Necessary shall be expanded to include those services necessary to treat a substance use disorder condition that is having a clinically significant impact on a Enrollee’s emotional, social, medical and/or occupational functioning. Substance use disorder services are limited to the services rendered by a physician (licensed under RCW 18.71 and RCW 18.57), a psychologist (licensed under RCW 18.83), a substance use disorder treatment program licensed for the service being provided by the Washington State Department of Social and Health Services (pursuant to RCW 70.96A), a 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 $300 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 $300 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 $250 Copayment per day up to $1,250 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. PEBB_VA_2024 42