Opioid Treatment Program (OTP) Clause Samples
The Opioid Treatment Program (OTP) clause defines the requirements and standards for facilities or providers that deliver treatment services to individuals with opioid use disorder. Typically, this clause outlines the necessary certifications, compliance with federal and state regulations, and the types of medications and therapies that may be administered, such as methadone or buprenorphine. Its core practical function is to ensure that opioid treatment is provided safely, legally, and effectively, thereby protecting patient welfare and maintaining regulatory compliance.
Opioid Treatment Program (OTP). The Contractor shall provide coverage for the daily Opioid Treatment Program (OTP). A daily opioid treatment program includes administration and coverage of methadone, routine drug testing, group therapy, individual therapy, pharmacological management, HIV testing, Hepatitis A, B, and C testing, pregnancy tests, Tuberculosis testing, Syphilis testing, follow-up examinations, case management and one evaluation and management office visit every 90 days for the management of patient activities identified in the individualized treatment plan that assist in patient goal attainment, including referrals to other service providers and linking patients to recovery support groups. OTP coverage will include those members as defined by OMPP and approved by CMS. The MCE will be responsible for OTP services provided by the provider type Addictions Provider and the provider specialty OTP as defined in the IHCP Provider Enrollment Type and Specialty Matrix. Eligible members include: Members 18 years and older who have become addicted at least one year prior to admission and are placed in the Opioid Treatment Services (OTS) Level of Care according to all six dimensions of the American Society of Addiction Medicine (ASAM) Patient Placement Criteria. Members under 18 years of age and have had two documented unsuccessful attempts at short-term withdrawal management or drug free treatment within a 12-month period. All members released from penal institution (within six months of release). Pregnant members. Previously treated members (up to two years after discharge).
Opioid Treatment Program (OTP). The Contractor shall provide coverage for the daily Opioid Treatment Program (OTP). A daily opioid treatment program includes administration and coverage of an FDA- approved opioid agonist or antagonist medication-assisted treatment (MAT) medication, routine drug testing, group therapy, individual therapy, pharmacological management, follow-up examinations, and one evaluation and management office visit every 90 days for the management of patient activities identified in the individualized treatment plan that assist in patient goal attainment, including referrals to other service providers and linking patients to recovery support groups. OTP coverage will include those members as defined by FSSA and approved by CMS. The MCE will be responsible for OTP services provided by the provider type Addictions Provider and the provider specialty OTP as defined in the IHCP Provider Enrollment Type and Specialty Matrix. Eligible members include: ▪ Members 18 years and older who have become addicted at least one year prior to admission and are placed in the Opioid Treatment Services (OTS) Level of Care according to all six dimensions of the American Society of Addiction Medicine (ASAM) Patient Placement Criteria. ▪ Members under 18 years of age and have had two documented unsuccessful attempts at short-term withdrawal management or drug free treatment within a 12-month period. ▪ All members released from penal institution (within six months of release). ▪ Pregnant members. ▪ Previously treated members (up to two years after discharge).
Opioid Treatment Program (OTP). The Contractor shall provide coverage for the Opioid Treatment Program (OTP) for members receiving services at OTPs. A daily opioid treatment program includes administration and coverage of an FDA-approved opioid agonist or antagonist medication- assisted treatment (MAT) medication, routine drug testing, group therapy, individual therapy, pharmacological management, follow-up examinations, and one evaluation and management office visit every 90 days for the management of patient activities identified in the individualized treatment plan that assist in patient goal attainment, including referrals to other service providers and linking patients to recovery support groups. OTP coverage will include those members as defined by OMPP and approved by CMS. The MCE will be responsible for OTP services provided by the provider type Addictions Provider and the provider specialty OTP as defined in the IHCP Provider Enrollment Type and Specialty Matrix. Coverage of OTP services will be restricted as follows: ▪ Individuals aged 18 and older seeking OTP services must meet the following medical necessity criteria: • Must be addicted to an opioid drug • Must have been addicted for at least one year before admission to the OTP • Must meet the criteria for the Opioid Treatment Services (OTS) level of care, according to all six dimensions of the American Society of Addiction Medicine (ASAM) Patient Placement Criteria ▪ Individuals under the age of 18 seeking OTP services must meet the following medical necessity criteria: • Must be addicted to an opioid drug • Must have two documented unsuccessful attempts at short-term withdrawal management or drug-free addiction treatment within a 12-month period preceding admission • Must meet the criteria for the Opioid Treatment Services (OTS) level of care, according to all six dimensions of the ASAM Patient Placement Criteria ▪ The following individuals are exempt from the one-year addiction requirement: • Members released from a penal institution – If the individual seeks OTP services within six months of release • Pregnant women • Previously treated individuals – If the individual seeks OTP services within two years after treatment discharge Prior authorization (PA) is not required for OTP services. However, providers must maintain documentation demonstrating medical necessity, that the coverage criteria are met, as well as the individual’s length of treatment, in the member’s records.
Opioid Treatment Program (OTP). The Contractor shall provide coverage for the daily Opioid Treatment Program (OTP). A daily opioid treatment program includes administration and coverage of methadone, routine drug testing, group therapy, individual therapy, pharmacological management, HIV testing, Hepatitis A, B, and C testing, pregnancy tests, Tuberculosis testing, Syphilis testing, follow-up examinations, case management and one evaluation and management office visit every 90