SUD Chronic Care Enrollment & APCM Checklist

Secure written consent that explicitly names the entities authorized to receive SUD-related data per 42 CFR Part 2 requirements.

Clearly state the purpose of data sharing (e.g., 'Chronic Care Coordination') within the consent form to maintain compliance.

Use multi-factor authentication or secure portals when enrolling patients via telehealth or phone to protect record integrity.

Ensure the patient record is flagged to prevent automated sharing with Health Information Exchanges (HIEs) without explicit SUD consent.

Educate the patient on their right to revoke consent at any time and document the process for doing so within your care management system.

Validate the diagnosis of OUD, AUD, or other substance use disorders to justify medical necessity for chronic care.

Document current dosage and frequency for Buprenorphine, Methadone, or Naltrexone to establish a monitoring baseline.

Perform PHQ-9 and GAD-7 screenings to identify depression or anxiety that may complicate SUD recovery.

Evaluate history of prior overdoses and current access to Naloxone/Narcan for emergency situations.

Define the frequency and protocol for urine drug screens (UDS) as part of the chronic care monitoring plan.

Confirm the patient is enrolled in Medicare or a participating Medicare Advantage plan for G0568-G0570 code eligibility.

Set up a tracking mechanism for the 20-minute monthly threshold required for chronic care and BHI billing.

Ensure the SUD care plan includes the required psychiatric consultation or behavioral health integration elements.

Configure your EMR or billing software to flag accounts once the minimum coordination time is documented each month.

Train staff to document all phone coordination, pharmacy calls, and family check-ins that count toward APCM time.

Set up automated check-ins to ask about cravings and triggers, escalating high-risk responses to clinical staff.

Use AI-powered voice calls to remind patients of upcoming pharmacy pickups for Buprenorphine or Naltrexone.

Automate high-frequency outreach during the first 30 days post-detox, the period of highest relapse risk.

Ensure the automated phone system has a clear 'Press 0' or keyword trigger to reach a live counselor immediately.

Monitor call completion rates and response trends to identify patients who may be disengaging from treatment.