisciplinary team with licensed or credentialed clinical staff.licensed state-approved program

Provider and staff credentials; clinical services must be provided by licensed or credentialed clinical staff (chunk 5)

Service delivery and documentation requirements: Member must receive a minimum of five (5) hours of professionally directed treatment services per week and receive two (2) or more service components per week; medically necessary services must be specified in the individualized treatment plan and clearly documented in the member's treatment file.>=5 hours/week and >=2 service components/week

Service Requirements (chunks 5)

It is not required that each member receive every service component listed in the ASAM 3.1 bundled service. However, any service billed must be medically necessary for that member and must be documented in the member's individualized treatment plan. Services actually delivered must be clearly recorded in the member’s treatment file to support billing and authorization.

Services are not covered unless the member meets the policy’s clinical admission criteria. Specifically, the member must meet the moderate or severe SUD severity criteria in this manual and must satisfy the ASAM diagnostic and dimensional admission criteria for the ASAM 3.1 level of care; if these criteria are not met, ASAM 3.1 services are not covered.

Clinically Managed Low-Intensity Residential (ASAM 3.1) Criteria

Clinically Managed Low-Intensity Residential (ASAM 3.1)

Level of care admission, continued stay, and discharge expectations for ASAM 3.1.

Admission: Member must meet the moderate or severe SUD criteria as described in this manual and meet the ASAM diagnostic and dimensional admission criteria for ASAM 3.1.moderate or severe SUD

chunk 3

Continued stay: Member must continue to meet the SUD criteria with a severity specifier of moderate or severe and meet ASAM diagnostic and dimensional criteria; continued stay review is required and the department/UR Contractor may authorize continued stays in increments up to 30 days, with authorizations up to 90 days per prior authorization.moderate or severe SUD

Utilization Management (chunks 6)

ASAM 3.1 Bundled Services and Treatment Components

ASAM 3.1 bundled services

ASAM 3.1 is a bundled service. To bill the bundle the following apply:

Included service components: Bundle includes availability of individual SUD therapy, group SUD therapy, family SUD therapy, educational groups, community based psychiatric rehabilitation support services (CBPRS), and care management.two or more components/week required to bill

Service Requirements (3) and (5)

Billing requirements for the bundle: Member must receive a minimum of five (5) hours of professionally directed treatment services per week AND receive two (2) or more service components per week; it is not required that each member receive every listed component, but services billed must be medically necessary and documented in the individualized treatment plan and treatment file.>=5 hours/week and >=2 service components/week

Service Requirements (4) and (5) (chunk 5)

Provider Requirements, Authorization, and Documentation

Prior Authorization

Prior authorization required; authorization length

Prior authorization must be obtained before providing ASAM 3.1 services. The department or the UR Contractor may authorize up to 90 days per authorization; continued stay review is required for up to 30 days.

Authorization may be issued for as many days as deemed medically necessary, up to 90 days.
Continued stay review required for up to 30 days.

Note

Provide services only through licensed, state‑approved ASAM 3.1 program

Ensure services are furnished by a state‑approved, licensed ASAM 3.1 program and delivered according to ASAM and state/federal service standards; clinical services must be provided by licensed or credentialed clinical staff.

Program must be state‑approved and licensed to provide ASAM 3.1.
Providers must have an interdisciplinary team.

Key Definitions

ASAM 3.1 — definition

TermASAM 3.1

DefinitionA licensed community-based residential home functioning as a supportive, structured living environment that provides stability and skills building to help prevent or minimize continued substance use.

Minimum treatment timeIncludes a minimum of 5 hours per week of professionally directed treatment services.

PopulationAdults and adolescents meeting ASAM 3.1 criteria.

Background and Level Description

ASAM 3.1 is a licensed, community-based residential level of care providing a supportive, structured living environment focused on stability and skills building to prevent or minimize continued substance use. The level requires a minimum of five (5) hours per week of professionally directed treatment and is delivered as a bundled service that makes available individual, group, and family SUD therapies, educational groups, CBPRS, and care management. Admission and coverage require that the member meet the moderate or severe SUD criteria and the ASAM diagnostic/dimensional admission criteria for ASAM 3.1; clinical services must be provided by licensed or credentialed clinical staff.

Authorization Periods and Stay Limits

ASAM 3.1 residential stay — authorization limits

Prior authorization requiredPrior authorization is required; the department or the UR Contractor may authorize up to 90 days per authorization.

Maximum authorization periodUp to 90 days per authorization (as many days as deemed medically necessary up to 90 days).

Continued stay reviewContinued stay review is required for up to 30 days.

Ongoing criteria for continued stayMember must continue to meet SUD criteria with severity specifier of moderate or severe and meet ASAM diagnostic and dimensional admission criteria for ASAM 3.1 level of care.