Substance Use Higher Level of Care Concurrent Review Outline

To expedite the review process, be sure to review our medical necessity criteria expectations for admission, continued stay and discharge.


Medical necessity criteria

Below is a general outline that our care managers will follow when reviewing Substance Use Cases; however depending on the specifics, the care manager may ask for additional information. In some instances, initial authorizations occur via our fast-certification process. This allows us to authorize days upfront with limited clinical information. For Concurrent Reviews, Care Managers will then need to obtain all clinical information that was not given during the initial review.

Working Diagnosis

  • Include any Clinical Disorders, Personality Disorders, Intellectual Disability, or General Medical Conditions

Clinical Presentation

  • Reason for admission (MH & SU HX, SA issues, stressors)
  • Current medications/medication changes: plan for titration
  • Current withdrawal symptoms; post-acute withdrawal
  • Clinical factors that support your requested level of care
  • Behavior with staff & peers; participation in program
  • Progress in recovery skill development/enhancement
  • Progress in building sober support; level of involvement in 12-step program
  • Progress in verifying/securing sober living environment (SLE)
  • Family/support sessions (when, who, what or why not)
  • Barriers to discharge and abstinence

Treatment Intervention/ Planning

  • How are you assisting in identification and management of personal relapse triggers?
  • How are you assisting in building a sober network (progress)?
  • Substance education
  • Step work progress
  • How are the healthy coping strategies being demonstrated?
  • Relapse prevention planning
  • Family sessions
  • How is SLE being addressed?
  • If in a Partial Program, describe how patient is using the skills outside of treatment hours

Discharge Planning

  • Discharge diagnosis, medication and plan
  • 7-day follow up appointments
  • Motivation for recovery
  • Please provide the discharge information during last review or if no further authorization is needed, you may leave the information on the designated staff’s voicemail.