Utilization Review Criteria for Substance Use Disorder Benefits

BULLETIN 19-18 Date: October 16, 2019 To: Insurers, Nonprofit Health Service Plans, Health Maintenance Organizations, and Private Review Agents Re: House Bill 599, Chapter 358, Acts of 2019 Utilization Review Criteria for Substance Use Disorder Benefits The purpose of this bulletin is to remind insurers, nonprofit health service plans, and health maintenance organizations (“carriers”) and private review agents (“PRAs”) of the new utilization review criteria requirement for substance use disorder benefits. Authority House Bill 599 of the 2019 legislative session, effective January 1, 2020, amends Insurance Article, § 15-802, Annotated Code of Maryland to require carriers and PRAs acting on behalf of carriers to use the most recent edition of the American Society of Addiction Medicine treatment criteria for addictive, substance–related, and co–occurring conditions (“ASAM criteria”) for all medical necessity and utilization management determinations for substance use disorder benefits provided under individual, group, and blanket health benefit plans that are delivered or issued for delivery in Maryland. The ASAM criteria establish guidelines for placement, continued stay, and transfer or discharge of patients with addiction and co-occurring conditions. PRA Requirements Beginning on January 1, 2020, PRAs with a certificate of registration to conduct utilization review in Maryland must use the ASAM criteria when making substance use disorder medical necessity and utilization review determinations for patients covered under insured health benefit plans that are issued or delivered in Maryland. PRAs providing utilization review services for substance use disorder benefits must also update their applications for certification to conform to the new requirement. The most recent edition of the ASAM criteria must be identified in Question 17 of the application as the specific criteria used in conducting utilization review for AL REDMER, JR. Commissioner LARRY HOGAN Governor BOYD K. RUTHERFORD Lt. Governor 200 St. Paul Place, Suite 2700, Baltimore, Maryland 21202 1-800-492-6116 TTY: 1-800-735-2258 www.insurance.maryland.gov substance use disorder benefits under insured health benefit plans. The amended application is required to be submitted to the Maryland Insurance Administration no later than January 1, 2020. Uniform Treatment Plan Form To facilitate the application of the ASAM criteria, the Maryland Insurance Administration anticipates that the uniform treatment plan (“UTP”) form required by Insurance Article, § 15- 10B-03, Annotated Code of Maryland will be modified to allow the PRA to request suitable information when conducting utilization review of services for the treatment of a substance use disorder. The Maryland Insurance Administration will notify all impacted parties once the UTP form is modified. Questions about this Bulletin may be directed to the Life/Health Section of the Maryland Insurance Administration at 410-468-2170. AL REDMER, JR. Commissioner By: Origin __________________ David Cooney Associate Commissioner Life and Health