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. Enrollee is given no less than two days of treatment, excluding weekends and holidays, in a behavioral health agency that provides inpatient or residential substance abuse treatment; and no less than three days in a behavioral health agency that provides withdrawal management services prior to conducting a medical necessity review for continued care. Enrollee or facility must notify KFHPWA within 24 hours of admission, or as soon as possible. Enrollees may request preauthorization for Residential Treatment and non- Emergency inpatient hospital services by contacting Member Services. KFHPWA reserves the right to require transfer of the Enrollee to a Network Facility/program upon consultation between a Network Provider and the attending physician. If the Enrollee refuses transfer to a Network Facility/program, all further costs incurred during the hospitalization are the responsibility of the Enrollee. Exclusions: Wilderness therapy or aversion therapy; facilities and treatment programs which are not certified by the Department of Social Health Services PEBB_CA_2024 42