Level of Care/Services Authorization Request (SUD)

Request Type: [initial / concurrent (continued stay) / extension / expedited]

Date Submitted: [Date]

Patient Name: [Full legal name]

DOB: [MM/DD/YYYY]

Member ID: [Member ID] (If unavailable, enter "Unknown" with brief explanation)

Payer/Plan: [Payer name and plan]

Requesting Clinician: [Name, credentials, NPI, phone/email]

Facility/Program: [Program name, address, NPI]

Requested Level of Care: [Level of care with ASAM level if known, e.g., Residential 3.5, IOP 2.1]

Requested Start Date: [MM/DD/YYYY]

Requested Duration: [Number of days or visits]

Primary Diagnosis: [ICD-10 code and description with severity specifier]

Co-occurring Diagnoses: [Diagnoses relevant to placement] (Omit if not applicable)

Medical Necessity Executive Summary

[4–8 sentence narrative identifying the requested level of care and precipitating factors, key clinical drivers such as withdrawal risk, overdose risk, psychiatric instability, medical comorbidity, or unsafe recovery environment, and explanation of why a lower level of care is insufficient at this time]

Clinical Findings Supporting Level of Care

(Provide a targeted, problem-focused narrative. Include only elements necessary to justify level of care. Use objective data when available; if not available, state "Not available at time of request.")

Presenting Problem and Referral Context: [Referral source, chief concern, current episode onset and timeline, precipitant for presentation]

• Substance Use Pattern: [Primary and secondary substances, route, frequency/amount, last use date/time, overdose history, withdrawal complications such as seizures or DTs, current intoxication/withdrawal symptoms]
• Functional Impairment: [Concrete examples attributable to SUD: occupational/academic failure, ADL impairment, unsafe behaviors, ED/hospital utilization, inability to adhere to outpatient care]
• Co-occurring Conditions Driving Placement: [Biomedical issues such as pregnancy, uncontrolled illness, infectious complications; psychiatric/cognitive conditions affecting safety or engagement; current medications and adherence issues] (Include only if relevant to placement decision)
• Objective Data: [Vitals, toxicology/BAL, pertinent labs, withdrawal scale scores such as CIWA-Ar or COWS, pertinent mental status findings] (If unavailable, note "Not available at time of request" and whether planned)

Risk Factors and Safety Concerns

(For each domain, provide supporting facts rather than conclusory statements. Indicate "not present" or "not assessed" as appropriate.)

• Suicide/Self-harm: [Ideation, intent, plan, recent attempts, protective factors, or not present / not assessed]
• Overdose Risk: [Recent overdose, polysubstance use, return-to-use after abstinence, using alone, naloxone access, or not present / not assessed]
• Severe Withdrawal Risk: [Prior seizures/DTs, autonomic instability, sedative/hypnotic use, or not present / not assessed]
• Grave Disability/Inability to Care for Self: [Examples or observations, or not present / not assessed]
• Victimization/Domestic Violence Risk: [Details if impacting placement, or not present / not assessed]

Overall Risk Synthesis: [Brief integrative statement summarizing how acute and chronic risks support requested level of care]

ASAM Multidimensional Placement Rationale

ASAM Criteria Edition: [3rd Edition / 4th Edition / per payer policy]

• Dimension 1 – Intoxication/Withdrawal/Addiction Medications: [low / moderate / high / unable to rate]. [1–2 sentences: current withdrawal status, risk of progression, medication needs]
• Dimension 2 – Biomedical Conditions: [low / moderate / high / unable to rate]. [1–2 sentences: medical issues affecting placement intensity]
• Dimension 3 – Psychiatric/Cognitive Conditions: [low / moderate / high / unable to rate]. [1–2 sentences: mental health or cognitive factors impacting safety or engagement]
• Dimension 4 – Substance Use–Related Risks: [low / moderate / high / unable to rate]. [1–2 sentences: readiness, relapse risk, harm patterns]
• Dimension 5 – Recovery Environment: [low / moderate / high / unable to rate]. [1–2 sentences: housing stability, social supports, environmental triggers]
• Dimension 6 – Person-Centered Considerations: [low / moderate / high / unable to rate]. [1–2 sentences: preferences, strengths, barriers to engagement]

(If data are insufficient to rate a dimension, state "unable to rate" and specify missing information.)

Level of Care Conclusion: [Requested level of care] is indicated because [explanation of why lower levels are insufficient, citing specific failures or risks]. [If applicable, explain why higher levels are not required.] [Anticipated response to this level of care.]

Prior Treatment and Response

(List clinically relevant recent episodes that inform current placement. Omit remote or non-contributory history.)

• [Episode 1]: [Dates, level of care, completion status vs AMA, interventions tried including psychosocial and MOUD/MAUD, objective response markers such as attendance or toxicology, reasons for nonresponse]
• [Episode 2]: [Same elements] (Add additional episodes only if they clarify the pattern driving current placement)

Requested Services and Intensity

• Setting/Program Type: [Level of care with ASAM level]
• Medical/Psychiatric Evaluation: [Frequency, e.g., admission and daily/weekly thereafter]
• Group Therapy: [Sessions per day/week and duration per session]
• Individual Therapy: [Frequency and duration]
• Case Management/Care Coordination: [Services and frequency]
• Peer Recovery Support: [Services and frequency] (Omit if not applicable)
• Toxicology Testing: [Frequency and clinical purpose]
• Medication Treatment: [Withdrawal management protocol, MOUD/MAUD initiation or continuation plan, naloxone distribution/education]
• Total Length Requested: [Days/visits]. Planned Reassessment: [Date or interval for continued stay vs step-down decision]

Goals and Expected Outcomes

(List 3–5 measurable goals for the authorization period.)

• [Goal 1 with measurable endpoint, e.g., complete withdrawal stabilization with CIWA-Ar <8 for 24 hours]
• [Goal 2, e.g., initiate buprenorphine with confirmed follow-up prescriber appointment]
• [Goal 3, e.g., attend ≥80% of scheduled programming]
• [Goal 4, e.g., establish discharge plan with confirmed step-down appointment and housing]
• [Additional individualized goal] (Include only if applicable)

Transition and Step-Down Plan

• Next Level of Care: [Planned step-down level and target timeframe]
• Recovery Supports: [Mutual-help, peer support, recovery residence, family involvement to be engaged]
• Follow-up Appointments: [MOUD prescriber, therapy, primary care, other; include dates if scheduled or note "to be arranged"]
• Barriers and Mitigation: [Identified barriers such as transportation, insurance, housing, childcare, legal issues, and planned mitigation steps]
• Safety Plan Elements: [Relapse/overdose/suicide risk strategies, naloxone plan, crisis contacts]

Authorization to Release Information

Patient Consent Status: [Consent provided / declined / unable to obtain]. (If declined, note impact on submission.) This request includes only the minimum necessary information for authorization and excludes psychotherapy process notes.

Clinician Attestation

Clinician Name and Credentials: [Name, degrees]

Role: [Treating clinician / Medical Director / Utilization Reviewer]

NPI: [NPI]

Date/Time: [MM/DD/YYYY HH:MM]

(If documentation was generated with dictation or AI assistance: "I reviewed, edited, and authenticated this document.")