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Medical Necessity for Residential Treatment The client must have a primary SUD DSM-5 diagnosis which is the cause of

significant functional and psychosocial impairment.

The client’s condition requires residential supervision to ensure the development

of effective coping skills to live safely in the community, to participate in self-care

and treatment and to manage the effects of his/her disorder.

The client’s own resources & social support system are not adequate to provide

the level of support and supervision needed to become abstinent and stabilize in

his/her recovery.

As a result of the client’s clinical condition (impaired judgment, behavior control,

or role functioning), there is a significant current risk of Hospitalization and/or

Harm to self or others based on recent events.

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ASSESSMENT AND

LEVEL OF CARE AUTHORIZATION

(ALOC)

The ALOC is a brief assessment and authorization form used to document the appropriate Level of Care using ASAM placement criteria.

It is done:

✓ At Intake ✓At Discharge ✓ For Transfers

and

✓ Authorization for Residential

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ASAM 6 DIMENSIONS

1. Dim 1 – Acute Intoxication and/or Withdrawal Potential

2. Dim 2 – Biomedical Conditions and Complications

3. Dim 3 – Emotional, Behavioral, or Cognitive Conditions & Complications

4. Dim 4 – Readiness to Change

5. Dim 5 – Relapse, Continued Use, or Continued Problem Potential

6. Dim 6 – Recovery/Living Environment

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ASSESSING RISK AT EACH DIMENSION

Freese & Hasson, UCLA, PSATTC www.uclaisap.org

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RISK RATING SCALES

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1. Initial Authorization for Residential LOC:

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2. Reauthorization for Residential LOC.

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3. Progress Report, Transfer or

Other Re-Assessment Documentation:

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ASAM DIMENSION 1

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ASAM DIMENSION 5

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ASAM DIMENSION 6

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(ASAM Criteria, p.222-224 ):

• Living situation toxic to recovery: substance exposure, substance-

infested environment, culture of substance-involved and antisocial

behaviors, peer use and pressure to use

• Chaotic home situation

• Drug using family or significant others

• Lack of daily structured activity, such as school or work, or not able to

function at school or work due to use

• Patient’s functional deficits include greater than average susceptibility

to peer or other influence

Dim 6 Environment-related issues

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1 OP

2.1 IOT

2.5 Partial

Hospitalization

3.1 Residential

3.2 WM

0.5 Early

Intervention

3.5 Res

3.3 Res

SBIRT (Screening, Brief Intervention & Referral to Treatment occur with

Primary Care) (Offered in Medical Homes-PCBH)

Less than 9 hrs adult

Less than 6 hrs adolescents

9 to 19 hrs/week - adult

6 to 19hrs/week - adolescent

Approx. 20 hrs per week (Only

in PSAP currently)

Withdrawal Mgmt., Intoxication Mgmt.

Non-medical clinical services where TX is

provided based on person’s ability

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Min 5 hrs clinical service/week

20 hrs per week

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3.1: Minimum 5 hrs. TX per week – not responding to increased services in OS,

IOS. Repeated returns to use, environment unsupportive of recovery efforts.

• Risk in environment; examples: using partner, family, dealers nearby,

released from custody and risk of overdose if not is safe environment

(particularly with Opiate use)

• Inability to deal with peer pressure

• Parental inability to support adolescent.

3.3: High intensity Res for Special Populations - cognitively impaired, Seniors,

developmentally delayed. Treatment is offered at slower pace, repetitive

• Cognitive deficits and related dangerous consequences of use

• Risk in environment

3.5: High Intensity Residential - Multiple limitations: SMI, chaotic interpersonal, have never

developed adequate coping skills

• Functional deficits in mental health, such as inability to control impulses

• Difficulty with or marked opposition to treatment with dangerous consequences

• No recognition of skills needed to prevent continued use, with imminent dangerous

consequences

• Risk in environment.

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LEAST RESTRICTIVE LEVEL OF CARE

Research findings: Outpatient Services are at least as effective as Residential.

Longer length of time in any type of treatment shows better outcomes.

(3+ months)

Outpatient Considerations: Increase number of group and individual sessions

Move to Intensive Outpatient Services

Use a Recovery Residence as adjunctive support to OP TX

No need to fail in treatment first if Residential is indicated per Medical

Necessity

Residential Treatment is primarily for STABILIZATION

RESIDENTIAL AUTHORIZATION

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Type of Authorization:

Determination:

Reason for Determination:

AUTHORIZATION DETERMINATION

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www.changecompanies.nethttps://www.changecompanies.net/account/register.php?reg_code=hhs052617

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QUESTIONS?

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