October 2025: Payor Behavior Updates
Optum and ASAM 4th Edition & Ambetter Claims Cadence Changes
Payor Behavior Updates
The Only Consistent in the Payor Landscape is Change.
A big thank you to Linda Shulman, Director of Payor Relations and Advocacy at Hansei Solutions, for an insightful discussion on what these payor changes mean for facilities, how to stay compliant, and strategies to protect revenue.
Key Topics Covered:
Optum: New revenue codes for ASAM 4th Edition
Ambetter: Billing must be submitted from admission to discharge only; telehealth for IOP is not covered
California: CARF accreditation and state licensing challenges, especially for 3.7 levels of care
General Trends: Inconsistencies between payor contracting and claims systems, updated billing practices to prevent denials, CMS guidelines, and federal prompt payment mandates
View Recording:
Passcode: wiqT5kS+
Highlights & Resources
ASAM Level of Care Certification
CARF-certified ASAM Level of Care (LOC) demonstrates a provider’s capacity to deliver residential substance use disorder treatment aligned with ASAM Criteria®. Certification differentiates providers to payers, regulators, referral sources, and patients.
Available for adult Levels of Care: 3.1, 3.5, 3.7
CARF is the only ASAM-approved certification program for residential SUD treatment
Cheat Sheet: Optum ASAM-4 Revenue Code Mapping
California DHCS Requirements & SB 823
All licensed adult AOD facilities must meet ASAM criteria or equivalent standards. Facilities can:
Obtain a DHCS Level of Care Designation, or
Secure ASAM LOC Certification via CARF, which satisfies DHCS requirements
Ambetter Billing Updates
Policy: Ambetter requires billing from admission to discharge only; interim billing for estimated charges is not accepted.
Why This Matters:
Reduces administrative burden
Minimizes denials for improper status billing
Simplifies reconciliation
Recommended Workflow:
Admit the patient and begin inpatient services
Capture all services, diagnostics, room & board, and ancillary charges
At discharge, assemble a final UB-04 (or electronic equivalent) with:
Admit & discharge dates
Discharge status code
All charges and itemized service lines
Submit final claim to Ambetter
Respond promptly to any requests for additional documentation
And that’s all for this month. Join us on Tuesday, November 11th, for our next discussion!