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Coverage criteria policies

Chemical health services - Minnesota Health Care Programs

These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

  • All chemical health residential services and treatment with room and board require prior authorization.
  • Members must have a Rule 25 assessment completed and submitted.
  • Assessments must be submitted on the Minnesota Department of Human Services Rule 25 Universal Assessment form. The chemical health Rule 25 assessment will be reviewed by a HealthPartners Quality and Utilization Coordinator and a Board Certified Psychiatrist as needed.
  • Providers are responsible for verifying a person’s eligibility monthly using MN–ITS to see whether:
    • the person has any public health care (e.g., MA or MinnesotaCare) and
    • that the person is enrolled with HealthPartners.


For member to meet admission criteria for residential services:

  1. A face to face chemical health Rule 25 assessment completed in the last 30 days by a licensed alcohol and drug chemical health professional or comparably licensed professional has been submitted and identifies a need for this particular level of care.
  2. The service is a covered benefit, when the member meets criteria according to the DHS Minnesota Matrix Coverage Criteria and Rule 25 Treatment Planning Decision Guide.

Indications that are covered

  1. DSM-5 diagnostic criteria for chemical dependency must be met to be considered for coverage.
  2. The level of intensity and duration of treatment must match the level of complexity of the clinical situation.
  3. A person who scores a severity rating of 2, 3 or 4 in Dimension IV, V or VI meets clinical eligibility requirements for treatment

Indications that are not covered

Chemical dependency treatment which exceeds the level of treatment intensity required based on the member’s clinical treatment needs.


Chemical Health Residential Services for Minnesota Health Care Programs products include room and board services.

Chemical Use Assessment or Rule 25 Assessment: An assessment that includes an interview, a written listing of the person’s specific problems related to chemical use, and a risk description that enables the assessor to make an appropriate treatment plan decision according to the Minnesota Matrix (DHS-5204B) (PDF)

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

The services associated with these codes require prior authorization:




Alcohol and /or other drug treatment program, per diem

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This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.


  1. Minnesota Department of Human Services Provider Manual: Substance Use Disorder Services (SUD) Revised January 25,2019
  2. Minnesota Statutes, section 254A.03 (Alcohol and Drug Abuse)
  3. Minnesota Statures, section 254B (Consolidated Chemical Dependency Treatment Fund)
  4. Minnesota Statues, section 256L (MinnesotaCare)
  5. Minnesota Rules, parts 9530.6600 to 9530.6655 (Rule 25)

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Policy activity

  • 10/31/2007 - Date of origin
  • 12/01/2016 - Effective date
Review date
  • 03/2019

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