Provider Checklist Level of Care Service Component Reveiew

DBH eMemo important new for you

The Division of Behavioral Health is reviewing 1115 service implementation to confirm these services meet the service component requirements as listed in the Alaska Behavioral Health Providers Services Standards & Administrative Procedures for Behavioral Health Provider Services (7 AAC 160.900(d) (68)), The Alaska Behavioral Health Providers Services Standards & Administrative Procedures for SUD Provider Services (7 AAC 160.900 (d) (67)), and The ASAM Criteria: Treatment Criteria for Addictive, Substance Related, and Co-Occurring Conditions. (2013). 3rd Edition. American Society of Addiction Medicine (7AAC 70.910 (2)). The purpose of this form is to assist providers in adequately submitting documentation to the Division of Behavioral Health when applying for a new SUD level of care or BH service under the 1115 Waiver.  Please use this checklist as a tool to verify all necessary documentation is present when applying for any of the following levels of care or services:

 Substance Use Disorder Levels of Care requiring review:

  • 2.5 partial hospitalization
  • Residential substance use treatment levels: 3.1, 3.3, 3.5, 3.7, 4.0
  • Withdrawal management programs: 1.0-WM, 2.0-WM, 3.2-WM, 3.7-WM, 4.0-WM.

 Behavioral Health Services requiring review:  

  • Assertive Community Treatment (ACT)
  • Adult Mental Health Residential Treatment levels 1 & 2
  • Children’s Mental Health Residential Treatment Levels 1 & 2
  • Behavioral Health Partial Hospitalization
  • Therapeutic Treatment Homes
  • 23 Hour Crisis Stabilization Observation
  • Mobile Outreach and Crisis Response Services
  • Crisis Residential Stabilization.

Instructions for application: Send the 1115 Application and the required attachments to MPASS via email at with the subject line, "adding new level of care/service." If provider is requesting 1115 services for any of the SUD/BH LOC/services listed above, please be sure to attach the documentation needed for each level of care/service.   Please utilize this checklist to verify complete submission of required documentation to MPASS for each level of care/service identified above. If you are applying for services that are not listed above, then you do not need to provide documentation for those. For example, if you are applying for SUD level of care 1.0 outpatient, SUD residential 3.1, and Home Based Family Treatment you would only need to submit required documentation for SUD residential 3.1. If you decide to rescind your request for this service/LOC, please notify MPASS immediately.

Community Behavioral Health service providers that already have Department approval for any of the above services only need to submit the supporting documentation for each service.

If you are a brand new to DBH agency, or for those who have already submitted for review the required supporting documentation, this e-memo does not apply. If your agency received approval prior to the revised application listing out service selections, please submit the revised application along with any supporting documentation for the above services.


For questions and submission of forms, please email MPASS:


*Providers, please forward this message to staff you would link Alaska Department of Health and Social Services Email or Text Update you would like to self-register for DBH Communications messages.