Skip to Main Content

Alcohol and Drug Screening, Assessment, Brief Interventions and Referral to Treatment

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

Counties Covered

  • Fresno
  • Kern  
  • Kings
  • Los Angeles
  • Madera
  • Riverside
  • Sacramento
  • San Bernardino
  • San Diego 
  • San Joaquin
  • Stanislaus
  • Tulare

Alcohol and drug treatment services are excluded from Health Net's coverage responsibilities under Health Net's Medi-Cal managed care contract. These services are overseen by the state of California.

Health Net, its affiliated health plans and subcontracting providers are available to coordinate referrals for members requiring substance use treatment and services. Members receiving services under this program remain enrolled in Health Net. Participating primary care physicians (PCPs) are responsible for maintaining continuity of care for the member.

Alcohol Misuse Screening and Behavioral Counseling

Consistent with U.S. Preventive Services Task Force (USPSTF) Grade A or B recommendations, AAP/Bright Futures, and the Medi-Cal Provider Manual, Managed Care Plans (MCPs) must provide alcohol and drug Screening, Assessment, Brief Interventions and Referral to Treatment (SABIRT) services for members 11 years of age and older, including pregnant women. These services may be provided by providers within their scope of practice, including, but not limited to, physicians, physician assistants, nurse practitioners, certified nurse midwives, licensed midwives, licensed clinical social workers, licensed professional clinical counselors, psychologists and licensed marriage and family therapists.

Screening

Alcohol and drug use screening must be conducted using validated screening tools. Validated screening tools include, but are not limited to:

  • Alcohol use disorders identification test (AUDIT).
  • Alcohol use disorders identification test (Audit-C).
  • Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT) for non-pregnant adolescents.
  • Cut down-annoyed-guilty-eye-opener adapted to include drugs (CAGE-AID).
  • Drug abuse screening test (DAST-10).
  • Drug abuse screening test (DAST-20).
  • Michigan alcoholism screening test geriatric (MAST-G) alcohol screening for geriatric population.
  • National institute on drug abuse (NIDA) quick screen for adults.
  • The single NIDA quick screen alcohol-related questions can be used for alcohol use screening.
  • NIDA-modified alcohol, smoking and substance involvement screening test (NM-ASSIST).
  • Parents, partners, past and present (4Ps) for pregnant women and adolescents.
  • Tobacco alcohol, prescription medication, and other substances (TAPS).

Brief Assessment

When a screening is positive, validated assessment tools should be used to determine if

alcohol use disorder (AUD) or substance use disorder (SUD) is present. Validated alcohol and drug assessment tools may be used without first using validated screening tools. Validated assessment tools include, but are not limited to:

  • NIDA-Modified Alcohol, Smoking and Substance Involvement Screening Test (NM-ASSIST)
  • Drug Abuse Screening Test (DAST)-20
  • Alcohol Use Disorders Identification Test (AUDIT)

Brief Interventions and Referral to Treatment

For members with brief assessments that reveal unhealthy alcohol use, brief misuse counseling should be offered. Appropriate referral for additional evaluation and treatment, including medications for addiction treatment, must be offered to members whose brief assessment demonstrates probable AUD or SUD. Alcohol and/or drug brief interventions include alcohol misuse counseling and counseling a member regarding additional treatment options, referrals, or services. Brief interventions must include the following:

  • Provide feedback to the patient regarding screening and assessment results;
  • Discuss negative consequences that have occurred and the overall severity of
  • the problem;
  • Support the patient in making behavioral changes; and
  • Discuss and agreeing on plans for follow-up with the patient, including referral to other treatment if indicated.

Alcohol Misuse: Screening and Behavioral Counseling Interventions in Primary Care

The USPSTF recommends that clinicians screen adults ages 18 or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse.

The following HCPCS codes may be used to bill for these services:

  • G0442 - annual alcohol misuse screening, 15 minutes
  • G0443 - brief face-to-face behavioral counseling for alcohol misuse, 15 minutes

Code G0442 is limited to one screening per year, any provider, unless otherwise medically necessary. Code G0443 may be billed on the same day as code G0442. Code G0443 is limited to three sessions per recipient per year, any provider, unless otherwise medically necessary.

Treatment Referral

Providers are responsible for referring members who meet criteria for alcohol and drug disorders to a county drug program for services. These services are not covered by Health Net. A list of county contacts for local substance use disorder treatment information and referrals is available on the DHCS website at www.dhcs.ca.gov/services/medi-cal/Pages/SBIRT.aspx, under Referral to Treatment.

Documentation Requirements

Member medical records must include the following:

  • The service provided (e.g., screen and brief intervention);
  • The name of the screening instrument and the score on the screening instrument
  • (unless the screening tool is embedded in the electronic health record);
  • The name of the assessment instrument (when indicated) and the score on the
  • assessment (unless the screening tool is embedded in the electronic health record); and
  • If and where a referral to an AUD or SUD program was made.

PCPs must maintain documentation of SABIRT services provided to members. When a member transfers from one PCP to another, the receiving PCP must attempt to obtain the member’s prior medical records, including those pertaining to the provision of preventive services.

Participating providers are responsible for providing services in a manner that ensures coordinated and continuous care to all members needing alcohol and drug treatment services, including timely referrals.

On receipt of a specific written request from the member, the primary care physician (PCP) must transfer requested summaries of the member's records to the substance abuse practitioner or program and to any organization where future care will be rendered. Any transfer of member medical records and other information must be done in a manner consistent with appropriate confidentiality standards.

A member receiving services under the Health Net Alcohol and Drug Treatment program remains enrolled with Health Net. The PCP and Health Net Health Services staff retain the responsibility for maintaining continuity of care for the member. The PCP is responsible for the coordination of the members care with the Alcohol and Drug Treatment program case managers and Health Net Health Services staff. The PCP monitors the member to ensure that follow-up care is provided as necessary.

A number of screening instruments are available to the primary care physician (PCP) to assist in detecting substance use. Refer to samples of the Drug Use Questionnaire (PDF), Red Flags for Alcohol or Drug Abuse (PDF), T-Ace (PDF), and TWEAK Test (PDF).

Criteria for Admission to a Partial Hospital Program

A member is a candidate for admission in a partial hospital program for treatment of substance use if all the following criteria are met:

  • A clearly documented pattern of substance use or dependence that meets current DSM criteria and is severe enough to interfere with social and occupational functioning and causes significant impairment in activities of daily living.
  • The member is medically stable enough that the criteria for inpatient detoxification services are not met.
  • The member requires up to eight hours of structured treatment per day in order to obtain the most benefit from coordinated services, such as individual, group or family therapy, education, or medical supervision.
  • The member's living situation and social support system are sufficiently stable to allow for treatment in this care setting.
  • There is evidence of sufficient motivation for successful participation in treatment in this care setting.
  • The member has demonstrated, or there is reason to believe, that he or shee can avoid the use of substances between treatment sessions based on an assessment of such factors as intensity of cravings, impulse control, judgment, and pattern of use.

 

Criteria for Admission to a Residential Facility

A member is a candidate for referral for admission to a residential facility for the treatment of substance use if all the following are present:

  • A clearly documented pattern of substance use or dependence that meets the current DSM criteria and is severe enough to interfere markedly with social and occupational functioning and cause significant impairment in activities of daily living.
  • The member is medically stable enough that the criteria for inpatient detoxification services are not met.
  • There is clearly documented evidence of the failure of partial hospital or structured outpatient treatment for substance use or dependence meeting the current DSM criteria.
  • The member's living situation is severely impaired as a result of inadequate or unstable support systems, including the work environment, that may jeopardize successful outpatient treatment.
  • There is significant risk of relapse if the member is treated in a less restrictive care setting related to severely impaired impulse control or a co-morbid disorder.
  • Pregnant and postpartum women are eligible to receive substance use services through certified perinatal programs. Women are eligible during the term of pregnancy and for a period of up to 60 days after delivery.

Criteria for Admission to a Structured Outpatient Program

A member is a candidate for referral for admission to a structured outpatient program for the treatment of substance use if all the following are present:

  • A clearly documented pattern of substance use or dependence that meets the current DSM criteria and is severe enough to interfere with social and occupational functioning and cause significant impairment in activities of daily living.
  • The member is medically stable enough that the criteria for inpatient detoxification services are not met.
  • The member requires up to four hours of structured treatment per day in order to obtain the most benefit from coordinated services, such as individual, group or family therapy, education, or medical supervision.
  • The member's living situation and social support system are sufficiently stable to allow for structured outpatient treatment at this level of care.
  • There is evidence of sufficient motivation for successful participation in treatment at this level of care.
  • The member has demonstrated, or there is reason to believe, that he or she can avoid the use of substances between treatment sessions based on an assessment of factors such as intensity of cravings, impulse control, judgment, and pattern of use. 

Criteria for Inpatient Detoxification

A member is a candidate for acute inpatient detoxification if symptoms are present that suggest that the failure to use this level of treatment would be life threatening or cause permanent impairment once substance use has stopped. All of the following must be present:

  • Fluids and medication to modify or prevent withdrawal complications that threaten life or bodily functions
  • 24-hour nursing care with close and frequent observation and monitoring of vital signs
  • Medical therapy, which is supervised and re-evaluated daily by the attending physician in order to stabilize the member's physical condition
  • At least two of the following symptoms of substance withdrawal:
    • tachycardia
    • hypertension
    • diaphoresis
    • significant increase or decrease in psychomotor activity
    • tremor
    • significantly disturbed sleep patterns
    • nausea or vomiting
    • clouding of consciousness with reduced capacity to shift, focus and sustain attention

Participating providers are responsible for performing all preliminary testing and procedures necessary to develop a diagnosis. Referrals to Drug Medi-Cal (D/MC) or Fee-for-Service Medi-Cal (FFS/MC) programs must include the appropriate medical records supporting the diagnosis and additional documentation. The referring provider must obtain a signed release from the member prior to making the referral.

The final decision on the acceptance of a member for FFS/MC or D/MC services (authorization of the referral) rests solely with the county alcohol and drug program (Tulare, Fresno, Kern, Kings, Los Angeles, Madera, Sacramento, San Diego, San Joaquin, Stanislaus).

The alcohol and drug treatment services covered by the Drug Medi-Cal (D/MC) program include:

  • Outpatient heroin detoxification services.
  • Outpatient methadone maintenance services.
  • Outpatient drug-free treatment services.
  • Day care habilitative services.
  • Perinatal residential substance use services.

Voluntary inpatient detoxification (VID) is a Medi-Cal fee-for-service (FFS) benefit. VID services are excluded from Health Net's coverage responsibilities and are the responsibility of the Medi-Cal FFS program. Health Net members receiving VID services remain enrolled with Health Net and primary care physicians (PCPs) remain responsible for coordinating ongoing care and services unrelated to VID.

Participating providers must refer members to a VID provider in a general acute care hospital. A list of general acute care hospitals is available online at https://hfcis.cdph.ca.gov/servicesandfacilities.aspx . VID services require authorization. It is the VID provider's responsibility to submit the Treatment Authorization Request (TAR) to the local Medi-Cal field office for approval.

Health Net Medi-Cal members who meet medical necessity criteria may receive VID services in a general acute care hospital. To receive VID services, a member must have one or more of the following:

  • Delirium tremens with any combination of the below clinical manifestations with cessation or reduced intake of alcohol or sedative:
    • hallucinations
    • disorientation
    • tachycardia
    • hypertension
    • fever
    • agitation
    • diaphoresis
  • A score greater than 15 on the Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA-Ar) form.
  • Alcohol or sedative withdrawal with CIWA score greater than 8 and one or more of the following high risk factors:
    • multiple substance abuse
    • history of delirium tremens
    • unable to receive the necessary medical assessment, monitoring and treatment in a setting with a lower level of care
    • medical comorbidities that make detoxification in an outpatient setting unsafe
    • history of failed outpatient treatment
    • psychiatric comorbidities
    • pregnancy
    • history of seizure disorder or withdrawal seizures
  • Complication of opioid withdrawal that cannot be adequately managed in the outpatient setting due to the following:
    • persistent vomiting and diarrhea from opioid withdrawal
    • dehydration and electrolyte imbalance that cannot be managed in a setting with a lower level of care
Last Updated: 06/16/2022