ASAM Clinical Criteria
Overview
Optum Behavioral Health uses the American Society of Addiction Management (ASAM) Criteria as part of our clinical decision making for substance use disorder (SUD) treatment.
The ASAM Criteria are nationally recognized standards and guidelines developed to support individualized and holistic treatment planning, with a focus on outcomes-driven treatment and recovery services. They guide clinicians and care managers in making objective assessments and decisions about patient admissions, levels of care, continuing care and movement along the care continuum.
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Implementation of the ASAM Criteria 4th Edition for adults
Beginning in November 2023, Optum Behavioral Health is implementing The ASAM Criteria, 4th Edition, for the treatment of substance use disorder in adults, unless otherwise mandated by state, federal or contractual requirements. Through 2024, the changes will only apply to Commercial health plans. Medicaid plans will not transition to the 4th Edition guidelines until Jan. 1, 2025 at the earliest. We will update you later this year when additional information is available from the states on their implementation timelines.
What facilities can expect
Optum Behavioral Health will reach out to existing network facilities to update and renew contracts (participation agreements). Note that the 4th Edition changes are not effective until you have a fully executed, updated contract. Until then, you should continue to follow 3rd Edition guidelines.
| If the facility is | Optum Behavioral Health will: | The facility will need to: |
| Currently contracted to provide SUD treatment services | Send the facility an updated contract that reflects the appropriate level(s) of care based on the ASAM 4th Edition definitions of levels of care | Sign and return the new service addendum and payment appendix |
| If the facility is | The facility will need to: | Optum Behavioral Health will: |
| Interested in adding additional ASAM levels of care to a current contract | Complete the Facility Application | Review the application and make contracting decisions, working with the facility for any documentation required |
| Not currently credentialed or contracted to provide SUD Services and wants to join the network | Submit a Facility Application and all required documentation | Review the application and make contracting decisions, working with the facility for any documentation required |
ASAM Level of Care Certification through CARF
The Commission on Accreditation of Rehabilitation Facilities (CARF) is an independent, nonprofit accrediting body that helps organizations measure and improve the quality of their programs and services.
CARF offers a certification program – the only program approved by ASAM – for the assessment, verification and certification of residential substance use disorder treatment services. In order to obtain certification, programs must demonstrate that they deliver services at the level of care defined by The ASAM Criteria. Certification is available for adult levels of care 3.1, 3.5 and 3.7.
Optum Behavioral Health recommends facilities complete CARF certification to better understand the differences in the three levels of care. CARF certification is preferred but not required. However, programs with CARF level of care certification will be prioritized during the ASAM 4th Edition contracting discussions with facilities. Visit CARF Certification to learn more.
About ASAM
ASAM, founded in 1954, is a professional medical society representing more than 7,500 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. Visit asam.org to learn more.
About the ASAM Criteria
First published in 1991, the ASAM Criteria was developed in partnership with a coalition of national and state organizations in the 1980s to define one national set of criteria for providing outcome-oriented and results-based care in the treatment of addiction. The 4th Edition of the ASAM Criteria was published in partnership with the Hazelden Betty Ford Foundation. It features an all-new digital subscription option with a searchable, reimagined e-reader, plus supplementary content for professionals and patients.
About the ASAM Criteria and InterQual
The ASAM Critera Navigator, powered by InterQual, is an interactive tool developed in partnership with ASAM. With a simple, easy-to-use Q&A format, it helps healthcare organizations, payers and providers make clinical decisions that are consistent with The ASAM Criteria. This includes level of care, admission, transfer and continued stay determinations. The ASAM Criteria Navigator significantly reduces the time required for patient assessments - from up to 30 minutes without the tool to less than 15 minutes using the tool. Healthcare organizations and providers may use the tool to help make effective utilization decisions at the point of care or during the preauthorization process.