Beginning November 2, 2024, Evernorth^® Behavioral Health (Evernorth), will adopt the use of The ASAM Criteria, 4th Edition to conduct substance use level of care medical necessity reviews for customers aged 18 and older, unless contractual requirements and/or federal or state law require the use of other specifically identified clinical criteria.

The ASAM Criteria, developed by the American Society of Addiction Medicine, have been accepted as the standard of care for the treatment of substance use disorders and are widely utilized by substance use treatment providers.

What this means to you
Currently, Evernorth uses The ASAM Criteria, 3rd Edition to conduct substance use level of care medical necessity reviews for all customers – no matter the age.

Effective November 2, 2024, Evernorth will use The ASAM Criteria, 3rd Edition only for customers aged 17 and under, and begin using The ASAM Criteria 4th Edition for customers aged 18 and older, unless contractual requirements and/or federal or state law require the use of other specifically identified clinical criteria.

Only the criteria used when conducting medical necessity reviews of substance use disorder levels of care for ages 18 and older is changing. This does not affect our medical necessity review processes.

You can access The ASAM Criteria, and evidence-based criteria, clinical support tools, and resources, including The ASAM Criteria, 4^th edition, at the Provider.Evernorth.com > Coverage Policies, see Supporting Behavioral Websites.

Please note, providers can only access The ASAM Criteria full guidelines and training by logging into the Evernorth provider portal on Provider.Evernorth.com.

• From the “Resources” drop-down in the portal, select Behavioral Health Resources > Doing Business with Evernorth > View Documents > The ASAM Criteria.
• If you do not have access to the provider portal, you can register here.

Additional resources
In addition to The ASAM Criteria, Evernorth will continue to use existing guidelines, criteria, and resources to make medical necessity determinations in other circumstances, when appropriate. 

• MCG Behavioral Health Guidelines
  We use this criteria, developed by MCG Health^®, for guidance in conducting medical necessity reviews of mental health levels of care for health plan business, unless contractual requirements, federal or state law require use of other clinical criteria.
• LOCUS and CALOCUS-CASII Criteria
  In California, we use this criteria for guidance in conducting medical necessity reviews of mental health levels of care for health plan business.
  • LOCUS Criteria
  • CALOCUS-CASII Criteria
• Evernorth and Cigna Healthcare^SM coverage policies
• Evernorth Behavioral Health Authorization and Billing Resource
• State and federal regulations and licensing standards

Additional information

If you have any questions, please call Provider Services at 800.926.2273.