MedicaidPrior AuthHigh impact
Changes to ASAM 3.5 Residential Treatment Authorizations
HMSA·HI · Psychiatry, Palliative Care·Prior Authorization
Effective date
Jan 1, 2027
We identified it
Oct 4, 2026
Summary
Effective January 1, 2027, HMSA will change ASAM 3.5 Residential Treatment authorization procedures for QUEST members aged 21-64. Initial authorizations will be limited to 15 days, with mandatory continued-stay reviews required thereafter based on clinical presentation, treatment progress, discharge barriers, and ASAM criteria.
Action Required
By December 15, 2026: Billing and prior authorization teams must update authorization workflows and system settings to implement 15-day initial authorization limits for ASAM 3.5 Residential Treatment claims for QUEST members aged 21-64. Update authorization request templates to include required documentation for continued-stay reviews (clinical presentation, treatment progress, discharge barriers, ASAM criteria). Train billing staff and providers on new authorization limits and continued-stay review requirements. Failure to comply will result in claim denials for authorizations exceeding 15 days without documented continued-stay approval.