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ASAM Clinical Criteria Information

ASAM 3.5 Clinical Criteria Information
Implementation of ASAM 3.5 goes into effect January 1, 2021

Additional Resources

 

For the treatment of Substance Use Disorders  

The American Society of Addiction Medicine’s (ASAM) nationally recognized set of criteria helps to simplify both the provider and consumer experience and facilitates clearer communication among families, treatment providers, and clinical reviewers. Optum uses the ASAM criteria in clinical decision making for Substance Use Disorder (SUD) treatment.

ASAM, founded in 1954, is a professional medical society representing over 6,000 physicians, clinicians and associated professionals in the field of addiction medicine. ASAM is dedicated to increasing access and improving the quality of addiction treatment, educating physicians and the public, supporting research and prevention, and promoting the appropriate role of physicians in the care of patients with addiction.

The ASAM Criteria was not written for health plans or insurance coverage but was written to improve assessment and outcomes-driven treatment and recovery services. It is used to match patients to appropriate types and levels of care. It defines specific levels of care within SUD services that comprise the care and evaluation within the six dimensions to determine patient placement.

Implementation of ASAM 3.5

Effective January 1, 2021, Optum is implementing and providing expanded coverage for ASAM 3.5 residential treatment for SUD unless otherwise mandated by state, federal or contractual requirements

How this impacts facilities

If a facility is currently contracted to provide SUD Residential Treatment Services, Optum will be updating the contract to reflect the appropriate level(s) of care based on ASAM definitions of levels of care 3.7 and 3.5. The facility will need to sign a new payment appendix and service addendum.

If a facility is not currently contracted to provide SUD Residential Treatment Services but does offer services that align with ASAM 3.5, a new application may be submitted online for contracting consideration here: https://optumprovider.secure.force.com/fnrf/

For an existing Optum facility that would like to add ASAM levels of care to their contract, please complete the Facility Application and the ASAM Levels of Care form. This information can also be found on our Forms page under Optum Forms - Clinical as well as on our Contact us page under Facility Record Maintenance.

All ASAM contracting, remediation and updates will require the completion of additional documentation. The Facility ASAM updates will require the following documents complete:

  • ASAM Level of Care Form 
  • ASAM Facility Daily Schedule of Activities - including a detailed account of facility daily activities, time, day, duration and facilitator type (Coming soon)
  • Facility Application (An abbreviated facility application demonstrating updates to facility programs must be completed)
ASAM and CARF Residential Addiction Treatment Certification

The Commission on Accreditation of Rehabilitation Facilities (CARF) is an independent, nonprofit accrediting body whose mission is to promote the quality, value, and optimal outcomes of services through a consultative accreditation process and continuous improvement services that center on enhancing the lives of persons served. This accrediting body establishes consumer-focused standards to help organizations measure and improve the quality of their programs and services.

As part of the certification process, CARF evaluates a facility’s treatment program capabilities. In order to obtain certification, programs must demonstrate that they deliver services at the level of care as defined by The ASAM Criteria. Programs with CARF level of care certification will be prioritized for re-contracting. In contracting for ASAM level of care 3.5, CARF certification is preferred but not required.