Alcohol & substance use disorder care

Definition

Alcohol abuse is a pattern of drinking that results in harm to one's health, interpersonal relationships, or ability to work. In the diagnosis manual DSM-5 alcohol abuse is combined with alcohol dependence to create one unified disorder, alcohol use disorder (AUD) that includes a graded clinical severity from moderate to severe with at least 2 criteria to make diagnoses.

Manifestations of alcohol or substance use disorder include failure to fulfill responsibilities at work, school, or home; drinking/using drugs in dangerous situations, including the operation of a motor vehicle; legal concerns associated with alcohol and substance use; and continued use despite problems that are caused or worsened by alcohol or drugs. Abuse can lead to dependence.

Alcohol and substance use clinical practice guidelines

• Screening, Diagnosis and Referral for Substance Use Disorders
• Adolescent and Young Adult Health Risk Behavior Assessment

Authorization for treatment of alcohol and substance use disorders

Members/participants/beneficiaries must meet InterQual® Behavioral Health medical necessity criteria for urgent/emergent admission to a substance use disorder facility.

We also require ongoing clinical reviews to ensure that the member continues to meet medical necessity criteria for treatment.

In network providers

Submit authorizations through GuidingCare.

Request an authorization

Out of network providers

Out of network providers request mental health and substance use disorder services using our authorization request forms.

• Behavioral Health prior authorization form
• Applied Behavior Analysis (ABA) prior authorization form
• Transcranial Magnetic Stimulation (TMS) prior authorization form

Information needed

• Legal involvement related to substance use
• Age of first use
• Age that substance use became problematic
• Type of substances used
• Frequency and amount
• Current vital signs
• Risk factors
• Recommendation