This in-depth pillar article empowers rehab centers and behavioral health providers by demystifying Elevance Health’s insurance coverage for substance abuse treatment. Discover expert tips on benefit verification, ASAM guideline compliance, prior authorizations, concurrent reviews, and accurate billing & coding—all designed to enhance reimbursement and streamline administrative processes.
Part 6 of 7: Health Care Service Corporation (HCSC): Medical Necessity Criteria for Addiction Treatment
Explore our in-depth guide on HCSC’s Blue Cross Blue Shield plans as they embrace ASAM 4.0 for adult substance use disorder treatment. This post covers critical aspects including detox protocols, inpatient/residential rehab, outpatient services (PHP/IOP), medication-assisted treatment, and billing/coding insights. Stay informed on state mandates and provider best practices to ensure compliance and optimal patient care.
Part 5 of 7: Kaiser Permanente: Medical Necessity Criteria for Addiction Treatment Services
Discover how Kaiser Permanente integrates addiction treatment services using ASAM Criteria to determine medical necessity. This guide covers everything from detox and residential rehab to outpatient programs and MAT, including key insights on billing codes, authorization processes, and provider collaboration.
Part 4 of 7: Cigna: Medical Necessity Criteria for Addiction Treatment Services
Discover how Cigna leverages ASAM criteria to define clinical necessity for substance use treatment. This blog breaks down the detailed guidelines for detox, inpatient and residential rehab, PHP, IOP, and MAT—including key billing codes and documentation tips to streamline the authorization process.
Part 3 of 7: CVS Health (Aetna): Medical Necessity Criteria for Addiction Treatment Services
In Part 3 of our 7-part series, we detail CVS Health’s Aetna guidelines for addiction treatment services. This post breaks down key elements—from detox and inpatient rehab to PHP/IOP and MAT—highlighting the use of ASAM Criteria, precertification protocols, and essential billing codes to ensure medical necessity and optimal reimbursement.
Part 1 of 7: Understanding Medical Necessity Criteria in Addiction Treatment (Introduction)
Welcome to our comprehensive blog series on navigating medical necessity criteria for addiction treatment by insurers. This series unpacks how leading payers—from UnitedHealth Group to Kaiser Permanente—determine coverage for detox, rehab, and therapy services. Discover in-depth analyses of ASAM guidelines, insurer-specific requirements, prior authorization protocols, and key billing codes. Whether you’re a treatment provider or healthcare administrator, our expert insights will empower you to align your documentation with industry standards and overcome coverage hurdles. Dive in to transform insurance challenges into pathways for effective patient care.
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How to Complete Registration as a Provider or Pharmacy with Express Scripts, Inc. for Addiction Treatment Centers
Express Scripts is the largest pharmacy benefit management organization in the United States. It also operates one of the nation’s largest by-mail pharmacies. Over 85 million people receive pharmacy coverage through Express Scripts. The company counts revenues in excess of $100 billion per year. Express Scripts works with many different health insurance payers - government plans, employer plans, and personal plans - to cover the pharmaceutical piece of health insurance. Express Scripts was acquired in recent years by Cigna, and is also associated with Evernorth, a Cigna company.
How to Work with Addiction Treatment Patients Who are Express Scripts Members
There are several situations where an addiction treatment center may need to deal with medical billing for Express Scripts.
The main Express Scripts-related situation most addiction treatment providers will encounter is when an addiction treatment center offers Medication Assisted Treatment (or MAT) for patients in addition to other types of behavioral health services. Examples of common MAT drugs include methadone, Suboxone and Vivitrol.
When providing MAT in-house, addiction treatment centers will be required by federal guidelines to have a medical professional, whether that's a practice nurse, physician assistant, or advanced-practice pharmacist, on staff to dispense medication. Many states require additional credentials or conditions on top of these blanket federal requirements, so check your local regulations to be sure that you're complying with all applicable laws and regulations.
Are Addiction Treatment Centers Who Dispense MAT Considered “Providers” or “Pharmacies” by Express Scripts?
There is no single answer to this question. It depends on how closely you decide to work with Express Scripts at your addiction treatment facility.
If you want to be treated as an enrolled pharmacy with Express Scripts, you’ll need to complete credentialing and enroll as a participating pharmacy. In order to do that, you can email Express Scripts at NetworkCompliance@express-scripts.com with your pharmacy NCPDP number. Express Scripts urges all would-be participating pharmacies to remember that it can take up to 30 days to actually complete the enrollment process after Express Scripts receives your signed contract and completed application.
If you want to be treated as a provider, you do not need to complete an enrollment process. However, you will need to decide how you want to submit Prior Authorization requests.
What Addiction Treatment Medications Does Express Scripts Cover?
Unlike its leading competitor, CVS Health, Express Scripts covers both methadone and buprenorphine in its formulary. (FYI - A “formulary” is just the technical term for a list of medications that a pharmacy benefit company covers.) Generally speaking, members can access both types of medications, although there are restrictions on certain specifics. For example, certain sublingual film versions of the drugs aren’t covered and name-brand Suboxone isn't covered, while the FDA-approved generic version of buprenorphine is covered by Express Scripts.
When Does Express Scripts Require Prior Authorizations for Addiction Treatment Centers?
Express Scripts requires prior authorizations for many medications, including some medications associated with addiction treatment.
Specifically, Express Scripts requires prior authorization for buprenorphine.
However, Express Scripts does NOT require prior authorization for methadone.
Many psychiatric medications, including many antipsychotics and antidepressants, do require prior authorization with Express Scripts. At addiction treatment centers, it’s not uncommon for dual diagnosis patients to be prescribed medications such as these, as well.
How Do I Complete a Prior Authorization with Express Scripts for my Addiction Treatment Centers’ MAT Medications?
Fortunately, Express Scripts offers providers many options for completing prior authorizations.
You may:
-Use an EHR with built-in ePA capabilities
-Use one of several ePA provider portals online that works with Express Scripts (such as Surescripts, covermymeds or ExpressPAth)
-Submit traditional paper prior authorization request forms to Express Scripts by fax
Express Scripts states on their website that over 60% of providers submit ePA requests now, but that still leaves 40% of billing departments opting for paper versions. Whatever you choose, Express Scripts will require your NPI number, so have that at the ready.
Trouble with Addiction Treatment Registration for Express Scripts? We Can Help.
BehaveHealth’s Revenue Cycle Management (RCM) service includes soup-to-nuts, hyper-detailed, hands-on attention to every single component of your addiction treatment billing needs. We have strong working relationships with every major insurance company in the United States.
Even better, we’re not health care generalists. We only work for behavioral health providers like you.
Let our team of specialists handle it all:
Verification of Benefits
Utilization Review
Billing and Collections
Patient Responsibility
Denials and Appeals
Get your free trial started today and see why more addiction treatment centers prefer Behave Health.