Electroconvulsive Therapy Prior Authorization Request Form
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A prior authorization request form and instructions for submitting authorization for electroconvulsive therapy (ECT) services for Anthem/Blue Cross Blue Shield lines serving Indiana populations; used by providers requesting initial or continuation ECT, inpatient or outpatient. Affects providers and administrative staff submitting ECT authorizations.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity
Medical necessity / payment note
Form-level statement regarding medical necessity and payment:
ALL of the following
- Authorization indicates 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.
ALL of the following
- Authorization determination does not ensure payment; eligibility and benefit limitations at the time services are rendered determine payment.
ALL of the following
- This form is an administrative prior authorization request used to document clinical and administrative information to support medical necessity review (per MCG).
Clinical evidence to accompany authorization
Clinical information requested to support coverage decisions:
Coding and Treatment Data
| No codes listed |
Submission & Documentation Requirements
Submission instructions
Submit prior authorization requests electronically using our preferred method at https://Availity.com. If you are unable to submit electronically, use one of the fax routes listed below (behavioral health fax numbers vary by product and inpatient/outpatient). Please print clearly; incomplete or illegible forms will delay processing.
- 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
- BH outpatient for Medicare Advantage: 844-430-1703
- BH for Indiana PathWays for Aging: 877-410-0623
- Preferred electronic submission: https://Availity.com
Authorization vs Payment disclaimer
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 the member's eligibility, benefit coverage, and any applicable limitations at the time services are rendered. Providers should verify member eligibility and benefits prior to delivering services.
Required documentation fields on form
Complete and submit all required fields on the authorization form. Incomplete documentation may delay or result in denial of the request.
- Member identification: member name and ID
- Provider identification: facility name, facility NPI, facility TIN, attending provider name and NPI
- Facility status: participating or nonparticipating; state of treatment (initial ECT series vs continuation)
- Location of treatment: inpatient or outpatient
- Number of treatments and dates of service
- Medical clearance: care provider name, date assessment completed, indication of inpatient/outpatient clearance and second opinion if applicable
- Recent ECT treatment record for continued care review: pretreatment scores (e.g., QUID, PHQ-9), unilateral/bilateral, seizure duration, response, and care provider name for each recorded treatment
- Contact information: UM representative contact name, phone, fax; discharge planner name, phone, fax
- Care provider signature, phone, fax, and date
Definitions and Status Fields
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