Oct. 27, 2017: New Rule Addresses Medical Necessity Review for Substance Use Disorders

The Department of Human Services, in consultation with the Department of Health, has issued adopted new rule N.J.A.C. 10:163, published in today’s New Jersey Register. The rule provides clinical guidelines and review tools approved for medical necessity review of treatment of substance use disorders. 

The evidenced-based and peer-reviewed clinical practice guidelines appropriate to review the medical necessity for treatment of substance use disorders are:

  • the American Society of Addiction Medicine (ASAM) criteria,
  • the Level of Care Index (LOCI), or
  • any similar tool with fidelity to the ASAM.

This scope of the rule applies to state-regulated health insurance carriers, the State Health Benefits Program and the School Employees' Health Benefits Program. According to DHS, in accordance with P.L. 2017, c. 28, this rule does not apply to benefit plans established by the Department of Human Services, benefits to those persons who are eligible for medical assistance under P.L. 1968, c. 413 (N.J.S.A. 30:4D-1 et seq.), the "Family Health Care Coverage Act," P.L. 2005, c. 156 (N.J.S.A. 30:4J-8 et seq.) or any other program administered by the Division of Medical Assistance and Health Services in DHS.