July 2025 Top of Mind

ASAM changes impact National Optum Gold Card waivers for SUD PHP programs

Optum Behavioral Health’s transition to ASAM (American Society of Addiction Medicine) 4th Edition Criteria for adult members covered by a Commercial health plan continues.*

The Criteria are used as part of our clinical decision making for substance use disorder (SUD) treatment. This transition requires program name and revenue code changes to some contracted programs, if contained within your Participation Agreement.

What’s changing 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 is no longer recommended if the member requires biomedical services for intoxication, withdrawal and/or biomedical and psychiatric comorbidities. If this level of care is needed, the treatment plan should be developed using Medically Managed Intensive Outpatient / ASAM 2.7 at an appropriately licensed facility.
ASAM 3rd Edition Level of Care	Revenue Code	ASAM 4th Edition Levels of Care	New Revenue Code
SUD Partial Hospitalization / ASAM 2.5	912 or 913	Medically Managed Intensive Outpatient / ASAM 2.7	944 or 945 with medical services billed appropriately
Details: Medical treatment for withdrawal, biomedical and psychiatric comorbidities can only be provided to members under ASAM 2.7. Services can only be provided at an acute care general hospital. They cannot be provided at a freestanding psychiatric hospital.

Note: The program names and revenue codes have not changed for Intensive Outpatient / ASAM 2.1 or ASAM 3.5 / Clinically Managed High Intensity Residential / ASAM 3.5 levels of care.

Contract updates required

Optum Behavioral Health will reach out to existing network providers/facilities to update Participation Agreements as needed. Until you have a fully executed, updated contract, you should continue to follow 3rd Edition guidelines for PHP treatment for adults covered by a Commercial health plan.

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.

Providers who have a National Gold Card exemption under 3rd Edition Criteria can continue to follow the waiver for services provided to adolescent members (ages 12-17), as well as for eligible Medicare Advantage and UnitedHealthcare Community plans.

New qualification period

Optum will evaluate the new 4th Edition Criteria levels of care/codes to determine if they can be added to the waiver in a future update.

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.

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