CommercialCoverageHigh impact
Medication-Assisted Treatment for Opioid Use Disorder (CPB 1104, reviewed 12-2026-08)
Aetna·Psychiatry, Internal Medicine, Family Medicine +1 more·Medical Policy
We identified it
Aug 27, 2026
Summary
Aetna has updated its Medication-Assisted Treatment (MAT) policy for opioid use disorder (CPB 1104), establishing comprehensive medical necessity criteria and program requirements. This policy defines strict documentation standards, qualified provider mandates, SAMHSA certification requirements, and mandatory clinical assessments (including urine toxicology, psychiatric evaluation, and annual physicals) for all MAT treatment. Billing teams must ensure claims include proper bundled HCPCS codes (G2067-G2075) and supporting clinical documentation meeting these new standards.
Action Required
IMMEDIATELY: (1) Billing team must update system to recognize and process bundled HCPCS codes G2067, G2068, G2069, G2073, G2074, and G2075 for MAT claims submitted to Aetna. (2) Implement claim validation requiring: provider SAMHSA certification verification, QHP licensure confirmation, program accreditation status (TJC or CARF), and CMS roster inclusion before processing payment. (3) Update denial protocols to reject claims lacking: DSM-5-TR OUD diagnosis documentation, comprehensive clinical evaluation (medical/psychiatric/substance use history), COWS/SOWS withdrawal assessment scores, laboratory serologies completed within 14 days of admission, urine toxicology results with physician signature and medical necessity rationale, medication dosing documentation, and annual physical assessment. (4) Providers and MAT programs must ensure all documentation is present before billing. (5) Revise prior authorization templates (if applicable) to require proof of SAMHSA certification, accreditation, state licensure of QHP, and completion of required clinical elements. (6) Flag all existing MAT claims for retrospective review against these criteria; claims lacking documentation should be resubmitted with required attachments or denied. Failure to implement will result in systematic claim denials for non-compliant submissions.