ASAM level of care assessment: how risk ratings work

In this article▾

1. What is an ASAM level of care assessment?
2. What are the six ASAM dimensions in the Fourth Edition?
3. How to score an ASAM assessment
4. How do ASAM risk ratings map to levels of care?
5. Example: How a clinician documents an ASAM recommendation
6. What should an ASAM level of care assessment document?
7. ASAM assessment, prior authorization, and billing
8. How AI can support ASAM assessment workflows
9. Frequently asked questions
10. Sources and further reading

How do you score an ASAM assessment? Under the ASAM Criteria Fourth Edition, clinicians assess a patient's needs across six dimensions, assign risk ratings to relevant areas, and use those findings with the Dimensional Admission Criteria to recommend an appropriate level of care. Ratings are not added together to produce a placement score.

The Fourth Edition uses risk ratings that include 0 through 4 and other designations, including EVAL, to help clinicians identify clinical needs and the minimum level of care indicated by particular risks. In withdrawal and biomedical areas, certain ratings specify minimum levels such as 1.7, 2.7, 3.7, or Level 4. These are clinical placement requirements for the applicable risk, not a complete placement algorithm.

The final recommendation also considers the patient's needs across dimensions, person-centered preferences, ability to engage in treatment, and the services available at the proposed level. Payer authorization and state-specific rules are separate considerations.

This guide explains how the assessment works, how to interpret risk ratings, and how to document a level-of-care recommendation under the Fourth Edition.

What is an ASAM level of care assessment?

An ASAM level of care assessment is a multidimensional clinical assessment used to determine the type and intensity of addiction treatment a patient needs. It helps clinicians identify immediate risks, evaluate treatment needs, and recommend a setting that can safely and effectively address those needs.

The ASAM Criteria are developed by the American Society of Addiction Medicine (ASAM). The Fourth Edition updates the clinical framework and the assessment process, including how clinicians evaluate risk and incorporate patient preferences. Our ASAM Criteria explainer covers what the framework is and why payer policies lag it; this guide is about the assessment itself.

ASAM describes three distinct assessment activities:

The Level of Care Assessment is not intended to replace a comprehensive biopsychosocial assessment. It is a focused process to support an initial placement recommendation.

ASAM's Fourth Edition Level of Care Assessment Guide includes interviewer and patient-directed questions for all dimensions, risk-rating tables for Dimensions 1 through 5, appendices supporting those decisions, and a Dimension 6 section for level-of-care selection. It is free for treatment providers, and it was developed by ASAM and pilot tested with UCLA's Integrated Substance Use and Addiction Programs across four California counties.

Who can complete it. ASAM does not specify a credential. Assessors should work within the scope of practice set by their state or local authority, and ASAM recommends that assessments be completed by clinical staff trained in applying the Criteria. Your state and your payers may both be stricter, and the Guide can be used before the patient reaches a program, including in a call center or central intake.

Sources: ASAM Criteria FAQ · Fourth Edition assessment guides

What are the six ASAM dimensions in the Fourth Edition?

The Fourth Edition organizes the assessment around six dimensions. Dimensions 1 through 5 inform the level-of-care recommendation through clinical risk assessment. Dimension 6 supports shared decision-making about the level of care the patient is willing and able to engage in.

The Fourth Edition changes the role of readiness to change. In the Third Edition, readiness was its own Dimension 4. In the Fourth Edition, it is considered across the dimensions and in treatment planning rather than functioning as an independent placement dimension.

Dimension 6 is also different from the first five dimensions. It supports a shared decision-making process. A patient may have significant clinical needs but face transportation, housing, work, caregiving, or other barriers that affect which services they can access.

Those barriers should be addressed in the care plan. They should not be used to erase or downgrade a clinically indicated level of care.

How to score an ASAM assessment

The Fourth Edition uses risk ratings to organize clinical findings and support a placement decision. Clinicians should use the official assessment guide's definitions and decision tables for the applicable dimension and subdimension.

A risk rating is not a standalone diagnosis, and the assessment is not a points-based quiz. The clinician must connect the rating to the patient's presentation, the services needed, and the level of care capable of meeting those needs.

Step 1: Gather the information needed for each dimension

Begin with the patient's current presentation and relevant history. The assessment should collect enough information to identify immediate risks and determine treatment needs.

Depending on the dimension, that may include:

• Recent substance use and the patient's history of withdrawal episodes.
• Current intoxication, withdrawal symptoms, and anticipated withdrawal severity.
• Physical health conditions and the need for medical monitoring or intervention.
• Psychiatric symptoms, cognitive concerns, and immediate safety needs.
• Substance-use-related risks and the patient's recovery environment.
• Current medications, medication initiation or titration needs, and the ability of a program to continue existing medications.

The clinician should distinguish current findings from historical information and anticipated risks. For example, a previous severe withdrawal episode may be relevant to the anticipated severity of a current withdrawal episode, but it is not automatically equivalent to current severe withdrawal.

When information is incomplete, the assessment should document the gap and determine whether further evaluation is needed.

Step 2: Assign the applicable risk ratings

Use the Fourth Edition's risk-rating tables and supporting guidance to determine the appropriate rating for the applicable subdimension.

The guide includes ratings such as 0, 1, 2, 3, and 4, along with designations such as EVAL and other dimension-specific indicators. Not every rating or designation applies to every subdimension.

The rating should reflect the clinical finding, not the treatment program's available services or the payer's preferred authorization outcome.

For the exact definitions and rating criteria, use ASAM's official Level of Care Assessment Guide. ASAM periodically updates the downloadable materials, so clinicians should check the current version rather than rely on an old printed form.

Step 3: Identify minimum levels indicated by specific risks

Some risk ratings identify a minimum level of care for the applicable clinical need. This is particularly important in withdrawal and biomedical assessment.

ASAM describes the mechanism plainly: risk ratings within each subdimension indicate the minimum level of care at which the patient should be treated to address the needs in that subdimension. In the withdrawal and biomedical subdimensions in particular, a rating can point directly at a medically managed level.

Two things follow from that, and they matter more than the numbers.

First, a minimum level is a floor, not a recommendation. It says the patient cannot be treated below that level for that particular need. Other dimensions may push the recommendation higher, and the Dimensional Admission Criteria, not any single rating, produce the final answer.

Second, the rating is a clinical finding about the patient. It is not a description of what your program offers or what you expect the payer to approve.

We do not reproduce the rating-to-level tables here. They are part of ASAM's copyrighted decision rules, and ASAM's permissions policy requires agreement for public-facing commercial use. The tables are in the Level of Care Assessment Guide, which ASAM publishes free for treatment providers. Work from that copy, because ASAM updates the materials periodically.

Sources: ASAM Criteria FAQ, risk ratings and Dimensional Admission Criteria · Fourth Edition Level of Care Assessment Guide

Step 4: Address EVAL and other special designations

EVAL indicates that a prompt medical evaluation is needed. It is not another number on the same risk scale, and it is not a level-of-care recommendation. It is an instruction to find something out before you decide.

When a patient requires prompt evaluation, the clinician should document what requires further assessment and the action taken to address the concern.

Other designations may identify specific clinical needs, such as addiction medication management or medication continuation. These designations can affect program selection and the services required without functioning as a general numerical risk score.

Do not convert a special designation into a numerical value or add it to the patient's other ratings.

Step 5: Apply the Dimensional Admission Criteria

Once the relevant risks and needs have been assessed, use the Dimensional Admission Criteria to determine the recommended level of care.

This is the point where the clinician considers the assessment as a whole. The recommendation should address the patient's clinical risks and identify a level capable of delivering the required services.

A minimum level identified in one dimension may establish a clinical floor. Other findings may indicate a need for a more intensive level or additional services. The final recommendation should be supported by the applicable admission criteria and the clinical record.

Dimension 6 then supports a shared decision-making discussion about the patient's preferences, barriers, and ability to engage in the recommended care.

There is no valid shortcut in which a clinician adds all six dimension ratings, averages them, or automatically selects the level associated with the highest numerical rating. Follow the actual criteria and decision process.

How do ASAM risk ratings map to levels of care?

The ASAM continuum runs from outpatient through intensive outpatient, high-intensity outpatient, residential, medically managed and hospital-level services. The level selected should reflect the patient's needs and the services required to address them. Our complete levels of care guide describes each one.

The Fourth Edition uses more specific level designations than the broad level numbers alone. For example, Level 2.1 and Level 2.5 are different service intensities, and Level 2.7 refers to medically managed intensive outpatient services.

This table is a general orientation, not a substitute for the Fourth Edition's complete level descriptions, admission criteria, or program requirements.

A patient may need a particular level because of a specific withdrawal or biomedical risk, while other dimensions may influence the services, staffing, and treatment planning required at that level.

For example, a patient with significant psychiatric symptoms may need a program with the capability to address co-occurring conditions alongside substance use disorder. A patient with a high biomedical risk may need medical services that an otherwise appropriate residential program cannot provide. That boundary is the subject of our Level 3.5 guide, which works through where clinically managed residential stops and medically managed residential begins.

The assessment should therefore answer two questions:

1. What level of care is clinically indicated by the patient's needs?
2. What capabilities and services must the selected program provide to address those needs?

Example: How a clinician documents an ASAM recommendation

Consider a hypothetical adult presenting for an initial substance use treatment assessment.

The patient reports recent heavy alcohol use, has a history of withdrawal, and describes current symptoms that require further clinical evaluation. The patient also reports anxiety and unstable housing.

The clinician should not assign a placement by adding numerical ratings across dimensions. Instead, the clinician would:

1. Assess current intoxication and anticipated withdrawal severity using the applicable Dimension 1 criteria.
2. Determine whether the patient's symptoms require prompt evaluation or medically managed withdrawal services.
3. Assess psychiatric needs and whether they affect safety or the services required.
4. Evaluate the recovery environment and practical barriers to engagement.
5. Apply the Dimensional Admission Criteria and document the recommended level and rationale.

If the applicable withdrawal rating indicates a minimum medically managed level, the recommendation must account for that clinical requirement. Anxiety and housing instability may affect the treatment plan, program capabilities, and shared decision-making, but they do not independently determine a numerical placement score.

This example illustrates the assessment process only. The actual level cannot be determined without a complete clinical evaluation and application of the current ASAM criteria.

What should an ASAM level of care assessment document?

A defensible assessment makes the connection between clinical findings, risk ratings, and the level-of-care recommendation clear to another clinician or reviewer.

The record should include:

• The patient's presenting concerns and relevant substance-use history.
• Findings supporting the applicable dimension and subdimension ratings.
• The rationale for any EVAL or other special designation and the resulting action.
• The minimum level indicated by applicable risk criteria, where relevant.
• The Dimensional Admission Criteria supporting the overall recommendation.
• The services, medical capabilities, or program features needed to address identified risks.
• Patient preferences, barriers to engagement, and shared decision-making.
• Any information gaps, clinical consultations, or additional evaluations required.

Avoid documentation that merely lists ratings without explaining what they mean for the patient.

For example, "Dimension 1 = 2; recommend Level 2.7" is less informative than a record that identifies the withdrawal-related findings, explains the applicable rating and minimum-level requirement, and connects that finding to the services the patient needs.

The assessment should also distinguish a clinical recommendation from a payer's authorization decision. A payer may request additional documentation or apply its own coverage criteria, but an authorization outcome is not itself a clinical risk rating.

ASAM assessment, prior authorization, and billing

An ASAM level-of-care assessment supports clinical placement. It does not automatically establish that a payer will authorize or reimburse the recommended service.

Payers may use their own medical-necessity policies, documentation requirements, authorization forms, service definitions, and billing rules. State Medicaid programs and commercial plans may also implement the ASAM Criteria on different timelines.

Before submitting an admission or continued-stay request, providers should verify:

• Which ASAM edition and assessment form the payer requires.
• Whether the payer uses its own service request form or clinical criteria.
• Which documentation supports the requested level and duration.
• Whether the requested service is covered under the patient's benefit.
• Which billing code, modifiers, authorization number, and claim requirements apply.

Do not assume that an ASAM level designation is itself a billable code. The correct code depends on the payer, state, benefit and service delivered. For Level 2.1, for example, the code most state Medicaid programs use is H0015, and our Level 2.1 guide covers what has to be true before you bill it.

If a claim is denied, review the reason and the payer's requirements. For example, CO-197 indicates that a required authorization or precertification is missing. It is an authorization-related denial code, not an ASAM clinical risk rating.

See our CO-197 denial code guide for more on authorization-related denials, and prior authorization in behavioral health for the workflow that prevents them.

How AI can support ASAM assessment workflows

AI may support administrative work around an assessment, but it should not replace clinical judgment or independently determine a patient's level of care.

ASAM expressly prohibits inputting its Criteria and other ASAM intellectual property into AI systems. Clinicians and organizations should review ASAM's current terms and use only workflows that comply with those restrictions.

Within permitted boundaries, technology may help teams organize their own clinical documentation, identify missing fields, track authorization deadlines, or assemble payer-required records for human review.

For example, an administrative workflow may flag that a service request is missing a clinician's signature or that an authorization expires before the next scheduled review. These tasks are different from feeding ASAM's proprietary criteria into an AI system or asking a model to assign clinical risk ratings.

Any AI-assisted documentation should be reviewed by an appropriately qualified clinician. The clinician remains responsible for the assessment, the clinical rationale, and the level-of-care recommendation.

Frequently asked questions

How do you score an ASAM assessment?

Assess the patient's needs across the six dimensions, assign the applicable risk ratings using the Fourth Edition guide, and apply the Dimensional Admission Criteria. Ratings are not added or averaged into a single score. Certain ratings in withdrawal and biomedical categories indicate minimum levels of care.

What do ASAM risk ratings 0 through 4 mean?

The Fourth Edition uses risk ratings from 0 through 4, along with additional designations that vary by dimension and subdimension. The exact meaning of each rating depends on the applicable risk category. Consult the current ASAM Level of Care Assessment Guide for the definitions and decision criteria.

What does EVAL mean on an ASAM assessment?

EVAL indicates that prompt evaluation is needed. It should trigger appropriate follow-up and documentation rather than being treated as a numerical rating or a final level-of-care recommendation.

Does the highest ASAM dimension rating determine the level of care?

Not automatically. Certain risk ratings establish a minimum level for a specific clinical need. The overall recommendation is determined by applying the Dimensional Admission Criteria to the assessment findings, with Dimension 6 supporting shared decision-making.

Is an ASAM assessment the same as a biopsychosocial assessment?

No. The Level of Care Assessment is a focused assessment used to recommend care before treatment begins. The Treatment Planning Assessment is a fuller biopsychosocial assessment, typically completed after admission, to develop an individualized treatment plan.

Who can complete an ASAM level of care assessment?

ASAM does not specify a credential. Assessors should operate within the scope of practice defined by their state or local authority, and ASAM recommends that assessments be completed by clinical staff trained in applying the Criteria. Check your state rules and your payer contracts, which may be stricter.

Is the ASAM Level of Care Assessment Guide free?

Yes. ASAM publishes it free for treatment providers, in print and digital versions, subject to accepting its terms. ASAM updates the materials periodically, so download a current copy rather than working from an old printed form.

When should the Level of Care Assessment be done?

Before the patient begins treatment. It can be completed before the patient reaches a program, in a call center or central intake, or at the program before admission. The fuller biopsychosocial Treatment Planning Assessment usually comes after admission.

How often should a patient be reassessed?

The Fourth Edition sets reassessment expectations per level. Levels 2.1, 2.5, 3.1 and 3.5 recommend monthly formal reassessment, with treatment planning continuous in between. State regulations can require more.

Does an ASAM level guarantee insurance authorization?

No. A clinical recommendation and payer authorization are separate. Providers must verify the payer's applicable medical-necessity criteria, documentation requirements, covered services, and authorization process.

Sources and further reading

• American Society of Addiction Medicine. ASAM Criteria Fourth Edition Assessment Guides. Official Level of Care Assessment Guide, instructions, and appendices.
• American Society of Addiction Medicine. The ASAM Criteria, Fourth Edition. Overview of the six dimensions, assessment types, and continuum of care.
• American Society of Addiction Medicine. ASAM Criteria Intake Assessment Form. Third Edition intake assessment resource, with a link to the Fourth Edition assessment guide.
• American Society of Addiction Medicine. Implementation Tools. Current assessment guides, service request forms, and implementation resources.
• American Society of Addiction Medicine. ASAM Criteria FAQ. Assessment resources and implementation questions.

Related reading: The ASAM Criteria explained · ASAM levels of care · ASAM Level 2.1 · ASAM Level 3.5 · CO-197 denial code

Editorial note: The ASAM Criteria are copyrighted clinical standards. This article describes the assessment process and does not reproduce ASAM's risk-rating tables, Dimensional Admission Criteria or other proprietary decision rules. ASAM states that inputting the Criteria and other ASAM intellectual property into artificial intelligence systems is strictly prohibited. Use the current official guide, your state regulations and your payer's policy when making placement and authorization decisions. Every source above was opened and checked on September 26, 2026.