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Upcoming Changes to the review process for Substance Use Disorder (SUD) ASAM Level 3.7 Services
Date: 09/08/26
Effective Date: Monday November 9th, 2026
Delaware First Health is notifying providers of an upcoming change to the review process for Substance Use Disorder (SUD) medically managed Residential Treatment services. This change is intended to align operational processes with current regulatory requirements and applicable ASAM criteria.
What Is Changing?
Effective November 9th, 2026, Delaware First Health will implement a retrospective medical necessity review process for ASAM Level 3.7 services.
Under this process:
- Prior authorization is not required as a condition of coverage for ASAM Level 3.7 services.
- Providers must continue to notify Delaware First Health of admissions using the Delaware First Health Behavioral Health/SUD Notification Form.
- Retrospective medical necessity review will occur after discharge based on submitted clinical documentation and will evaluate all days of service using ASAM criteria.
- Clinical documentation supporting medical necessity must be submitted following discharge for retrospective review.
Services Impacted
The following procedure codes are associated with ASAM 3.7 Medically Managed Residential Treatment: H2036 TG, 118, 128, 138, 148, and 158
Admission Notification Requirements Remain Unchanged
Providers must continue to notify Delaware First Health of member admissions within required notification timeframes using the Behavioral Health/SUD Notification Form found on the Delaware First Health provider website, under the Provider Manuals, Forms and Resources webpage.
These notifications support care coordination, discharge planning, and member outreach activities and are unchanged by this update.
Provider Expectations
To support timely and accurate review, providers are expected to:
- Ensure timely admission notification with Behavioral Health/SUD Notification Form (within 48 hour)
- Maintain complete and accurate clinical documentation
- Demonstrate ongoing medical necessity throughout the length of stay
- Submit required clinical documentation promptly at discharge
- Claims submitted without the required retrospective review determination may be subject to denial in accordance with Delaware First Health payment policies.
- Outreach to assigned Delaware First Health Care Coordination or LTSS case managers to assist with care management and discharge planning. If assigned case manager is not known, outreach:
- DSHP Plus LTSS members: DFHLTSS@delawarefirsthealth.com
- DSHP members: DECareCoordination@delawarefirsthealth.com
Additional Information
Updated forms and operational guidance will be available on Delaware First Health website prior to implementation.
Questions regarding this notification may be directed to
Provider Services at 1-877-236-1341.
Thank you for your continued partnership with serving Delaware First Health members!