master’s level therapist (licensed under RCW 18.225.090), an advance practice psychiatric nurse (licensed under RCW 18.79) or, in the case of non-Washington State providers, those providers meeting equivalent licensing and certification requirements established in the state where the provider’s practice is located. The severity of symptoms designates the appropriate level of care and should be determined through a thorough assessment completed by a licensed provider who recommends treatment based on medical necessity criteria. Court-ordered substance use disorder treatment shall be covered only if determined to be Medically Necessary. Preauthorization is required for outpatient, intensive outpatient, and partial hospitalization services. Preauthorization is not required for Residential Treatment and non-Emergency inpatient hospital services provided in-state. Enrollee is given two days of treatment and is then subject to medical necessity review for continued care. Enrollee or facility must notify KFHPWA within 24 hours of admission, or as soon as possible. Enrollee may request prior authorization for Residential Treatment and non-Emergency inpatient hospital services. Enrollee may contact Member Services to request Preauthorization. Withdrawal Management Services for Alcoholism and Emergency Services Network Facility: After Substance Use Disorder. Deductible, Enrollee pays $250 Copayment Withdrawal management services means the management of Emergency Services Non-Network Facility: After symptoms and complications of alcohol and/or substance Deductible, Enrollee pays $250 Copayment withdrawal. The severity of symptoms designates the appropriate level of care and should be determined through a Hospital - Inpatient: After Deductible, Enrollee thorough assessment completed by a licensed provider who pays $150 Copayment per day up to $750 per recommends treatment based on medical necessity criteria. admission Outpatient withdrawal management services means the symptoms resulting from abstinence are of mild/moderate severity and withdrawal from alcohol and/or other drugs can be managed with medication at an outpatient level of care by an appropriately licensed clinician. Preauthorization is required for outpatient withdrawal management services. Coverage for inpatient withdrawal management services is provided without Preauthorization. If an Enrollee is admitted as an inpatient directly from an emergency department, any Emergency services Copayment is waived. Coverage is subject to the hospital services Cost Share. Enrollees must notify KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. PEBB_CRCOB_2024 41