ASAM level of care documentation is the part of a substance use disorder (SUD) record that shows, dimension by dimension, why a patient needs the level of care you bill and why a less intensive one won't work. ASAM criteria compliance means writing that record to the edition your payer applies: the Fourth Edition, published by the American Society of Addiction Medicine in 2023, or the 2013 Third Edition that many Medicaid programs still use as of November 2026.
Here's what trips up good programs. Claims rarely get denied because the care was wrong. They get denied because the note didn't show the work, and the result is a denial, an appeal and weeks of staff time spent proving something that was true all along.
This guide covers the six dimensions in both editions and what to document in each, what the Fourth Edition changed, who uses it as of November 2026, and the gaps that cost SUD programs revenue. For the medical necessity side of the same record, see our guide to medical necessity documentation in behavioral health.
The short version
- ASAM is the framework payers and Medicaid programs use to judge SUD level of care. The Fourth Edition came out in 2023 for adults, and its youth volume followed in 2026.
- The Fourth Edition renamed and reordered the six dimensions. Dimensions 1 to 5 set the recommended level, and the new Dimension 6, Person-Centered Considerations, shapes where the patient will engage.
- Adoption is uneven as of November 2026. Optum's adult commercial reviews and Kentucky and Louisiana Medicaid have moved, while Oregon, Colorado and Washington set dates in 2027 and 2028.
- A defensible justification rates every dimension and says why a less intensive level won't meet the need. That last sentence is still the most common miss.
- Bill the level you actually deliver, and give continued stays fresh ratings, not a copy of the admission note.
Last reviewed: November 2026.
Why ASAM decides whether you get paid
The ASAM Criteria aren't just a clinical framework. For SUD, they're the payment framework. Health plans and state Medicaid programs use them to decide whether a level of care is appropriate, and utilization reviewers apply them every day when they authorize admissions, approve continued stays and adjudicate claims.
Federal and state rules push the same way. Medicaid section 1115 SUD demonstrations must require SUD-specific, multidimensional placement criteria, and CMS says states usually meet that with ASAM, though it doesn't mandate ASAM by name. California's SB 855 requires state-regulated health insurance to use the most recent nonprofit association criteria for level of care decisions, which for a primary SUD diagnosis means The ASAM Criteria.
So your ASAM documentation does double duty. It records your clinical reasoning, and it's the evidence a payer uses to decide whether to pay.
What the ASAM Criteria are, and which edition is current
ASAM stands for the American Society of Addiction Medicine, which publishes The ASAM Criteria. The Criteria assess six dimensions of need and recommend the least intensive level of care where the patient can be safely and effectively treated.
The current version is the Fourth Edition. ASAM released its adult volume digitally on October 5, 2023, ten years after the Third Edition, and a volume for adolescents and transition-aged youth followed on March 31, 2026. Volumes on correctional settings and behavioral addictions are still to come. Here's how the adult levels line up across editions:
| Fourth Edition level | What it is | Closest Third Edition level |
|---|---|---|
| 1.0 Long-Term Remission Monitoring | Checkups and fast re-engagement in sustained remission | New |
| 1.5 Outpatient Therapy | Outpatient psychosocial treatment | Level 1, outpatient |
| 1.7 Medically Managed Outpatient | Outpatient care plus biomedical and withdrawal management | 1-WM |
| 2.1 Intensive Outpatient (IOP) | 9 or more structured hours a week for adults | 2.1, intensive outpatient |
| 2.5 High-Intensity Outpatient (HIOP) | 20 or more structured hours a week | 2.5, partial hospitalization |
| 2.7 Medically Managed Intensive Outpatient | Intensive outpatient with medical management | 2-WM |
| 3.1 Clinically Managed Low-Intensity Residential | 24-hour structure, 9 to 19 clinical hours a week | 3.1, with fewer clinical hours |
| 3.5 Clinically Managed High-Intensity Residential | 24-hour clinically managed care, now including former 3.2-WM services | 3.5 and 3.2-WM |
| 3.7 Medically Managed Residential | Residential care with medical management | 3.7, medically monitored intensive inpatient, and 3.7-WM |
| 4 Medically Managed Inpatient | Hospital-level medical or psychiatric care | 4 and 4-WM |
Level 0.5, early intervention, moved to its own chapter, and Level 3.3 was eliminated because cognitive impairment is now addressed at every level. The Fourth Edition also adds co-occurring enhanced (COE) and 3.7 BIO variants, a Level 4 Psychiatric option, and a possible recovery residence recommendation alongside Levels 1 and 2.
The six ASAM dimensions, Fourth Edition and Third Edition
A reviewer wants to see all six dimensions assessed, with the level tied back to them. The Fourth Edition renamed them and changed the order. That's where most forms go wrong.
Every dimension rating rests on the intake assessment. Our guide to the biopsychosocial assessment shows how its domains map to the six dimensions.
| Fourth Edition dimension (2023) | Third Edition equivalent (2013) | Role in placement |
|---|---|---|
| 1. Intoxication, Withdrawal, and Addiction Medications | Dimension 1, Acute Intoxication and/or Withdrawal Potential | Sets the recommended level |
| 2. Biomedical Conditions | Dimension 2, Biomedical Conditions and Complications | Sets the recommended level |
| 3. Psychiatric and Cognitive Conditions | Dimension 3, Emotional, Behavioral, or Cognitive Conditions and Complications | Sets the recommended level |
| 4. Substance Use-Related Risks | Dimension 5, Relapse, Continued Use, or Continued Problem Potential | Sets the recommended level |
| 5. Recovery Environment Interactions | Dimension 6, Recovery/Living Environment | Sets the recommended level |
| 6. Person-Centered Considerations (new) | Replaces Dimension 4, Readiness to Change, which is now weighed within each dimension | Assessed after the recommendation, to settle where the patient will engage |
Read the numbers carefully. A Fourth Edition "Dimension 4" finding is about substance use risks, not readiness, so mixed numbering tells the reviewer something you didn't mean. Readiness no longer contributes independently to the level. It informs risk judgments in the other dimensions, and Dimension 6 covers barriers to care (including social determinants of health), patient preferences and the need for motivational enhancement.
What to document in each dimension
- Intoxication, Withdrawal, and Addiction Medications (Third Edition D1). Withdrawal risk scored with a tool such as CIWA-Ar or COWS, symptoms and the management plan. The Fourth Edition adds addiction medications, so record whether medications for opioid or alcohol use disorder were discussed, started, continued or declined.
- Biomedical Conditions (D2). Medical conditions, pregnancy or pain that affect treatment, or the documented absence of acute biomedical need.
- Psychiatric and Cognitive Conditions (D3). Psychiatric symptoms, risk of harm to self or others, stability, and any cognitive impairment that changes how treatment is delivered.
- Substance Use-Related Risks (Third Edition D5). Recent use, cravings, overdose risk, triggers and other harmful use-related behaviors. Prior treatment response is evidence here, not a prerequisite.
- Recovery Environment Interactions (Third Edition D6). Function, safety and support where the patient lives: housing, people using in the home, work, family and recovery supports.
- Person-Centered Considerations (new D6). Barriers such as transportation, childcare or work hours, the patient's preferences, and readiness. Record the shared decision and, if the selected level differs from the indicated one, why.
A defensible note shows the rating in each dimension, describes severity in clinical facts, and connects that picture to the level chosen. Interpret your scores, too. A CIWA-Ar number with no sentence about placement does little for a reviewer.
Free checklist
ASAM documentation checklist by level of care (PDF)
Three pages your UR and documentation staff can run against any chart: seven checks every record needs at every level, including six rated and justified dimensions, the "why a lower level isn't enough" sentence and continued-stay notes that restate current ratings, plus level-specific checks for Levels 1 through 3.7. It uses the Third Edition level numbers many payers still apply and flags where the Fourth Edition differs.
Get the ASAM documentation checklist Free, with a work email.
What the Fourth Edition changed for documentation and level of care decisions
ASAM kept the core principles, including placement based on need and a multidimensional assessment. What changed is how the record gets from assessment to a level:
| What changed | What it means on the page |
|---|---|
| Dimensions renamed and reordered | Update intake forms, note templates and EHR fields together. Never mix numbering in one chart. |
| Risk ratings by subdimension, each tied to a minimum level of care, plus decision rules | Record each rating with the clinical facts behind it. |
| An indicated level (Dimensions 1 to 5) and an adjusted level (after Dimension 6) | Document both, and why they differ if they do. |
| Separate Level of Care and Treatment Planning Assessments | Placement can rest on a focused assessment. The full biopsychosocial assessment follows for the plan, so date and sign each. |
| New and renamed levels, with withdrawal management folded into medically managed levels | Licenses, contracts and codes may lag. Document to the level your payer and license define, and keep a crosswalk. |
| Level 3.1 now expects 9 to 19 clinical hours a week, with structured services 7 days a week | A 3.1 chart showing a few groups a week won't support a Fourth Edition 3.1 claim. |
| Co-occurring capable care and access to addiction medications at every level | Address co-occurring conditions in every chart and document how medication access was offered. |
| Admission based on current need, not prior treatment failure | Don't justify residential care with "failed IOP" alone. |
ASAM also publishes free admission and continued service request forms, organized by dimension and subdimension, that ask for risk ratings, dimensional drivers, level of care adjustments and measures such as COWS and CIWA. Even where payers don't require them, they show the structure a Fourth Edition reviewer expects.
Which payers and states use the Fourth Edition (as of November 2026)
Adoption is uneven. A Medicaid program has to rewrite its licensing rules and state plan before switching, and commercial plans move contract by contract. Here's where several stand as of November 2026:
| Payer or program | Status as of November 2026 |
|---|---|
| Optum Behavioral Health, commercial | Fourth Edition for adult SUD treatment since November 2023, unless state, federal or contract rules say otherwise. For a facility, it applies once the updated contract is executed. |
| Ambetter (Kansas) | Fourth Edition for adult SUD admissions from June 21, 2026. Child and adolescent requests stay on the Third. |
| Kentucky Medicaid | Adult SUD services moved effective June 25, 2025. Adolescent services stayed on the Third. |
| Louisiana Medicaid | Full compliance with revised rules and Medicaid policy required by July 1, 2026. |
| California, state-regulated commercial insurance | SB 855 requires the most recent nonprofit association criteria, which for SUD means The ASAM Criteria. |
| California Medi-Cal (DMC and DMC-ODS) | DHCS planning materials target July 1, 2027. Final guidance is pending. |
| Colorado | Behavioral Health Administration materials point to July 1, 2027. Confirm against current BHA rules. |
| Oregon | July 1, 2027. OHA reviews use the Third Edition until then. |
| Washington | SB 5361 delays adoption to January 2028. |
Dates have moved more than once, and this isn't a complete list. Check payer manuals and contracts against your state's licensing rule before you change templates.
Where payers differ, write for both. Use Fourth Edition names and ratings, and make readiness explicit in the narrative, because a Third Edition reviewer still scores it as its own dimension.
ASAM Level of Care Certification is a separate matter. Delivered with CARF International, it covers adult residential programs at Levels 3.1, 3.5 and 3.7, and CARF has updated its rating elements to align with the Fourth Edition.
How to build a level of care justification that holds up
A justification that survives review rates all six dimensions, describes severity, explains why this level is the least intensive one that meets the need, and says why a lower level won't. Compare two illustrative notes for the same Level 2.1 patient, written to the Fourth Edition.
Weak: Patient meets criteria for IOP. Continue current level of care.
Strong: ASAM assessment (Fourth Edition). D1: low withdrawal risk, CIWA-Ar 6, continues buprenorphine. D2: no acute biomedical needs. D3: stable depressive symptoms, denies suicidal ideation. D4: high likelihood of risky use, positive screen 10 days ago, daily cravings. D5: unstable housing, active use in the home. Indicated level 2.1: weekly therapy (1.5) can't contain daily cravings in an unsafe home, and nothing in D1 to D3 needs 24-hour care. D6: ambivalent, works days, prefers evenings. Selected: evening IOP, 9 or more hours weekly, no adjustment. Reassess in two weeks.
The strong note gives the reviewer everything needed to say yes. Two sentences do the heavy lifting: why a lower level is insufficient, and why a higher level isn't required. Reviewers look for both, and I'd start every chart review there.
For a payer still on the Third Edition, keep the facts and relabel them. Readiness becomes Dimension 4, use risk becomes Dimension 5, and the home becomes Dimension 6.
For a Level 3.5 admission, show current risk that needs 24-hour structure, such as a high likelihood of harmful use in Dimension 4 and an environment in Dimension 5 that undermines treatment, and note the absence of instability that would point to 3.7 or Level 4. Prior IOP episodes can support that picture but can't replace it, since ASAM bases admission on current need rather than prior treatment failure.
Documentation by level: a quick tour
Each level has its own documentation center of gravity:
- Level 1 (1.0, 1.5, 1.7), outpatient. A diagnosis, functional impairment and a treatment plan, plus medical necessity for continued services. At 1.7, add vitals, withdrawal scores and prescriber notes. At 1.0, document remission status and re-engagement triggers.
- Level 2.1, intensive outpatient. Nine or more structured hours a week for adults, attendance, and why outpatient therapy isn't enough. Our IOP and PHP billing and documentation guide covers the payer side.
- Level 2.5, high-intensity outpatient (Third Edition: partial hospitalization). 20 or more structured hours a week, physician involvement and a reason IOP isn't enough. Many payers still say partial hospitalization, so match your contract's term and code.
- Level 2.7, medically managed intensive outpatient. IOP-level programming plus withdrawal scores, vitals and medical orders.
- Level 3.1, clinically managed low-intensity residential. Why 24-hour structure is needed, usually carried by Dimensions 4 and 5, and under the Fourth Edition, 9 to 19 clinical hours a week.
- Level 3.5, clinically managed high-intensity residential. The 24-hour need in clinical terms, plus any withdrawal monitoring once billed as 3.2-WM.
- Level 3.7, medically managed residential (Third Edition: medically monitored intensive inpatient). Physician and nursing assessments and the withdrawal or biomedical monitoring that separate it from 3.5.
- Level 4, medically managed inpatient. Acute biomedical or psychiatric instability requiring hospital-level care, documented contemporaneously.
The level you bill has to match the intensity you deliver and document. Billing 2.5 while delivering IOP hours, or the reverse, is a fast denial and an audit flag.
Reassessments and continued stays
Continued stays are where a lot of SUD revenue is lost, because the review needs fresh dimensional ratings, not a copy of the admission note. Reviewers want to see which dimensions improved, which didn't, and why the current level is still the least intensive appropriate setting.
The Fourth Edition gives this step its own transition and continued service criteria. A strong continued-stay note reads like a short update: withdrawal resolved (D1), mood improving (D3), one return to use this week with cravings (D4), housing still unstable (D5), patient open to stepping down once housing is set (D6). A weak one repeats the admission, and repetition is exactly what reviewers are trained to deny.
Where SUD claims fall short
The gaps that drive denials are consistent, and once you know them they're avoidable:
- Level not tied to the dimensions. A level asserted without the ratings behind it.
- No "why not lower" logic. The single most common miss.
- Copy-forward notes. Repeats of the last visit read as boilerplate.
- Billed level doesn't match delivered hours. The claim and the record disagree on intensity.
- Missing reassessments. Continued stays without fresh ratings.
- Mixed editions. Fourth Edition forms with Third Edition numbering, or Third Edition notes sent to a payer that has moved.
- No indicated versus adjusted level. Preference or access changed the placement, and the chart doesn't say so.
- Fail-first reasoning. "Failed outpatient" as the whole case for residential care.
- Scores without interpretation. A CIWA-Ar number with no narrative tying it to the level.
The habits that prevent them are unglamorous. Rate all six dimensions at intake and at every reassessment, write the explicit "why this level, why not lower" sentences, and confirm each payer's ASAM edition before you touch a template.
How ASAM connects to medical necessity
ASAM level of care and medical necessity are two sides of the same coin. Medical necessity shows treatment is needed at all: a diagnosis, functional impairment and a clinical rationale. ASAM shows this particular intensity is needed. A claim can fail on either axis, so a complete note carries both, and the same impairments and risks become the dimensional findings that justify the level.
It helps to know how review happens. Many payers apply ASAM directly for SUD, some through the ASAM Criteria Navigator software built with InterQual, while mental health levels run on other criteria (California names LOCUS for adults). The reviewer isn't re-deciding the case. They're checking your record against a rubric, so a note written to the rubric tends to pass, and a clean record makes any appeal fast.
How Adentris helps
Adentris reviews every active chart, not a sample, against payer and regulatory rules before claims go out, including ASAM level of care, medical necessity, 42 CFR Part 2, Medicaid and payer documentation rules, and treatment plan and signature timing. For ASAM, that means checking whether every dimension is rated and justified, whether the note says why a lower level won't meet the need, and whether the level billed matches the hours delivered.
Each finding cites the rule that fired and comes with a drafted correction for staff to approve. Documentation Compliance runs that review continuously while the patient is on census, on top of any EHR through API or FHIR, HL7 feeds, an API our agents build where none exists, or the AI Web Agent, usually with no IT project on your side.
At Solutions 2 Recovery, a detox-through-outpatient program in Los Angeles that runs on Kipu, we ran 3,433 checks on the records of 18 patients, with 58 controls applied by level of care. To see it on your own charts, book a 30-minute call with our team.
Related reading
- Best ASAM Assessment and Level-of-Care Tools for Behavioral Health (2026)
- CO-50 Denials in Behavioral Health: Why Medical Necessity Gets Denied and How to Appeal (Template Included)
- 42 CFR Part 2 in 2026: What the Final Rule Changed and What SUD Providers Must Do Now
Sources
- ASAM, About The ASAM Criteria
- ASAM, The ASAM Criteria, Fourth Edition
- ASAM news release on the Fourth Edition, October 5, 2023
- ASAM, Adolescents and Transition-Aged Youth volume
- CMS, ASAM Criteria Fourth Edition: Impacts on States with Medicaid Section 1115 Demonstrations, December 2025
- CMS, State Medicaid Director Letter #17-003, 2017
- ASAM training materials, Major Changes in the Fourth Edition
- ASAM presentations at NAIC, August 2024 and NAATP
- Mountain Plains ATTC, ASAM 4th Edition Overview, October 2023
- ASAM Service Request Forms and Level of Care Certification
- Optum Provider Express, ASAM Clinical Criteria Information and Ambetter Kansas notice, May 2026
- Kentucky DMS provider letter, May 2025 and Louisiana Informational Bulletin 24-2, revised April 2026
- Oregon OHA memo, July 2025, Colorado BHA laws and rules, Washington HCA letter on SB 5361 and California DHCS workgroup, 2026 Q1
- California Department of Insurance, SB 855 notice, December 2020
Frequently asked questions
What are the six dimensions of the ASAM Criteria?
In the Fourth Edition (2023) they are: 1, Intoxication, Withdrawal, and Addiction Medications. 2, Biomedical Conditions. 3, Psychiatric and Cognitive Conditions. 4, Substance Use-Related Risks. 5, Recovery Environment Interactions. 6, Person-Centered Considerations. Dimensions 1 to 5 drive the level of care recommendation. In the Third Edition, Dimension 4 was Readiness to Change, Dimension 5 was relapse potential and Dimension 6 was the recovery environment.
When was the ASAM Criteria Fourth Edition published?
ASAM released the Fourth Edition's adult volume digitally on October 5, 2023. The adolescent and transition-aged youth volume followed digitally on March 31, 2026, with print in June 2026. The Third Edition dates from 2013.
What are the ASAM levels of care in 2026?
Under the Fourth Edition: 1.0 Long-Term Remission Monitoring, 1.5 Outpatient Therapy, 1.7 Medically Managed Outpatient, 2.1 Intensive Outpatient, 2.5 High-Intensity Outpatient, 2.7 Medically Managed Intensive Outpatient, 3.1 and 3.5 Clinically Managed Low- and High-Intensity Residential, 3.7 Medically Managed Residential and 4 Medically Managed Inpatient. Programs still on the Third Edition use its levels, such as 2.5 partial hospitalization.
Do payers require the ASAM Fourth Edition yet?
Not everywhere, as of November 2026. Optum has applied it to adult commercial SUD cases since November 2023, and Kentucky and Louisiana Medicaid have moved. Oregon and Colorado set July 1, 2027, and Washington delayed adoption to January 2028. Check each payer's provider manual and contract.
What is the difference between ASAM Level 3.5 and Level 3.7?
Level 3.5 is clinically managed high-intensity residential care, with 24-hour structure and clinical services. Level 3.7 is medically managed residential care, which adds medical management of withdrawal and of biomedical or psychiatric conditions. The Third Edition called 3.7 medically monitored intensive inpatient.
What is ASAM level of care certification?
It is a certification, delivered in partnership with CARF International, that a program meets ASAM standards for its level of care. It covers adult residential programs at Levels 3.1, 3.5 and 3.7, and CARF has updated its rating elements to align with the Fourth Edition.
