Substance Use Disorder (SUD) Services

Overview

PrimeWest Health covers SUD treatment for our members. Members must have a comprehensive assessment performed by a qualified professional to receive treatment. The assessor will make recommendations for the most appropriate level of treatment based on the results of the comprehensive assessment. If a member screens positive after completing a valid Screening, Brief Intervention, Referral to Treatment (SBIRT) tool, they qualify for an initial set of SUD outpatient services. 

Eligible Providers

To provide, bill, and receive payment for SUD services, a provider must:

• Be enrolled as a Minnesota Health Care Program (MHCP) provider for alcohol and drug abuse
• Complete American Society of Addiction Medicine (ASAM) certification for ASAM level(s) of care provided. For more information, refer to ASAM Certification in the SUD Services section of the MHCP Provider Manual. 
• Enroll and participate in the Drug and Alcohol Abuse Normative Evaluation System (DAANES) as required by MN Stat. 254B.05, subd. 1b. (3). As a SUD treatment provider, you will not receive reimbursement unless you have complied with the DAANES requirements for each PrimeWest Health member. Contact the DAANES office at 1-651-431-2631 or by email dhs.daanes@state.mn.us to obtain the necessary training and documents required for participation in DAANES.
• Must provide services within regulatory requirements and within scope of practice

Eligible providers include the following:

• Licensed residential SUD treatment programs (ASAM levels of care 3.1, 3.3, and 3.5)
• Licensed nonresidential (outpatient) SUD treatment programs (ASAM levels of care 1.0, 2.1, and 2.5)
• Counties and Tribes
• Recovery Community Organizations (RCOs)
• Hospitals
• Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) with a substance use disorder program license
• Licensed professionals in private practice
• Substance Use Disorder Treatment with Medication for Opioid Use Disorder (SUD-MOUD)
• Residential withdrawal management programs

ASAM Certification

The following MHCP providers of SUD services must certify ASAM level(s) of care provided: 

• Licensed residential SUD treatment programs
• Licensed nonresidential (outpatient) SUD treatment programs
• Licensed withdrawal management programs
• Approved out-of-state nonresidential (outpatient) SUD providers
• Approved out-of-state residential SUD providers

The following programs do not need to certify ASAM level of care: 

• Tribally licensed programs
• ASAM 3.7 medically monitored inpatient programs
• Adolescent residential programs

Licensee's use and interpretation of the ASAM Criteria for Addictive, Substance-Related, and Co-Occurring Conditions does not imply that ASAM has either participated in or concurs with the disposition of a claim for benefits.

Enrollment/Disenrollment

Members who apply for and receive public health care coverage may be enrolled in PrimeWest Health. PrimeWest Health becomes responsible for managing the member’s health care as of the first day of the month in which the member is enrolled with PrimeWest Health. When a member is referred to substance use disorder (SUD) treatment and becomes enrolled in PrimeWest Health, PrimeWest Health is responsible for the member’s SUD treatment as of the first day of the month in which the member is enrolled in PrimeWest Health.

A member enrolled in PrimeWest Health may become disenrolled from PrimeWest Health but keep their public health care coverage. The patient’s health care is then covered through fee-for-service (FFS), and the patient is entitled to have their SUD treatment services paid with public funds. Because the patient is no longer a PrimeWest Health member, PrimeWest Health is no longer responsible for the patient’s health care coverage. The patient’s county or Tribe of residence is responsible for payments through the Behavioral Health Fund (BHF) as of the first day of the month following the member’s PrimeWest Health disenrollment.

Eligible Members

Eligibility for SUD treatment is based on two criteria: clinical and financial eligibility. If a member is determined to have both a clinical need for treatment and is financially eligible for PrimeWest Health, then PrimeWest Health may pay for their SUD treatment services. Clinical eligibility is determined via the comprehensive assessment. An initial set of SUD services (up to 6 hours of SUD outpatient treatment) is determined by the SBIRT.

SUD providers should verify member eligibility during admission and then on a monthly basis.

American Indians enrolled in pre-paid health plans that are placed at Behavioral Health Fund (BHF)-enrolled Tribal 638 facilities are paid through the BHF.

Providers must check the following:

• If the member has any public health care coverage (e.g., Medical Assistance [Medicaid] or MinnesotaCare)
• Whether the member is enrolled in PrimeWest Health

Eligibility Verification

To verify member eligibility, review the Member Eligibility and Benefits section.

Institutions of Mental Disease (IMDs)

PrimeWest Health, as a placing authority, is responsible for institutions for mental diseases (IMD) placements that are authorized. All IMD placements for members must be coordinated and notification must be submitted to PrimeWest Health. PrimeWest Health is then responsible for the member and associated payments through discharge, or until the member disenrolls from PrimeWest Health, whichever comes first.

Members who are initially placed in an IMD through the BHF and are then enrolled in PrimeWest Health become the responsibility of PrimeWest Health until discharge or until the member disenrolls from PrimeWest Health, whichever comes first.

Hospital-Based Inpatient Placements

When a placing authority (PrimeWest Health, Tribe, or BHF) initiates a placement at a hospital-based inpatient program, the placing authority remains responsible for the placement through discharge, regardless of whether the member’s eligibility status changes.

Financial Eligibility

Financial eligibility is determined by the county human services agency located in the county of the member’s residence. PrimeWest Health members meet financial eligibility requirements.

Clinical Eligibility

Clinical eligibility is determined by a comprehensive assessment or a positive SBIRT tool screening that meets clinical eligibility for an initial set of SUD services. When a comprehensive assessment is used to determine clinical eligibility, the assessment must include a diagnosis of a substance use disorder and a recommendation for the American Society of Addiction Medicine (ASAM) level of care identified in MN Stat. Chap. 254B.19, subd. 1.

Comprehensive Assessment

The comprehensive assessment is an interview conducted by an alcohol and drug counselor. The alcohol and drug counselor must be employed by a licensed 245G treatment provider or be independently enrolled with Minnesota Health Care Programs (MHCP) to complete a comprehensive assessment for members. There is no standardized format for the comprehensive assessment, but assessments must meet requirements specified in MN Stat. sec. 245G.05.

Screening, Brief Intervention, Referral to Treatment (SBIRT)

Valid SBIRT tools can be utilized to refer a member to an initial set of SUD services if the result of the screening is positive. The initial set of services can include any combination of up to four hours of individual or group SUD treatment, and two hours of SUD treatment coordination or two hours of SUD peer support services provided by a qualified individual according to MN Stat. Chap. 245G, totaling six hours.

The following enrolled Minnesota Health Care Programs (MHCP) providers are eligible to provide SBIRT:

• Advanced practice registered nurses
• Clinical nurse specialists
• Licensed alcohol and drug counselors
• Licensed independent clinical social workers
• Licensed marriage and family therapists
• Licensed professional clinical counselors
• Licensed psychologists
• Nurse midwives
• Nurse practitioners
• Physician assistants
• Physicians
• Psychiatric nurse practitioners
• Psychiatrists
• Tribal certified professionals

Valid SBIRT tools include the following:

• ASSIST – Alcohol, Smoking, and Substance Involvement Screening Test
• AUDIT – Alcohol Use Disorders Identification Test
• AUDIT-C
• CAGE (Cut Down, Annoyed, Guilty, Eye-opener)
• CRAFFT (Car, Relax, Alone, Forget, Family or Friends, Trouble)
• DAST (Drug Abuse Screening Test)
• DAST-A
• MAST (Michigan Alcohol Screening Test)
• NIDA Drug Use Screening Tool
• POSIT (Problem-Oriented Screening Instrument for Teenagers)
• TWEAK (Tolerance, Worried, Eye-openers, Amnesia, (K) Cut down)

A member may access the initial set of treatment services up to three months after the positive SBIRT. If three months have passed or the member uses the initial set of services, the member must complete another SBIRT or complete a comprehensive assessment that indicates the member is appropriate for SUD treatment.

Service Notification

Members who are determined clinically eligible for treatment services may immediately access treatment services without prior authorization from PrimeWest Health. Notification of residential services is required prior to payment for those services. The provider must submit the notification, along with proper supporting documentation, to PrimeWest Health through the provider portal. If unable to submit through the portal, the notification may be faxed to PrimeWest Health at 1-866-431-0804.

Receiving the notification does not ensure payment. Providers must follow PrimeWest Health billing policy guidelines. Providers are subject to participation in utilization reviews as defined in MN Stat. secs. 245B.04, subd. 15, and 254A.03, subd. 3, paragraph b.

Effective for dates of service beginning January 1, 2026, outpatient substance use disorder treatment and medications for opioid use disorder treatment no longer require notification to be submitted to PrimeWest Health.  

Members who are determined clinically eligible for the initial treatment set through a positive SBIRT may access these SUD services immediately or for up to three months after the positive screening. No notification is currently required for the SUD outpatient services accessed through SBIRT.

Disclosing Patient Information Under 42 CFR Part 2

Effective February 16, 2026, when disclosing patient information protected under Title 42 Code of Federal Regulations (CFR) Part 2, and the disclosure is being made based on the patient’s written consent, Federal regulations require you to include the following two items with the disclosure:

1. A Part 2 Confidentiality Notice  – This notice tells the recipient that the information is protected by Federal law (42 CFR Part 2) and that the information cannot be redisclosed unless allowed by Part 2 or otherwise permitted under the Health Insurance Portability and Accountability Act (HIPAA).
2. A Copy of the Patient’s Consent Form or a Brief Summary of the Consent (42 CFR 2.32[b]) – This requirement ensures the recipient understands the scope of what the patient has consented to. If using a summary instead of the full consent form, it must describe the following:
   1. Who the information may be shared with (the recipients or class of recipients),
   2. What information may be shared, and
   3. Why the information is being shared (the purpose authorized by the patient).

These items must accompany any disclosure of Part 2-protected information made under a patient’s consent, including disclosures for the following:

• Utilization review
• Care coordination
• Treatment or other health care operations
• Any other disclosure made under a valid patient consent
• Payment activities (billing or claims) 

These requirements help to ensure that anyone receiving Part 2-protected information understands the patient’s authorization, knows how the information may be used, and recognizes the confidentiality protections that still apply after the disclosure.

Substance Use Disorder (SUD) Covered Treatment Services

All services that are provided under a licensed program of care, maintain a provider agreement with MHCP are covered by the Behavioral Health Fund (BHF) and PrimeWest Health. Providers must be enrolled with MHCP as an eligible provider of specific services, certified ASAM level(s) of care, specialties, or complexity add-ons to receive reimbursement from PrimeWest Health. Providers are responsible for knowing and understanding the rules and regulations pertaining to any service they submit for reimbursement. This includes the following:

• Nonresidential individual and group treatment services
• Residential treatment services
• Hospital-based inpatient treatment
• Comprehensive assessments completed by a qualified assessor (an SUD-licensed facility can begin providing services before completion of a comprehensive assessment when the comprehensive assessment is completed within the time frame set forth in MN Stat. Chap. 245G.)
• Treatment coordination
• Peer recovery support
• Tobacco use disorder cessation*
• Residential withdrawal management (245F license)
• Substance Use Disorder Treatment with Medication for Opioid Use Disorder (SUD-MOUD)/Opioid Treatment Programs (OTP)

*Tobacco use disorder cessation when provided as counseling by an alcohol and drug counselor and indicated as needed on a treatment plan can be provided in an individual or group counseling session (H2035 or H2035 HQ). Providing coordination to tobacco use disorder cessation resources can fall under the role of a treatment coordination (T1016 HN U8) by assisting in coordination with and follow-up for medical services as identified in the treatment plan or facilitating referrals to SUD services as indicated by a member's medical provider, comprehensive assessment, or treatment plan.

Refer to the BHF Rate Grid found in MN–ITS for covered services and complexity add-on rates.

Treatment Coordination

Treatment coordination is a treatment services involving the deliberate collaborative planning of SUD services with the member and other professionals involved in the member’s care. It addresses an array of issues (e.g., medical, mental health, family, employment, criminal justice, housing, finances) concurrently to improve treatment outcomes.

Treatment coordination is defined at 245G.07, subd.1, a(6), and includes:

• Assistance in coordination with significant others to help in the treatment planning process whenever possible
• Assistance in coordination with and follow-up for medical services as identified in the treatment plan
• Facilitation of referrals to SUD services as indicated by the member’s medical provider, comprehensive assessment, or treatment plan
• Facilitation of referrals to mental health services as identified by a member’s comprehensive assessment or treatment plan
• Assistance with referrals to economic assistance, social services, housing resources, and prenatal care according to the member’s needs
• Life skills advocacy and support accessing treatment follow-up, disease management, education services, and referral and linkages to long-term services and supports, as needed
• Documentation of the provision of treatment coordination services in the member’s file

Treatment coordination should be identified as a needed service in the member’s treatment plan.

Peer Recovery Support

Peer recovery support services can be provided before, during, and after SUD treatment to help individuals connect with resources that support recovery. Peers are individuals who are willing to share their personal recovery experience and often engage quickly with individuals to offer reassurance, reduce fears, answer questions, support motivation, and convey hope. Qualified peers must be employed by and supervised by an eligible provider of this service and are not eligible for direct reimbursement.

Peer recovery supports are defined in 245G.07, subd 2, (8), and include education, advocacy, mentoring through self-disclosure of personal recovery experiences, attending recovery and other support groups with a member, accompanying the member to appointments that support recovery, assistance accessing resources to obtain housing, employment, education, and advocacy services, and nonclinical recovery support to assist the transition from treatment into the recovery community.

Peer recovery support should be identified as a needed service in the member’s treatment plan.

Recovery Community Organization

A Recovery Community Organization (RCO) is an independent organization led and governed by representatives of local communities of recovery. A RCO mobilizes resources within and outside of the recovery community to increase the prevalence and quality of long-term recovery from addiction. RCOs provide peer-based recovery support activities such as training of recovery peers. RCOs are defined in 254B.01, subd. 8.

Services provided through a RCO should be identified as a needed service in the member’s treatment plan.

Withdrawal Management

A withdrawal management program is a licensed program that provides short-term medical services on a 24-hour basis for the purpose of stabilizing intoxicated patients, managing their withdrawal, and facilitating access to SUD treatment as indicated by a comprehensive assessment. Members receiving this service receive medical observation, evaluation, stabilization services during the detoxification process, a comprehensive assessment according to MN Stat. sec. 245G.05, and access to medications administered by staff trained to manage withdrawal. Eligible providers must be a licensed 245F withdrawal management program.

There are two levels of withdrawal management in the SUD continuum to address intoxication and withdrawal:

1. Level 3.2 – Clinically managed programs are residential settings with staff comprised of a medical director and a licensed practical nurse (LPN). The LPN must be on site 24 hours a day, seven days a week and a qualified medical professional must be available by telephone or in person for consultation around the clock.
2. Level 3.7 – Medically monitored programs are residential settings with staff that includes a registered nurse (RN) and a medical director. The RN must be on site 24 hours a day and a medical director must be on site seven days a week and must be able to see a member within 24 hours.

The following Level 3.2 clinically managed covered services are included in the per diem rate: 

• Individual or group motivational counseling sessions
• Individual advocacy and case management services
• Care coordination 
• Peer recovery support services 
• Patient education
• Referrals to mutual aid, self-help, and support groups
• An initial health assessment conducted by a nurse upon admission
• Daily on-site medical evaluation by a nurse
• Comprehensive assessment
• Stabilization planning 
• Standardized collection tool for collecting health-related information 

The following Level 3.7 medically monitored covered services are included in the per diem rate: 

• An initial health assessment conducted by a registered nurse upon admission
• Medical evaluation and consultation with a registered nurse 24 hours a day
• Availability of licensed practitioner by telephone or in person for consultation 24 hours a day
• Ability to be seen within 24 hours or sooner by a licensed practitioner 
• Availability of on-site monitoring of patient care seven days per week by a licensed practitioner 
• Administer medications according to prescriber-approved orders
• Individual or group motivational counseling sessions
• Individual advocacy and case management services 
• Care coordination 
• Peer recovery support services 
• Stabilization planning 
• Comprehensive assessment 
• Daily on-site medical evaluation by a nurse
• Referrals to mutual aid, self-help, and support group
• Standardized collection tool for collecting health-related information 

Detoxification

Detoxification is only covered by PrimeWest Health if the service is deemed medically necessary.

Residential SUD Treatment Services

Residential program is defined in 245A.02, subd 14 (a), as a program that provides 24-hour-a-day care, supervision, food, lodging, rehabilitation, training, education, habilitation, or treatment outside of a person’s own home. Residential SUD treatment must offer the treatment services in 245G.07 subd. 1 (1) – (5) to each member, unless clinically inappropriate and the justifying clinical rationale is documented.

The treatment services in 245G.07, subd. 1 (1) to (5) include:

• Individual and group counseling to help the member identify and address needs related to substance use and develop strategies to avoid harmful substance use after discharge and to help the member obtain the services necessary to establish a lifestyle free of the harmful effects of substance use disorder;
• Member education strategies to avoid inappropriate substance use and health problems related to substance use and the necessary lifestyle changes to regain and maintain health. Member education must include information on tuberculosis education on a form approved by the commissioner, the human immunodeficiency virus according to section 245A.19, other sexually transmitted diseases, drug and alcohol use during pregnancy, and hepatitis;
• A service to help the member integrate gains made during treatment into daily living and to reduce the member's reliance on a staff member for support;
• A service to address issues related to co-occurring disorders, including member education on symptoms of mental illness, the possibility of comorbidity, and the need for continued medication compliance while recovering from substance use disorder. A group must address co-occurring disorders, as needed. When treatment for mental health problems is indicated, the treatment must be integrated into the member's individual treatment plan; and
• Treatment coordination provided one-to-one by an individual who meets the staff qualifications in section 245G.11, subd. 7.

Residential Treatment Services require notification to be submitted to PrimeWest Health through the PrimeWest Health Provider Portal.

Nonresidential (Outpatient) SUD Treatment Programs

Nonresidential is defined in 245A.02, subd. 10, as care, supervision, rehabilitation, training or habilitation of a person provided outside the person’s home and provided for fewer than 24 hours a day. Nonresidential SUD treatment, according to 245G.07, subd. 1, must offer all treatment services in clauses (1) to (5) and document in the individual treatment plan the specific services for which a member has an assessed need and the plan to provide the services:

• Individual and group counseling to help the member identify and address needs related to substance use and develop strategies to avoid harmful substance use after discharge and to help the member obtain the services necessary to establish a lifestyle free of the harmful effects of substance use disorder;
• Member education strategies to avoid inappropriate substance use and health problems related to substance use and the necessary lifestyle changes to regain and maintain health. member education must include information on tuberculosis education on a form approved by the commissioner, the human immunodeficiency virus according to section 245A.19, other sexually transmitted diseases, drug and alcohol use during pregnancy, and hepatitis;
• A service to help the member integrate gains made during treatment into daily living and to reduce the member's reliance on a staff member for support;
• A service to address issues related to co-occurring disorders, including member education on symptoms of mental illness, the possibility of comorbidity, and the need for continued medication compliance while recovering from substance use disorder. A group must address co-occurring disorders, as needed. When treatment for mental health problems is indicated, the treatment must be integrated into the member's individual treatment plan; and
• Treatment coordination provided one-to-one by an individual who meets the staff qualifications in section 245G.11, subd. 7.

Effective January 1, 2026, non-residential (outpatient) SUD treatment services no longer require notification.

Substance Use Disorder Treatment with Medications for Opioid Use Disorder (SUD-MOUD)/Opioid Treatment Programs (OTP)

An Opioid Treatment Program means a program or practitioner engaged in opioid treatment of an individual that provides dispensing of an opioid agonist treatment medication, along with a comprehensive range of medical and rehabilitative services, when clinically necessary, to an individual to alleviate the adverse medical, psychological, or physical effects of an opioid addiction. OTP includes detoxification treatment, short-term detoxification treatment, long-term detoxification treatment, maintenance treatment, comprehensive maintenance treatment, and interim maintenance treatment.

Effective January 1, 2020, Medicare is the primary payer for Medicare-enrolled opioid treatment providers for members with Medicare Part B.

The following are covered under the Medicare Part B benefit:

• U.S. Food and Drug Administration (FDA)-approved opioid agonist and antagonist opioid treatment medications
• Dispensing and administration of medication assisted treatment (MAD) medications
• Substance use counseling
• Individual and group therapy
• Toxicology testing
• Intake activities
• Periodic assessments

For more information on becoming a Part B provider, refer to the Centers for Medicare & Medicaid Services (CMS) Opioid Treatment Programs (OTPs) Medicare Enrollment Fact Sheet.

Individuals Providing SUD Services in Private Practice

A licensed professional in private practice must be enrolled with MHCP and licensed under Minnesota Statutes 148F, or is exempt from licensure under that chapter but is otherwise licensed to provide alcohol and drug counseling services; practices solely within the permissible scope of the individual's license as defined in the law authorizing licensure; and does not affiliate with other licensed or unlicensed professionals to provide alcohol and drug counseling services.

Affiliation includes but is not limited to the following:

• Using the same electronic record system as another professional, except when the system prohibits each professional from accessing the records of another professional;
• Advertising the services of more than one professional together;
• Accepting client referrals made to a group of professionals;
• Providing services to another professional's clients when that professional is absent; or
• Appearing in any way to be a group practice or program.

Affiliation does not include the following:

• Conferring with another professional;
• Making a client referral to another professional;
• Contracting with the same agency as another professional for billing services;
• Using the same waiting area for clients in an office as another professional; or
• Using the same receptionist as another professional if the receptionist supports each professional independently.

Licensed professionals in private practice can provide comprehensive assessments, individual and group counseling, and treatment coordination services. They may not provide peer recovery support services. Treatment services, plans, and discharge must be documented according to 245G.06.

Substance Use Disorder Treatment with Medications for Opioid Use Disorder (SUD-MOUD)

Programs providing Substance Use Disorder Treatment with Medications for Opioid Use Disorder (SUD-MOUD) and licensed according to Minnesota Stat. secs. 245G.01 to 245G.17 and 245G.22, or applicable tribal license, must  certify their program’s ASAM level(s) of care with MHCP. 

SUD-MOUD services are reimbursed on a per diem basis and may also be included as an add-on to the residential treatment service per diem. Participating demonstration providers licensed as residential SUD programs must offer medication-assisted treatment services on site or facilitate access to medication-assisted treatment services off site. SUD-MOUD may include:

• SUD-MOUD – Methadone
• SUD-MOUD – Methadone-PLUS
• SUD-MOUD – all other-PLUS
• SUD-MOUD services may be provided through consultation off-site by a qualified practitioner and reimbursed through the member’s medical benefits

When providers are paid the Indian Health Service (IHS) encounter rate, encounter payments are not available for self-administered medication.

Telehealth Services

Per MN Stat. sec. 254B.05, subd. 5, as amended by chapter 78, article 2, sec. 3 of the 2015 Minnesota Session Laws, telehealth SUD services are covered and paid at the same rate as direct face-to-face services. The use of two-way interactive video must be medically appropriate to the condition and needs of the person being served. The interactive video equipment and connection must comply with Medicare standards in effect at the time the service is provided.

The following medically necessary substance use disorder (SUD) services provided by eligible SUD providers via telehealth are covered:

• Comprehensive assessments
• Individual and group treatment services
• Peer recovery support services

See the Telehealth Services section of the Provider Manual for more information.
 
PW_11-19_590
Updated_02/05/2026