CurrentPennsylvania Insurance DepartmentPolicy N/A

Emergency Department Opioid Use Disorder (OUD) Program — Coverage Criteria

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Guidance and Q&A on DHS's ED-focused OUD program covering definitions of denominator/numerator, required pathways (including pregnant patients), data/reporting (claims, CCD/ADT submission), attendance/staffing and attestation requirements for hospitals participating in Pennsylvania's HealthChoices program.

Policy Summary

PayerPennsylvania Insurance Department

PolicyEmergency Department Opioid Use Disorder (OUD) Program — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes in this revision.

Effective DateN/A

Next Review DateN/A

Key ActionHospitals must be able to provide documentation and attestation that patients followed established ED OUD pathways if audited.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7 daysFollow-up timeframe

Tier thresholdsTier thresholds

WeeklyADT/CCD frequency

24/7Care management availability

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CurrentPennsylvania Insurance DepartmentPolicy N/A

Emergency Department Opioid Use Disorder (OUD) Program — Coverage Criteria

Customize your policy alerts

Sign up for all Pennsylvania Insurance Department policy alerts

Know when Pennsylvania Insurance Department releases new policies or updates existing guidance.

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Policy Summary

PayerPennsylvania Insurance Department

PolicyEmergency Department Opioid Use Disorder (OUD) Program — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes in this revision.

Effective DateN/A

Next Review DateN/A

Key ActionHospitals must be able to provide documentation and attestation that patients followed established ED OUD pathways if audited.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7 daysFollow-up timeframe

Tier thresholdsTier thresholds

WeeklyADT/CCD frequency

24/7Care management availability

Jan 17, 2019Pathway attestation date

Coverage and Follow-up Measures

ED OUD follow-up measure (numerator/denominator logic)

Covered when the following claim-based logic is met:

Denominator inclusion: Patient has an OUD diagnosis in the first 9 positions on an emergency department paid claim; exclude ED visits that result in acute inpatient admission unless the admission is primarily for methadone, buprenorphine, or detoxification, or the patient is placed in outpatient observation for buprenorphine induction.

ICD-10 code list provided to HAP.

Numerator inclusion: Denominator patient obtains treatment for OUD within 7 days of discharge from the ED. Treatments include any ASAM level of care (acute inpatient rehabilitation, detoxification, inpatient/outpatient residential rehabilitation, partial hospitalization, halfway houses) or any claim for medication assisted treatment (MAT).7 days

Spreadsheet of numerator claim types provided to HAP.

Pregnant patient exception

Special handling for pregnant patients presenting in ED:

Pregnancy admissions/observation: Pregnant patients seen in the ED who are admitted for methadone induction within 7 days of the ED visit, or placed in outpatient observation for buprenorphine induction within 7 days, are included in both the denominator and numerator (exception to standard HEDIS specification).7 days

Applies when the ED has a specific protocol for pregnant women (Pathway 3).

Pathway follow-up requirement

Covered when ALL of the following are met

Pathway outcome requirement: Patient obtains follow-up treatment for OUD within 7 days of ED discharge (when observation or inpatient stay is used, that stay is treated as discharge from the ED). Follow-up treatments include ASAM levels of care and any claim for MAT.within 7 days

Includes inpatient admissions where MAT is initiated during the stay; methadone induction requires co-occurring diagnosis and adherence to state/federal regulations.

Inpatient initiation criteria

Admission counting criteria

Inpatient admission as pathway: An inpatient admission counts toward the pathway if methadone or buprenorphine treatment is initiated during the acute inpatient hospital stay. Methadone induction requires a co-occurring diagnosis and must follow applicable state and federal regulations.initiation during stay

Examples of co-occurring illnesses include pregnancy, cellulitis, endocarditis, aspiration pneumonia, and respiratory failure.

ED visits that result in admission to an acute inpatient stay are excluded from the denominator unless one of the following exceptions applies: the admission is primarily for methadone, buprenorphine, or detoxification, or the patient is placed in outpatient observation for buprenorphine induction. Patients meeting one of these exceptions are included in both the denominator and numerator when the other numerator criteria are satisfied (treatment within 7 days of ED discharge).

Hospitals that choose to report identifiable ED OUD Continuity of Care Documents (CCDs) for Medicaid recipients to DHS via the MAHIT Direct address or through their Health Information Organization’s (HIO) Public Health Gateway must secure written patient consent per the HIO consent requirements before sending protected health information to DHS (specifically to the named DHS clinical contact). Failure to obtain the required written consent prevents reporting identifiable CCDs through these channels.

Diagnosis, Tiers, and Code Lists

Denominator diagnosis codesICD-10

ICD-10 F11 series (as provided to HAP)

OUD-related diagnosis codes used to identify denominator (full list provided separately to HAP)

ICD-10 OUD codesICD-10

No codes listed

Included MCO plan identifiersmixed

Aetna Better Health	MCO participating in Physical Health HealthChoices program
AmeriHealth Caritas Pennsylvania	MCO participating in Physical Health HealthChoices program
Gateway Health Plan	MCO participating in Physical Health HealthChoices program
Geisinger Health Plan	MCO participating in Physical Health HealthChoices program
Health Partners Plans	MCO participating in Physical Health HealthChoices program
Keystone First	MCO participating in Physical Health HealthChoices program
United Healthcare Community Plan of Pennsylvania	MCO participating in Physical Health HealthChoices program
UPMC for You	MCO participating in Physical Health HealthChoices program

Tier volume thresholds

Tier 1Fewer than 20 ED OUD visits

Tier 220 to 200 ED OUD visits (inclusive)

Tier 3More than 200 ED OUD visits

Attestation tier determination

Attestation tier source yearHospital tiers are determined using CY2016 ED OUD visit counts

Attestation statement contentAttestation requires reporting number of OUD ED visits in the most recent 12 months and the number of HealthChoices recipients expected to use the pathway by January 17, 2019

Provider Requirements, Licensing, and Documentation

Prior Authorization

Licensing and inpatient induction rules

Induction with buprenorphine may be performed in outpatient or observation status without OTP/NTP licensing; inpatient methadone induction requires a co‑occurring medical diagnosis and must follow current state and federal regulations. Inpatient admissions count toward the pathway numerator only if methadone or buprenorphine treatment is initiated during the acute inpatient stay.

Buprenorphine induction in outpatient or observation status: no OTP/NTP license required.
Methadone inpatient induction: requires co‑occurring diagnosis and adherence to state and federal regulations.
For numerator counting, MAT (methadone or buprenorphine) must be initiated during the inpatient stay.

Note

Prior authorization

No prior authorization requirements are specified in this guidance (N/A).

Program Background and Scope

The program focuses on identifying Emergency Department patients with Opioid Use Disorder when an OUD diagnosis appears in the first nine diagnosis positions on a paid ED claim. Those ED encounters form the denominator for the follow-up measure, with the goal of connecting patients to treatment: a claim for any ASAM level of care service or any medication assisted treatment (MAT) within 7 days of ED discharge qualifies the patient for the numerator. ED visits that proceed to acute inpatient admission are excluded from the denominator except for the specific exceptions (primary admission for methadone, buprenorphine, or detoxification, or outpatient observation for buprenorphine induction); inpatient admissions in which MAT is initiated during the stay may count toward the measure when initiation occurs during that admission.

Key Definitions

Denominator OUD case definition

Denominator case definitionPatient with an OUD diagnosis in one of the first nine diagnosis positions on a paid ED claim

Exclusion — inpatient admissionED visits that result in admission to an acute inpatient stay are excluded from the denominator

Denominator exceptionsIncluded if admitted primarily for methadone, buprenorphine, or detoxification, or if placed in outpatient observation for buprenorphine induction

Numerator follow-up — treatment within 7 days of ED discharge

Numerator timeframeTreatment for OUD must occur within 7 days of ED discharge to count

Included treatmentsAny ASAM level of care (acute inpatient rehab, detoxification, inpatient/outpatient residential rehab, partial hospitalization, halfway houses) and any MAT claim

ASAM and Level-of-Care Mapping

Various ASAM levels (inpatient, residential, PHP, outpatient, observation)

ASAM and related levels qualify: Treatment services at ASAM levels of care qualify when initiated within 7 days of ED discharge; includes acute inpatient rehab, detoxification, inpatient/outpatient residential rehab, partial hospitalization, halfway houses, and MAT claims.7 days

Includes both inpatient and outpatient observation initiation as specified.

Observation and outpatient induction: Buprenorphine induction may occur in outpatient or observation status without OTP/NTP licensing and still count toward follow-up treatment.

No special OTP/NTP licensing required for buprenorphine induction in outpatient or observation status.

Inpatient level care: Inpatient initiation of methadone is permitted to count when there is a co-occurring medical diagnosis and regulatory requirements are met; initiation during the stay is required for counting.

Medication-Assisted Treatment and Related Interventions

Medication Assisted Treatment (MAT)/Buprenorphine/Methadone

MAT initiation in ED/observation/outpatient: Buprenorphine induction is allowed in ED, observation, or outpatient settings and may be provided without OTP/NTP licensing; telemedicine by an x‑waivered physician with e‑prescribing of buprenorphine is permitted.7 days (for counting)

Bridge dosing capacity may be limited in some settings.

Methadone inpatient initiation: Methadone induction may be initiated during an inpatient stay and count toward follow-up only when there is a co‑occurring medical diagnosis and all state and federal regulations are followed.initiation during stay

Examples of qualifying co‑occurring illnesses are provided in policy Q&A.

MAT

Reporting Frequency and ADT/CCD Requirements

ADT/CCD reporting to HIO or DHS — weekly submission minimum

Minimum submission frequencyHospitals must send ADT/CCD messages at least weekly after onboarding to a DHS-certified HIO or via DHS Direct

Onboarding deadlineHospitals should be onboarded/connected to a DHS-certified HIO between now and 7/1/2019; if not connected by that date, use DHS Direct

No retro-batching requiredThere is no need to retro-batch ADTs/CCDs back to September 2018 once weekly submission is established

Policy Summary

PayerPennsylvania Insurance Department

PolicyEmergency Department Opioid Use Disorder (OUD) Program — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes in this revision.

Effective DateN/A

Next Review DateN/A

Key ActionHospitals must be able to provide documentation and attestation that patients followed established ED OUD pathways if audited.

SourceLink

On This Page

Attestation form submission levelAttestations are accepted at the hospital level identified by the hospital's Medicare CCN

Step Therapy

Telemedicine evaluation and buprenorphine initiation

Telemedicine evaluation by an X‑waivered physician with subsequent e‑prescribing of buprenorphine is permitted to engage patients in community treatment; telemedicine may limit the ability to provide bridge dosing pending community prescriber availability.

Telemedicine + e‑prescribe of buprenorphine is allowed for community treatment engagement.
Bridge dosing capacity via telemedicine may be limited, especially in areas with few MAT providers.

Note

Step therapy

No step‑therapy rules are specified in the document (N/A).

Documentation Required

Attestation and documentation for pathway implementation

Hospitals must develop and retain an attestation checklist verifying pathway development by 9/28/2018 and implementation by 1/17/2019; DHS will require submission of attestations and may audit to confirm pathways were implemented (recipients run through the pathway by 1/17/19).

Develop a brief checklist attestation form documenting pathway development (by 9/28/2018) and implementation (by 1/17/2019).
Submit the attestation to DHS/HAP as required; retain documentation to demonstrate recipients were run through the pathway by 1/17/2019.

Documentation Required

Written patient consent required for CCD submission to DHS

If reporting ED OUD CCDs to DHS via the MAHIT Direct Messaging Account or through an HIO's P3N PHG, hospitals must secure written patient consent for sending protected health information to Dr. David Kelley at DHS.

Obtain written consent from the affected patient per HIO consent requirements before sending identifiable ED OUD CCDs to DHS.
Consent is specifically required for sending PHI to Dr. David Kelley, Chief Medical Officer, Office of Medical Assistance Programs.

Denial Risk

Audit risk: DHS may require supporting documentation

DHS may audit submitted attestations and require supporting documentation; failure to provide requested documentation could result in noncompliance with program requirements.

Retain documentation demonstrating pathway use and be prepared to produce it if DHS audits the attestation.
Failure to provide requested documentation may risk noncompliance with program monitoring.

Denial Risk

Reporting noncompliance risk: weekly ADT/CCD submission required

Hospitals must send ADT/CCD messages at least weekly to a DHS‑certified HIO or via DHS Direct; failure to connect and transmit weekly after 7/1/2019 may prevent meeting reporting expectations and program monitoring.

If unable to connect to an HIO by 7/1/2019, transmit ADTs/CCDs via the DHS Direct account: PADPW-OMAP-MAHEALTHIT@directaddress.net.
Starting 7/1/2019, ADTs/CCDs must be sent at least weekly to DHS.

Pregnant patient notePregnant patients admitted or placed in observation for induction within 7 days are included in numerator as specified in the pregnant-patient exception

Attestation definition

Attestation definitionA hospital's signed statement that it has had a specified number of OUD ED visits in the most recent 12 months and will have the indicated number of HealthChoices recipients use the established pathway by January 17, 2019

Attestation granularityAttestation is completed at the hospital level using the hospital's MA PROMISe™ 13-digit ID or Medicare CCN as specified on the form

Attestation deadline referenceAttestation form must be submitted by the specified program deadline (see attestation guidance)

ADT/CCD reporting definition

ADT/CCD reporting definitionSending ADT (admission/discharge/transfer) messages and Continuity of Care Documents (CCD) from EDs to DHS via a DHS-certified Health Information Organization (HIO) or via DHS Direct (PADPW-OMAP-MAHEALTHIT@directaddress.net)

Technical standard for CCDsCCD messages should conform to the HL7 Implementation Guide: CDA Release 2 - Continuity of Care Document (CCD)

Patient consent requirementHospitals reporting ED OUD CCDs to DHS via MAHIT Direct or HIO PHG must secure written patient consent for sending PHI to DHS leadership when using the MAHIT Direct or P3N PHG route

initiation during stay

Inpatient methadone induction must follow state and federal regulations.

Inpatient / Observation / ED follow-up

Post-ED inpatient/observation follow-up: When a patient is placed in observation or admitted and treated as discharged from the ED, the patient must obtain follow-up OUD treatment within 7 days of ED discharge for the event to count; included treatments are ASAM levels of care and MAT claims.7 days

Applies whether patient was discharged directly from the ED or after observation/inpatient stay treated as ED discharge.

ED follow-up recording: If MAT is initiated during an inpatient stay that originated in the ED, the initiation counts toward follow-up when started during that stay.initiation during stay

Methadone induction in inpatient setting requires a co-occurring diagnosis and adherence to regulations.

Claims for MAT count as follow-up: Claims for MAT—including buprenorphine, methadone, and injectable naltrexone—count as follow-up treatment when received within 7 days of ED discharge. Inpatient initiation counts if started during the inpatient stay.treatment within 7 days

Methadone induction has additional co‑occurring diagnosis and regulatory requirements.