AdministrativeMedicaidJanuary 29, 2025

Alcohol and drug screening, assessment, brief interventions, and referral to treatment

There have been recent updates to the requirements for Medi‑Cal Managed Care providers around alcohol and drug screening assessment, brief interventions, and referral to treatment (SABIRT) for members ages 11 years and older, including pregnant women.

APL 17‑016, formerly called Screening, Brief Intervention and Referral to Treatment for Misuse of Alcohol (SBIRT), was replaced on September 14, 2018, by the updated all plan letter (APL), APL 18‑014 formerly called Alcohol Misuse: Screening and Behavioral Counseling Interventions in Primary Care by the State of California Department of Health Care Services (DHCS). The updated APL 21‑014, Alcohol and Drug Screening, Assessment, Brief Interventions, and Referral to Treatment supersedes APL 18‑014 and aligns with the November 2018 and June 2020 updates to the United States Preventive Services Task Force (USPSTF) recommendations.

As stated in the APL, Primary Care Providers (PCPs) are contractually required to provide screening services for all members under 21 years of age under the Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT) benefit. As part of the EPSDT requirement, PCPs are contractually required to provide services as recommended by the American Academy of Pediatrics (AAP) Bright Futures initiative for all members under 21 years of age. The AAP develops guidance and recommendations for preventive care screenings and well‑child visits for children and regularly publishes updated tools and resources for use by clinicians and state agencies. Per AAP/Bright Futures recommendations, tobacco, alcohol, and drug use screening and assessment with appropriate follow‑up action as necessary shall begin to occur at 11 years of age. PCPs are also contractually required to provide all preventive services for members who are 21 years of age or older consistent with USPSTF Grade A and B recommendations. The USPSTF assigned a Grade B recommendation for Screening and Behavioral Counseling Interventions to Reduce Unhealthy Alcohol Use in Adolescents and Adults, as of November 2018, and for Screening for Unhealthy Drug Use, as of June 2020. The USPSTF recommends screening for unhealthy alcohol use in primary care settings in adults 18 years or older, including pregnant women, and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use. Additionally, the USPSTF recommends screening by asking questions about unhealthy drug use in adults aged 18 years or older. Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred.

The USPSTF uses the term unhealthy alcohol use to define a spectrum of behaviors, from risky drinking to alcohol use disorder (AUD) (for example, harmful alcohol use, abuse, or dependence). Risky or hazardous alcohol use means drinking more than the recommended daily, weekly, or per‑occasion amounts, resulting in increased risk for health consequences, but not meeting criteria for AUD. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) defines heavy use as exceeding the recommended limits of four drinks per day or 14 drinks per week for adult men or three drinks per day or seven drinks per week for adult women. The term unhealthy drug use is defined as the use of illegally obtained substances, excluding alcohol and tobacco products, or the nonmedical use of prescription psychoactive medications; that is, use of medications for reasons, for duration, in amounts, or with frequency other than prescribed or by persons other than the prescribed individual.

Unhealthy alcohol and drug use plays a contributing role in a wide range of medical and behavioral health conditions. Counseling interventions in the primary care setting can address risky drinking behaviors in adults by reducing weekly alcohol consumption and increasing long‑term adherence to recommended drinking limits. Brief behavioral counseling interventions decrease the proportion of persons who engage in episodes of heavy drinking. Additionally, brief counseling interventions increase the likelihood pregnant women will abstain from alcohol throughout their pregnancy. Effective treatment options for AUDs and/or substance use disorders (SUDs) depend on the severity of the disorder and include some combination of the following: alcohol and/or drug counseling sessions, participation in mutual help groups, structured, evidence‑based psychosocial interventions, Federal Drug Administration‑approved medications, residential treatment (when medically necessary), or some combination of these services.

SABIRT Requirements: Consistent with USPSTF Grade A or B recommendations, AAP/Bright Futures, and the Medi‑Cal Provider Manual, PCPs must provide SABIRT services for members 11 years of age and older, including pregnant women. These services may be provided by providers within their scope of practice, including, but not limited to, physicians, physician assistants, nurse practitioners, certified nurse midwives, licensed midwives, licensed clinical social workers, licensed professional clinical counselors, psychologists and licensed marriage and family therapists. In providing SABIRT services, PCPs must comply with all applicable laws and regulations relating to the privacy of SUD records, as well as state law concerning the right of minors over 12 years of age to consent to treatment, including, without limitation, Title 42 Code of Federal Regulations (CFR) Section 2.1 et seq., 42 CFR Section 2.14, and Family Code Section 6929.

Screening: Unhealthy alcohol and drug use screening must be conducted using validated screening tools. Validated screening tools include, but are not limited to:

Brief Assessment: When a screening is positive, validated assessment tools shall be used to determine if unhealthy alcohol use or SUD is present. Validated alcohol and drug assessment tools may be used without first using validated screening tools. Validated assessment tools include, but are not limited to:

Brief Interventions and Referral to Treatment: For recipients with brief assessments that reveal unhealthy alcohol use, brief misuse counseling shall be offered. Appropriate referral for additional evaluation and treatment, including medications for addiction treatment, must be offered to recipients whose brief assessment demonstrates probable AUD or SUD. Alcohol and/or drug brief interventions include alcohol misuse counseling and counseling a member regarding additional treatment options, referrals, or services. Brief interventions must include the following:

  • Providing feedback to the patient regarding screening and assessment results;
  • Discussing negative consequences that have occurred and the overall severity of the problem;
  • Supporting the patient in making behavioral changes; and
  • Discussing and agreeing on plans for follow‑up with the patient, including referral to other treatment if indicated.

PCPs must make good faith efforts to confirm whether members receive referred treatments and document when, where, and any next steps following treatment. If a member does not receive referred treatments, the PCP must follow up with the member to understand barriers and adjust the referrals if warranted. The PCP shall also attempt to connect with the provider to whom the member was referred to facilitate a warm handoff to necessary treatment.

PCPs may call their local health department for referrals for alcohol and substance abuse. For questions, please call the Anthem behavioral health department at 888‑831-2246. Select option 1 and then option 2 to request care coordination.

Documentation Requirements: Member medical records must include the following:

  • The service provided (for example, screen and brief intervention);
  • The name of the screening instrument and the score on the screening instrument (unless the screening tool is embedded in the electronic health record);
  • The name of the assessment instrument (when indicated) and the score on the assessment (unless the screening tool is embedded in the electronic health record); and
  • If and where a referral to an AUD or SUD program was made.

PCPs should maintain documentation of SABIRT services provided to members. When a member transfers from one PCP to another, the receiving PCP must attempt to obtain the member’s prior medical records, including those pertaining to the provision of preventive services.

To view the detailed requirements in the updated APL 21‑014 including a list of other validated screening and assessment tools, please visit:

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Blue Cross of California Partnership Plan, Inc. are independent licensees of the Blue Cross Association. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Anthem is a registered trademark of Anthem Insurance Companies, Inc.