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UnitedHealth Group (including UnitedHealthcare and Optum Behavioral Health) uses evidence-based criteria to determine coverage for substance use disorder (SUD) treatment. In fact, Optum (UnitedHealth’s behavioral health arm) has adopted the American Society of Addiction Medicine (ASAM) Criteria as the official guideline for SUD levels of care (Clinical Criteria and Guidelines). This means that decisions about detox, rehab, outpatient treatment, and medication-assisted treatment must align with ASAM’s nationally recognized standards. Below we break down how UnitedHealth Group applies these criteria to different levels of addiction care, what the prior authorization process entails, and key billing codes providers should know.
ASAM Criteria and UnitedHealth’s Coverage Guidelines
UnitedHealth’s utilization reviewers use the ASAM Criteria, 4th Edition as the clinical benchmark for SUD treatment needs (Clinical Criteria and Guidelines). ASAM provides a multidimensional assessment of patient needs (covering withdrawal risk, medical status, psychiatric needs, readiness to change, relapse risk, and environment). For providers, this means that documenting each of ASAM’s six dimensions in patient assessments can help demonstrate medical necessity. UnitedHealth will cover SUD treatment at the “least intensive, but safe” level of care appropriate for the patient, in line with ASAM’s placement guidelines. Providers should explicitly tie treatment recommendations (e.g. inpatient detox vs. outpatient) to ASAM level-of-care indications. For example, if requesting residential rehab, note why the patient cannot be safely treated at an intensive outpatient level – such as failed attempts at lower care or lack of a supportive home environment (ASAM Dimension 6).
Detoxification (Withdrawal Management) Criteria
Detox (withdrawal management) is considered medically necessary by UnitedHealth when a patient is at risk of severe or life-threatening withdrawal symptoms that require 24-hour medical supervision. UnitedHealth follows ASAM Criteria for Withdrawal Management (ASAM Level 4 or 3.7WM). Signs like high CIWA or COWS scores, seizure history, delirium tremens risk, or acute co-occurring medical conditions support the need for inpatient detox. UnitedHealth’s coverage determination guidelines explicitly reference ASAM’s criteria for withdrawal management in determining if inpatient detox is justified (Chemical Dependency/Substance Abuse Rehabilitation – UnitedHealthcare West Benefit Interpretation Policy). Providers should document the specific withdrawal symptoms observed, substances used and last use, vital signs, and any prior complications from withdrawal. If withdrawal can be managed safely with medications in an outpatient setting, United may approve ambulatory detox instead. ASAM Level 2-WM (ambulatory withdrawal management) criteria must be met: for instance, the patient is mildly to moderately symptomatic and has a safe home environment for detox. Always indicate why a lower level of detox care is insufficient – e.g. lack of reliable support at home or co-existing medical issues that warrant inpatient monitoring.
Common billing codes for detox: UnitedHealthcare plans typically recognize HCPCS “H-codes” for detox services. For inpatient hospital-based detox, use codes like H0008 (sub-acute detox, inpatient) or H0009 (acute detox, inpatient). For non-hospital residential detox, use H0010 (sub-acute detox, residential) or H0011 (acute detox, residential) (Everything You Ever Wanted to Know About Aetna Precertification for Addiction Treatment Billing) (Understanding HCPCS and CPT Billing Codes for Addiction Treatment Detox : Inpatient, Residential, and Outpatient ). Ambulatory (outpatient) detox is billed with H0014 (ambulatory detoxification) for services like medication management and monitoring without 24-hour facility care (Understanding HCPCS and CPT Billing Codes for Addiction Treatment Detox : Inpatient, Residential, and Outpatient ) . Make sure to follow United’s billing guidelines – for example, detox in a hospital may require revenue codes on a UB-04 claim, whereas outpatient detox could be billed on a CMS-1500 with appropriate CPT/HCPCS codes. Always verify whether the particular United plan uses UB or HCFA billing for the level of care.
Residential Inpatient Rehabilitation Criteria
Residential treatment (ASAM Level 3.7 or 3.5) under UnitedHealth is authorized when round-the-clock care is necessary for a patient’s safety and recovery. Typically, UnitedHealthcare looks for moderate to severe SUD diagnoses (e.g. meeting 6+ DSM-5 criteria for dependence) accompanied by functional impairments and inability to succeed in outpatient care. For instance, a patient with repeated relapses in outpatient programs, or one with unstable living conditions that sabotage recovery, may meet criteria for residential rehab. Insurers like United often expect to see that less intensive levels of care were attempted or considered before jumping to residential, unless the patient’s initial presentation is so acute that outpatient treatment isn’t safe. According to Optum’s guidelines, there must be evidence that the patient requires 24-hour structure to prevent relapse or harm, and that without residential care their condition is likely to deteriorate (Substance Use Disorder Intensive Outpatient Programs) (Substance Use Disorder Intensive Outpatient Programs). Documentation should highlight factors like cravings, psychiatric co-morbidities, lack of sober supports, or past treatment failures that justify residential placement.
For inpatient rehab (sometimes used interchangeably with residential in insurance terms), UnitedHealth uses ASAM Criteria to assess dimensions such as relapse potential and recovery environment. For example, ASAM Dimension 5 (Relapse/Continued Use risk) being high (patient unable to remain sober outside of a controlled setting) and Dimension 6 (Recovery Environment) being unsupportive are strong justifications for residential care (Substance Use Disorder Intensive Outpatient Programs) (Substance Use Disorder Intensive Outpatient Programs). Providers should include notes from any prior intensive outpatient (IOP) or partial hospitalization program (PHP) attempts, or if none, explain why those levels aren’t appropriate (e.g. patient lacks housing or has medical needs needing on-site care).
Common billing codes for residential rehab: UnitedHealthcare plans generally recognize H0017, H0018, H0019 for residential SUD treatment. These HCPCS codes denote short-term and long-term residential treatment per diem. For instance:
H0018: short-term residential treatment (non-hospital, typically up to 30 days).
H0019: long-term residential treatment (non-medical, longer than 30 days). In some cases, H0010/H0011 might also be used for residential programs that include detox services. Always bill the code that reflects the service setting and intensity. United may require prior authorization for each admission and periodically for continued stay. Utilization review will use ASAM continuing care criteria to decide if continued residential days are necessary, so keep documenting progress and ongoing needs.
Outpatient Programs (PHP and IOP) Criteria
Outpatient addiction treatment spans several levels, notably Partial Hospitalization Programs (PHP) and Intensive Outpatient Programs (IOP). UnitedHealth covers PHP (ASAM Level 2.5) and IOP (ASAM Level 2.1) when those intensive services are medically necessary.
Partial Hospitalization (PHP) – typically 5 days a week, ~20 hours per week of structured therapy – is indicated for patients who need a high level of support but can still safely reside at home or in a sober living environment. United will approve PHP if the patient has significant impairment (e.g. persistent cravings, co-occurring mental health issues, or recent relapse) and requires near-daily monitoring, yet does not require 24-hour care. Providers should show that without daily structure the patient is at risk of hospitalization, but with PHP level support they can avoid inpatient treatment. For example, a patient just discharged from inpatient rehab might step down to PHP if they still need intensive therapy and medical oversight (like daily vitals or medication adjustments) to maintain recovery.
Intensive Outpatient (IOP) – typically 3 days a week, 3 hours per day (9+ hours weekly) – is a step down from PHP. UnitedHealth’s criteria for IOP generally require that the patient still has notable symptoms or risk (e.g. unstable relapse triggers, mild withdrawal symptoms, or a co-occurring condition) that can’t be managed with standard weekly therapy. However, the patient must be safe enough to live in the community. Blue Cross NC’s policy (which is similar to many insurers’ approach) provides a good example of IOP admission criteria: the patient must have a SUD diagnosis as the primary focus, need at least 9 hours of treatment weekly, have some functional impairment, and have recent active substance use (or high relapse risk) despite lower treatment (Substance Use Disorder Intensive Outpatient Programs) (Substance Use Disorder Intensive Outpatient Programs). UnitedHealth will expect similar justifications. Document any failed attempts at traditional outpatient therapy or any escalation in symptoms that necessitate structured IOP programming (for instance, increased frequency of use, or mental health decompensation when seen only once a week).
Both PHP and IOP require strong support for why a less intensive outpatient schedule is not sufficient. On the flip side, ensure the patient’s condition doesn’t require a residential level – if there are severe withdrawal or safety concerns, United may deny PHP/IOP and suggest a higher level. So it’s a balance: the patient’s profile should fit in the moderate range of severity – too severe and they need inpatient, too mild and weekly outpatient is enough.
UnitedHealthcare’s prior authorization guidelines often bundle PHP/IOP under behavioral health services requiring precertification. Notably, as of a few years ago some states have parity laws prohibiting insurers from requiring prior auth for routine outpatient SUD services. UnitedHealthcare adheres to such laws – for example, per federal regulation, they no longer require prior auth for standard outpatient therapy or basic office visits. However, IOP and PHP typically still require authorization because they are higher-intensity. Always check the member’s plan; failure to pre-certify an IOP/PHP could lead to denial even if medically necessary.
Common billing codes for PHP/IOP: UnitedHealthcare may accept HCPCS code H0015 for IOP services. H0015 is defined as alcohol/drug IOP services, per day (minimum 3 hours per day, 3 days a week) (Understanding HCPCS and CPT Billing Codes for Outpatient Addiction Treatment: H0015, H2036, S0201, and S9480) (Understanding HCPCS and CPT Billing Codes for Outpatient Addiction Treatment: H0015, H2036, S0201, and S9480). If billing by units of 3 hours, some payers allow one unit of H0015 per 3-hour session. Important: Some UnitedHealth plans or employer groups prefer using CPT code S9480 (Intensive outpatient psychiatric service, per diem) for IOP, especially if the plan doesn’t use H-codes. United does cover S9480 in many cases as an equivalent code for IOP** (Understanding HCPCS and CPT Billing Codes for Outpatient Addiction Treatment: H0015, H2036, S0201, and S9480) (Understanding HCPCS and CPT Billing Codes for Outpatient Addiction Treatment: H0015, H2036, S0201, and S9480). For PHP, the billing might use HCPCS H0035 (mental health PHP, per day) or sometimes S0201 (partial hospitalization, per diem) depending on the contract. Always verify United’s billing policy: for example, Optum may require PHP to be billed on a facility claim with revenue code 912 along with a CPT like 90791 or H0035. In contrast, IOP might be billed on a professional claim with H0015. These nuances can vary, so reviewing United’s provider manual or contacting Provider Services can prevent coding issues.
Medication-Assisted Treatment (MAT) Criteria
UnitedHealth Group covers Medication-Assisted Treatment (MAT) for opioid use disorder (OUD) and alcohol use disorder as a highly effective, medically necessary service in most cases. Thanks to the support of parity laws and evidence-based guidelines, United does not impose undue restrictions on MAT. For opioid addiction, FDA-approved medications like buprenorphine (Suboxone/Subutex), methadone, and naltrexone (Vivitrol) are considered standard of care. UnitedHealthcare typically deems MAT medically necessary for any patient diagnosed with moderate to severe OUD who consents to treatment. There is no “fail-first” requirement (United will not require a patient to try abstinence-only rehab before approving MAT). In fact, fail-first policies for MAT are widely recognized as inappropriate and are not used by United – this aligns with CMS and ASAM recommendations that MAT be available without arbitrary prerequisites (CP.BH.100 Substance Use Disorder Final).
Providers should document the patient’s OUD diagnosis (using DSM-5 criteria), their treatment history (if any), and the rationale for MAT (e.g. history of relapse off MAT, or patient preference coupled with evidence that MAT improves outcomes). Urine drug screen results, if available, can support the diagnosis but are not strictly required for initial authorization. United may require periodic documentation for continued MAT (such as evidence of adherence, counseling attendance, and absence of adverse effects). However, maintenance MAT can be covered indefinitely as long as it’s medically necessary – there’s no set cutoff since United follows the principle that treatment duration should be individualized (many individuals require long-term or lifetime MAT, similar to diabetics needing ongoing insulin) (CP.BH.100 Substance Use Disorder Final).
For alcohol use disorder, medications like naltrexone, acamprosate, or disulfiram are also covered when appropriate. These typically don’t require pre-authorization, but the counseling and monitoring services as part of a MAT program might. If a patient is in a methadone maintenance program (OTP clinic), UnitedHealthcare generally covers the methadone administration (often billed as H0020, see below) and associated therapy as a bundle. United has updated its policies in compliance with the SUPPORT Act, so prior authorization is no longer required for OUD treatment medications in many plans. For example, methadone in licensed OTPs and buprenorphine prescriptions should not face PA in Medicaid and often commercial plans now follow suit.
Common billing codes for MAT: If you are billing an OTP (opioid treatment program) service to United, use H0020 for methadone administration (per diem). UnitedHealthcare does not require PA for methadone dosing at in-network OTP providers (Substance Use Disorder Treatment | Clinical Review Criteria). Buprenorphine treatment in an office-based setting is typically billed with evaluation/management codes (e.g. 99213 with a modifier for MAT such as HF or HG in some plans) or the HCPCS G-codes for opioid treatment that Medicare uses (G2067-G2075) if applicable. Check United’s policy; many commercial plans simply use standard E/M plus a urine drug test code. Naltrexone injections (Vivitrol) are billed with J2315 for the medication plus an injection administration code; these usually require notification but not full PA for each shot once approved. United may cover peer support and counseling under separate codes (like H0004 for individual counseling) as part of MAT – ensure these services are documented as part of the comprehensive MAT plan.
UnitedHealthcare encourages coordination of behavioral therapy alongside MAT. When requesting authorization for MAT in an intensive program (IOP or PHP with MAT), make sure to include that MAT is integrated with counseling and psychosocial support, as this meets ASAM criteria for comprehensive treatment (Substance Use Disorder Treatment | Clinical Review Criteria).
Prior Authorization Process and Documentation for UnitedHealthcare
Prior authorization (PA) is required by UnitedHealth Group for most SUD treatment services beyond standard outpatient therapy. This includes inpatient detox, residential rehab, PHP, IOP, and often MAT in structured programs. United has a centralized process for behavioral health prior authorization, typically handled through Optum’s provider portal or phone line. Best practice: Obtain authorization at least 5 business days before admission whenever possible. UnitedHealthcare advises allowing five business days for PA processing, and they will issue a determination letter once review is complete (How to Determine the Medical Necessity of Addiction Treatment Services for UnitedHealth Group, Inc). In urgent situations (e.g. crisis admissions), United can do expedited reviews – providers should indicate if the request is urgent (service needed within 72 hours to prevent harm).
When submitting a PA request to United, include thorough clinical documentation to demonstrate medical necessity:
Initial assessment and diagnosis: Provide the SUD diagnosis (with DSM-5 criteria symptoms) and any co-occurring mental or physical diagnoses.
ASAM dimensions: Structure your clinical summary around the six ASAM dimensions. For example, Dimension 1 (Withdrawal Potential): describe vital signs, withdrawal scale scores, substances used and last use. Dimension 2 (Medical): list any acute or chronic medical issues. Dimension 3 (Mental Health): note depression, anxiety, PTSD, etc. and how they impact SUD. Dimension 4 (Readiness to Change): patient’s motivation level. Dimension 5 (Relapse Risk): history of relapse, cravings, triggers. Dimension 6 (Environment): living situation, support system, any ongoing substance use in the home.
Why requested level of care is needed: Clearly articulate why the patient needs the level of care being requested and why a lower level would be insufficient. For instance, “Patient experienced severe alcohol withdrawal (CIWA=18) requiring Ativan taper – cannot be managed safely outpatient, thus inpatient detox is required” or “Patient failed IOP last month (continued use occurred), lacks sober support at home, indicating need for residential treatment.”
Treatment plan: Outline the intended treatments (e.g. “Will initiate buprenorphine induction and provide daily CBT and relapse prevention groups”) and goals. United wants to see that the planned services align with the patient’s needs.
If continuing stay: provide an update on progress and ongoing needs. For continuing residential or IOP authorizations, use ASAM continued stay criteria – e.g. patient has made progress but still has cravings or co-occurring symptoms that require continued intensive treatment ().
UnitedHealthcare’s reviewers will check the request against four key questions (How to Determine the Medical Necessity of Addiction Treatment Services for UnitedHealth Group, Inc): (1) Is the treatment medically necessary? (2) Is it a covered benefit in the member’s plan? (3) Is it not excluded by plan terms? (4) Does any exclusion or limitation in the plan documents apply? The medical necessity question is addressed by meeting ASAM criteria and generally accepted standards. The other questions are more administrative – for example, some employer plans might exclude residential care or limit MAT coverage (though under mental health parity such exclusions are rare now). It’s crucial for providers to verify benefits (often via a Verification of Benefits (VOB) process) before providing services (How to Determine the Medical Necessity of Addiction Treatment Services for UnitedHealth Group, Inc). During the VOB call, ask United specifically which levels of SUD care are covered and which require precertification.
Tip: When dealing with UnitedHealthcare, always obtain a reference number for the authorization and get the determination in writing. If a service is denied, United’s determination letter will explain the reason (e.g. not meeting criteria, or not a covered benefit) (How to Determine the Medical Necessity of Addiction Treatment Services for UnitedHealth Group, Inc). Providers have the right to appeal denials, providing additional information or correcting any misunderstandings. In many cases, denial issues come from insufficient documentation, so a robust initial PA request can prevent back-and-forth. If you are “stumped” by what United is requiring, remember that federal parity law mandates they use comparable standards as for medical/surgical care (How to Determine the Medical Necessity of Addiction Treatment Services for UnitedHealth Group, Inc) – you can reference this if you ever need to advocate during an appeal.
UnitedHealthcare uses an online portal (Provider Express for Optum) where you can submit clinical information and check authorization status. Many providers find it helpful to use the Optum authorization request forms which often mirror ASAM dimensions. Also, ensure you complete any insurer-specific forms (some United plans have a SUD treatment request form).
Finally, note that failing to obtain a required prior authorization can result in claim denial. UnitedHealthcare is strict about this – a claim can be denied for no PA even if it was medically necessary. Thus, integrate PA checks into your intake process. According to a Behave Health article on UnitedHealth billing, not securing PA in advance is one of the most common reasons for denial, and United will deny claims on that basis alone (How to Determine the Medical Necessity of Addiction Treatment Services for UnitedHealth Group, Inc). So, treat PA as mandatory unless you have written notice that no PA is needed for a particular service.
Additional Resources: For more guidance, see Behave Health’s blog post on How to Determine the Medical Necessity of Addiction Treatment Services for UnitedHealth Group. It offers additional tips on navigating United’s processes and emphasizes the importance of prior authorization for UnitedHealthcare (How to Determine the Medical Necessity of Addiction Treatment Services for UnitedHealth Group, Inc).
Billing Codes and Documentation Tips for UnitedHealthcare
UnitedHealth Group accepts a range of billing codes for SUD treatment, but providers must use the codes consistent with the level of care and the billing type (facility vs professional). We’ve mentioned many of the relevant HCPCS codes above (H0001 series for services, H003x for programs, etc.). Here we summarize key codes by service and any United-specific nuances:
SUD Assessment: Use H0001 for initial alcohol/drug assessment. Many United plans cover one assessment without auth to establish medical necessity.
Individual therapy: Use standard CPT codes 90832, 90834, 90837 (for 30, 45, 60-min psychotherapy) with an appropriate SUD diagnosis code (F10-F19 series). No auth required for basic therapy visits typically.
Group therapy: Use H0005 (alcohol/drug group counseling) or CPT 90853. United usually covers group therapy in IOP or PHP; check if they prefer H0005 for SUD groups.
Medical evaluation: Use 90792 (psychiatric diagnostic eval with medical services) for intake psychiatric evaluations, if applicable.
Detoxification: As noted, H0008/H0009 for inpatient hospital detox, H0010/H0011 for residential detox, H0014 for ambulatory detox. United will look at revenue codes as well – e.g. inpatient detox often billed under revenue code 012x or 0912 (detox). Ensure the correct rev code on UB-04.
Residential treatment: H0017, H0018, H0019 per diem codes. United might require splitting billing: for example, some plans want the room and board portion separated (if not covered) – but generally, these H-codes are all-inclusive per diem. Verify if a modifier (like TG for complex/high level) is needed; Optum sometimes uses modifiers to denote adult vs adolescent programs.
Partial Hospitalization (PHP): Could use H0035 or sometimes CPT 90791/90899 with rev code 0913. United’s claims systems often expect a combination of PHP-specific revenue code and a generic CPT since not all use H-codes. Check United’s Behavioral Health Billing guide for your state or plan.
Intensive Outpatient (IOP): H0015 (IOP per day) is common. Some United plans alternatively accept S9480 (non-hospital IOP, per diem). A few may even use H2036 (Day treatment, per diem) to represent a full day of IOP when needing granularity (Understanding HCPCS and CPT Billing Codes for Outpatient Addiction Treatment: H0015, H2036, S0201, and S9480). Always include appropriate units (e.g. 1 unit = 1 day).
Medication Management: For MAT visits with an MD/DO or NP, use E/M codes (99201-99215 series) with a diagnosis of OUD. Add modifier -HG for opioid program in some Medicaid plans.
Methadone dosing (OTP): H0020 as mentioned for daily dosing. United may require weekly or monthly bundling of H0020 (some pay per week of service, 5 units/week).
Lab Testing: H0003 for drug screening (collection and handling) and G0480-G0483 or G0659 for definitive urine drug tests (if you’re a lab provider). United follows CMS guidelines on frequency (e.g. 8 per month in high-risk cases ([PDF] Substance use disorders | Humana)). Ensure that any lab testing billed is supported by the treatment plan (random tests in MAT, etc.).
Insurer-specific nuances: UnitedHealthcare often aligns its billing requirements with CMS guidelines and the National Correct Coding Initiative (NCCI) (Chemical Dependency/Substance Abuse Rehabilitation – UnitedHealthcare West Benefit Interpretation Policy). They may audit claims for correct code usage (for example, not billing two per diem codes on the same date). United also periodically updates its policies – a notable update is that effective November 2023, Optum began using ASAM Criteria 4th edition which didn’t directly change codes but reinforces that documentation must reflect current ASAM terminology (Clinical Criteria and Guidelines). Also be mindful of United’s concurrent review process: for inpatient/residential, United might only initially authorize a few days and then require a clinical update call for extension. Always submit those updates on time to extend auth and ensure claims for longer stays are paid.
Bottom line for billing: match your claim codes to what was authorized. If United authorized “IOP 3x week for 4 weeks,” billing H0015 for 12 days total is expected. Deviating (like billing more units than authorized) can trigger denials. Use modifiers as needed (e.g., UA, UB modifiers for level distinctions in some Medicaid plans with United). When in doubt, reach out to United’s provider support or consult their provider manual. Accurate coding, paired with solid documentation, will lead to smoother reimbursement. For a deeper dive into coding for addiction services, see Behave Health’s guide Understanding HCPCS and CPT Billing Codes for Addiction Treatment – it covers detox, inpatient, residential, and outpatient codes in detail and can help ensure you’re using the right codes for UnitedHealthcare claims.