Caring for Substance Use Disorders

March 4, 2023

Providers can play an important role in our members’ care by discussing the signs of substance use disorder and encouraging them to seek help, if appropriate. We’ve created resources for members that may help.

To monitor our members’ care, we track the following Healthcare Effectiveness Data and Information Set (HEDIS®) measures related to substance use disorders:

Initiation and Engagement of SUD Treatment

This measure applies to members ages 13 and older with a new episode of SUD. We capture two stages of adequate and timely follow-up treatment:

  • Initiation of SUD treatment: One treatment within 14 days of the diagnosis
  • Engagement of SUD treatment: Two or more additional treatment sessions within 34 days of the initiation visit

Treatment may occur in an inpatient SUD admission, outpatient visit, intensive outpatient encounter, partial hospitalization, telehealth or medication-assisted treatment.

Follow-up after Emergency Department Visit for Substance Use

This measure captures ED visits for members ages 13 and older with a principal diagnosis of SUD, or any diagnosis of drug overdose, who had a follow-up visit for SUD. We track:

  • ED visits for which the member received follow-up within 30 days (31 total days)
  • ED visits for which the member received follow-up within seven days (eight total days)

Follow-Up After High-Intensity Care for Substance Use Disorder

This measure tracks the percentage of discharges for members ages 13 and older who were hospitalized, received detoxification or residential treatment for a diagnosis of SUD and who had a follow-up visit or service for SUD. The follow-up visit must be on a different date than the discharge date. We track:

  • Discharges that had a follow-up visit within 30 days after discharge
  • Discharges that had a follow-up visit within seven days after discharge

Pharmacotherapy for Opioid Use Disorder

We capture the percentage of new pharmacotherapy treatment events for OUD among our members 16 and older with a diagnosis of OUD. The treatment of OUD with medication must continue for at least 180 days.

Tips to Consider

  • Discuss the importance of timely follow-up visits with our members.
  • Use the same diagnosis for substance use at each follow-up.
  • Coordinate care between behavioral health and primary care providers. Share progress notes and include the diagnosis for substance use.
  •  Reach out to members who cancel appointments and help them reschedule as soon as possible.

HEDIS is a registered trademark of the National Committee for Quality Assurance.

The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their member contract or member guide for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.