CurrentAnthemPolicy N/A

Electroconvulsive Therapy (ECT) Prior Authorization Request Form

This form governs prior authorization requests for ECT services for Anthem Blue Cross and Blue Shield members in Indiana across multiple programs (Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, Indiana PathWays for Aging, and Medicare Advantage). It affects providers and facilities requesting authorization for initial or continuation ECT, inpatient or outpatient settings.

Policy Summary

PayerAnthem

PolicyElectroconvulsive Therapy (ECT) Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the ECT prior authorization request electronically via Availity (preferred) or fax with the completed form and required clinical details before services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Indianajurisdiction covered

Multipleprograms included

Inpatient/Outpatienttreatment locations

Initial/Continuationtreatment intent

Availablefax alternative

Coverage Criteria

Authorization indicates that Milliman Care Guidelines (MCG) medical necessity guidelines have been met for the requested service(s) but does not guarantee payment. Payment is contingent upon member eligibility and benefit limitations at the time services are rendered. Providers should confirm eligibility and benefits prior to scheduling services to avoid denied claims.

Provider Submission & Documentation Requirements

Denial Risk

Form completeness

Please print clearly; incomplete or illegible forms will delay processing and may result in denial or delayed authorization. Submit your request electronically using our preferred method, https://Availity.com. If unable to submit via Availity, fax to the program-specific behavioral health fax numbers below.

Preferred electronic submission: https://Availity.com
Fax alternatives (use the program-specific number matching member/product): Behavioral health (BH) inpatient for Hoosier Healthwise, Healthy Indiana Plan, and Hoosier Care Connect: 844-452-8074
BH outpatient for Hoosier Healthwise, Healthy Indiana Plan, and Hoosier Care Connect: 844-456-2698
BH inpatient for Medicare Advantage: 844-430-1702

Policy Summary

PayerAnthem

PolicyElectroconvulsive Therapy (ECT) Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the ECT prior authorization request electronically via Availity (preferred) or fax with the completed form and required clinical details before services.

SourceLink

On This Page

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Documentation Required

Documentation of prior treatment trials

Provide a complete medication and treatment history, including prior adequate trials of antidepressants, responses, adverse effects, and any prior response to ECT. This information is required to evaluate medical necessity for ECT.

Current medications (behavioral and physical health) with dose and frequency or submit a medication administration record
History of medications tried in the past and their results
Does the patient have a history of poor response to several adequate antidepressant trials? (Yes/No). If yes, provide details including medications, doses, durations, and outcomes
Does the patient have a history of a good response to ECT during an earlier episode? (Yes/No). If yes, provide details
History of adverse effects with medications that are less likely/severe with ECT? (Yes/No). If yes, provide details
For continued care reviews, include recent ECT treatment records: care provider name, pretreatment score (e.g., QUID, PHQ-9), unilateral/bilateral, seizure duration, response, and dates

Background

Electroconvulsive therapy (ECT) is included on the prior authorization form as a treatment option for members with significant psychiatric risk factors or inadequate response to medication. The form captures clinical risk status (for example, suicidal or homicidal ideation), medical clearance for ECT, current medications and medication history, and prior treatment response to support determinations of medical necessity.

The form differentiates between an initial ECT series and continuation ECT, and records whether treatment will occur in an inpatient or outpatient setting; recent ECT treatment records (including pretreatment scores such as QIDS or PHQ‑9, electrode placement, seizure duration, and clinical response) are specifically requested for continuation reviews.

Providers must supply care team and facility information (for example, facility name, facility NPI, attending provider name and NPI) and may be asked for medical clearance documentation completed by an appropriate clinician prior to authorization.

The form also requests current treatment team contact information and social support details to inform safe treatment planning and continuity of care.

Submit the completed form with the required clinical details via Availity (preferred) or by fax to the program-specific behavioral health fax numbers listed on the form to obtain authorization before services are rendered.

Key Definitions

Initial ECT series vs Continuation of treatment

Treatment intent options on formInitial ECT series or Continuation of treatment are selectable to indicate whether this is a new series or ongoing/maintenance care.

Treatment location options on formInpatient ECT or Outpatient ECT are selectable to specify the setting where ECT will be delivered.

Authorization pathway determined by selectionsThe combination of initial vs continuation and inpatient vs outpatient determines the type of authorization requested and routing on the form.

Facility and provider identifiers requiredForm captures facility name, facility NPI, facility TIN, attending care provider name and NPI to support authorization and claims processing.

Treatment scheduling details requiredNumber of treatments and dates of service must be provided on the form.

Electroconvulsive Therapy (ECT) Treatment Modalities

ECT (Electroconvulsive Therapy) Coverage Criteria

Covered when ALL of the following are met:

ALL of the following

The authorization request includes completed recent ECT treatment records when this is a continuation of care, including care provider name, pretreatment score (for example, QIDS or PHQ-9), unilateral or bilateral electrode placement, seizure duration, and clinical response.
The form documents the treatment location as Inpatient ECT or Outpatient ECT as applicable on the care provider information section.
Medical clearance for ECT is provided on the form and specifies whether clearance and/or second opinion are for Inpatient or Outpatient setting as appropriate.
Provider and facility administrative data are provided (facility name, facility NPI, facility TIN, attending provider name and NPI), number of treatments and dates of service.
The request includes treating team and support information (current treatment team contacts such as PCP, psychiatrist, anesthesiologist, psychologist, ARNP, social worker) and documentation of treatment history and prior treatment response where applicable.

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