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July 2025 Top of Mind
ASAM changes impact Optum Gold Card waivers for SUD PHP programs
Optum Behavioral Health’s transition to ASAM (American Society of Addiction Medicine) 4th Edition Criteria is wrapping up. Beginning no later than July 1, 2025, all network providers who offer substance use disorder (SUD) services to adult members (ages 18+) covered by a fully insured Commercial health plan must follow the updated criteria. This includes developing treatment plans that align with the 4th Edition Criteria levels of care and submitting claims with the associated billing codes.*
What’s changed for PHPs
For partial hospitalization programs (PHPs), the most significant change is to where medical care can be provided in conjunction with SUD treatment:
ASAM 3rd Edition Level of Care |
Revenue Code |
ASAM 4th Edition Level of Care |
New Revenue Code |
SUD Partial Hospitalization / ASAM 2.5 |
912 or 913 |
High Intensity Outpatient / ASAM 2.5 |
907 |
Details: Partial hospitalization for SUD services with medical treatment is no longer recommended at this level of care. If a member needs medical services to support withdrawal treatment or for biomedical and psychiatric comorbidities, the treatment plan should be developed using Medically Managed Intensive Outpatient / ASAM 2.7. |
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ASAM 3rd Edition Level of Care |
Revenue Code |
ASAM 4th Edition Levels of Care |
New Revenue Code |
SUD Partial Hospitalization / ASAM 2.5 and |
912 or 913 |
Medically Managed Intensive Outpatient / ASAM 2.7 |
xxx |
Details:Medical treatment for withdrawal, biomedical and psychiatric comorbidities can only be provided to members under ASAM 2.7, and services can only be provided at an acute care general hospital. They cannot be provided at a freestanding psychiatric hospital. |
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Impact on Gold Card exemptions
With the changes to the levels of care under the 4th Edition Criteria, the former programs and revenue codes no longer exist. In effect, this ends these levels of care and your ability to access Optum’s Gold Card prior authorization exemptions for adult members.
New qualification period
Optum will automatically evaluate these new levels of care/codes from July 1 – Dec. 31, 2025, to determine if you are eligible for an Optum Gold Card exemption beginning next year. To receive an exemption for new levels of care/codes, you must submit at least 5 prior authorization requests between July 1 – Dec. 31, 2025. Requests with a 90% or higher prior authorization approval rate will be granted an Optum Gold Card prior authorization exemption.
Gold Card background
On Oct. 1, 2024, UnitedHealthcare launched a national Gold Card program that waives some behavioral health prior authorization requirements for services covered by eligible UnitedHealthcare commercial, Individual Exchange,* Medicare Advantage and UnitedHealthcare Community plans. At this time, the changes noted above only apply to adult members (ages 18+) covered by a fully insured Commercial health plan.* Review the Quick Reference Guide for detailed information.
Questions? We’re here to help
If you have further questions, please contact the Network Management Team for your state.
*ASAM 3rd Edition Criteria continues to be used for clinical decision making for adolescents. Optum follows CMS guidelines for assessing and treating Medicare members who have substance use disorders. For Medicaid plans, we will follow each state’s requirements as they make the transition to the ASAM 4th Edition Criteria for adult members.
