C.R.S. Section 25.5-5-424
Residential and inpatient substance use disorder treatment

  • MCE standardized utilization management process
  • medical necessity
  • report

(1)

On or before October 1, 2021, the state department shall consult with the behavioral health administration in the department of human services, residential treatment providers, and MCEs to develop standardized utilization management processes to determine medical necessity for residential and inpatient substance use disorder treatment. The processes must incorporate the most recent edition of “The ASAM Criteria for Addictive, Substance-related, and Co-occurring Conditions” and align with federal medicaid payment requirements.

(2)

On or before January 1, 2022, the state department shall incorporate the standards developed pursuant to subsection (1) of this section into existing MCE contracts, and each MCE shall adhere to the standards when conducting utilization management for residential and inpatient substance use disorder treatment.

(3)

On or before January 1, 2022, each MCE’s notice of an adverse benefit determination must demonstrate how each dimension of the most recent edition of “The ASAM Criteria for Addictive, Substance-related, and Co-occurring Conditions” was considered when determining medical necessity.

(4)

Intentionally left blank —Ed.

(a)

Beginning October 1, 2021, and quarterly thereafter, the state department shall collaborate with the behavioral health administration in the department of human services, residential treatment providers, and MCEs to develop a report on the residential and inpatient substance use disorder utilization management statistics. At a minimum, the report must include:

(I)

The average length of an initial authorization and the average length of continued authorizations for each MCE and provider disaggregated by level of residential care;

(II)

Denials of initial authorizations reported for each MCE and provider and the reasons for the denials; and

(III)

The average response time for an initial authorization and continued authorization, disaggregated by each MCE; level of residential care, including the percentage of extensions granted to health-care providers to submit complete clinical documentation; retroactive authorization requests; incomplete authorization requests; and the number of requests that met and did not meet the state department’s response time requirements.

(b)

The state department shall make the report developed pursuant to subsection (4)(a) of this section publicly available on the state department’s website.

(c)

Any information required to be reported pursuant to subsection (4)(a) of this section may be aggregated as necessary to ensure confidentially pursuant to 42 CFR part 2.

Source: Section 25.5-5-424 — Residential and inpatient substance use disorder treatment - MCE standardized utilization management process - medical necessity - report, https://leg.­colorado.­gov/sites/default/files/images/olls/crs2023-title-25.­5.­pdf (accessed Oct. 20, 2023).

25.5–5–101
Mandatory provisions - eligible groups - rules - repeal
25.5–5–102
Basic services for the categorically needy - mandated services
25.5–5–103
Mandated programs with special state provisions - rules
25.5–5–104
Qualified medicare beneficiaries
25.5–5–105
Qualified disabled and working individuals
25.5–5–201
Optional provisions - optional groups - rules - repeal
25.5–5–202
Basic services for the categorically needy - optional services
25.5–5–203
Optional programs with special state provisions - repeal
25.5–5–204
Presumptive eligibility - pregnant person - children - long-term care - state plan
25.5–5–204.5
Continuous eligibility - children
25.5–5–206
Medicaid buy-in program - disabled children - disabled adults - federal authorization - rules
25.5–5–207
Adult dental benefit - adult dental fund - creation - legislative declaration
25.5–5–208
Additional services - training - grants - screening, brief intervention, and referral
25.5–5–301
Clinic services
25.5–5–302
Clinic services - children and pregnant women - utilization of certain providers
25.5–5–303
Private-duty nursing
25.5–5–304
Hospice care
25.5–5–305
Pediatric hospice care - legislative declaration - federal authorization - rules - fund
25.5–5–307
Child mental health treatment and family support program
25.5–5–308
Breast and cervical cancer prevention and treatment program - creation - legislative declaration - definitions - funds - repeal
25.5–5–309
Pregnant women - needs assessment - referral to treatment program - definition
25.5–5–310
Treatment program for high-risk pregnant and parenting women - cooperation with private entities - definition
25.5–5–311
Treatment program for high-risk pregnant and parenting women - data collection
25.5–5–312
Treatment program for high-risk pregnant and parenting women - extended coverage - federal approval
25.5–5–314
Substance use disorder treatment for Native Americans - federal approval
25.5–5–315
Acceptance of gifts, grants, and donations - Native American substance abuse treatment cash fund
25.5–5–316
Legislative declaration - state department - disease management programs authorization - report
25.5–5–318
Health services - provision by school districts - repeal
25.5–5–319
Family planning pilot program - rules - federal waiver - repeal
25.5–5–320
Telemedicine - reimbursement - disclosure statement - rules - definition
25.5–5–321
Telemedicine - home health care - home health telemedicine cash fund - rules - repeal
25.5–5–321.5
Telehealth - interim therapeutic restorations - reimbursement - definitions
25.5–5–322
Over-the-counter medications - rules
25.5–5–323
Complex rehabilitation technology - no prior authorization - metrics - report - rules - legislative declaration - definitions
25.5–5–324
Nonemergency medical transportation - urgent and secure transportation need - report - repeal
25.5–5–325
Residential and inpatient substance use disorder treatment - medical detoxification services - federal approval - performance review report
25.5–5–326
Access to clinical trials - definitions
25.5–5–327
Eligible peer support services - reimbursement - definitions
25.5–5–328
Secure transportation for behavioral health crises - benefit - funding
25.5–5–329
Family planning services - federal authorization - rules - definitions
25.5–5–330
Screening for perinatal mood and anxiety disorder
25.5–5–331
Federally qualified health center - clinical pharmacy services - reimbursement - rules
25.5–5–332
Therapy using equine movement - federal authorization - definition
25.5–5–333
Primary care and behavioral health statewide integration grant program - creation - report - definition - repeal
25.5–5–334
Community health worker services - federal authorization - reporting - rules - definition
25.5–5–335
Continuous medical coverage for children and adults feasibility study - federal authorization - rules - report - definition
25.5–5–336
Prohibition on using the body mass index or ideal body weight - medical necessity criteria
25.5–5–401
Short title
25.5–5–402
Statewide managed care system - rules - definitions - repeal
25.5–5–403
Definitions
25.5–5–406.1
Required features of statewide managed care system
25.5–5–408
Capitation payments - availability of base data - adjustments - rate calculation - capitation payment proposal - preference - assignment of medicaid recipients - definition
25.5–5–410
Data collection for managed care programs
25.5–5–412
Program of all-inclusive care for the elderly - services - eligibility - legislative declaration - rules - definitions
25.5–5–414
Telemedicine - legislative intent
25.5–5–415
Medicaid payment reform and innovation pilot program - legislative declaration - creation - selection of payment projects - report - rules
25.5–5–418
Primary care provider sustainability fund - creation - use of fund
25.5–5–419
Accountable care collaborative - reporting - rules
25.5–5–420
Advancing care for exceptional kids
25.5–5–421
Parity reporting - state department - public input
25.5–5–422
Medication-assisted treatment - limitations on MCEs - definition
25.5–5–423
Independent review organization - review denial of residential and inpatient substance use disorder treatment claims - contract
25.5–5–424
Residential and inpatient substance use disorder treatment - MCE standardized utilization management process - medical necessity - report
25.5–5–425
Audit of MCE denials for residential and inpatient substance use disorder treatment authorization - report
25.5–5–500.3
Authorization to bill third party
25.5–5–501
Providers - drug reimbursement
25.5–5–502
Unused medications - reuse - rules - definition
25.5–5–503
Prescription drug benefits - authorization - dual-eligible participation
25.5–5–504
Providers of pharmaceutical services
25.5–5–505
Prescribed drugs - mail order - rules
25.5–5–506
Prescribed drugs - utilization review
25.5–5–507
Prescription drug information and technical assistance program - rules
25.5–5–509
Substance use disorder - prescription drugs - opiate antagonist
25.5–5–510
Pharmacy reimbursement - substance use disorder - injections
25.5–5–511
Reimbursement for pharmacists’ services - legislative declaration
25.5–5–512
Pharmacy benefit - mental health and substance use disorders - legislative declaration
25.5–5–513
Pharmacy benefits - prescription drugs - rebates - analysis
25.5–5–514
Prescription drugs used for treatment or prevention of HIV - prohibition on utilization management - definition
25.5–5–515
Pharmacy reimbursement - vaccine administration to children - legislative declaration
25.5–5–516
Serious mental illness - prescribed drugs
25.5–5–801
Legislative declaration
25.5–5–802
Definitions
25.5–5–803
High-fidelity wraparound services for children and youth - federal approval - reporting
25.5–5–804
Integrated funding pilot
Green check means up to date. Up to date

Current through Fall 2024

§ 25.5-5-424’s source at colorado​.gov