CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Electroconvulsive Therapy (ECT) Request Form — Prior Authorization / Benefit Verification

A form to request verification of benefits and authorization for ECT services for Blue Cross Medicare Advantage HMO and PPO members in New Mexico. It collects patient, provider, clinical, and treatment plan information needed for benefit verification and utilization review.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyElectroconvulsive Therapy (ECT) Request Form — Prior Authorization / Benefit Verification

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete all sections of the ECT Request Form and fax to 505-816-4902 for prior authorization/benefit verification, listing CPT 90870 and tentative start date.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1CPT code listed for ECT visit

faxsubmission method

MA HMO/PPOplan types

requestedclinical history items

Coverage Criteria

This ECT Request Form functions as an authorization and benefit verification request for Blue Cross Medicare Advantage HMO and PPO members. It collects the clinical and administrative information necessary for utilization review and benefit determination but does not itself specify formal coverage inclusion criteria — providers must complete and submit the form to initiate prior authorization/benefit verification for ECT services.

The form does not list explicit non‑covered conditions or state circumstances that would be considered not medically necessary. It is an intake/authorization tool used to gather diagnoses, treatment history, and the proposed ECT plan to support benefit verification and utilization review.

Electroconvulsive Therapy (ECT) — Medical Necessity Documentation Criteria

Covered when ALL of the following form-based documentation elements are provided to support authorization and benefit verification for electroconvulsive therapy (ECT):

Completed patient and subscriber demographics (patient name, date of birth, subscriber name, subscriber ID, group).

Provider and facility identification including facility/provider name, addresses, and NPI(s) for treating MD and facility.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyElectroconvulsive Therapy (ECT) Request Form — Prior Authorization / Benefit Verification

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete all sections of the ECT Request Form and fax to 505-816-4902 for prior authorization/benefit verification, listing CPT 90870 and tentative start date.

SourceLink

On This Page

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Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Submission

Prior authorization (benefit verification) is required for ECT. Submit requests using the Blue Cross BCBSNM Electroconvulsive Therapy (ECT) Request Form; visits should be reported with CPT code 90870. Fax the completed form to BCBSNM at 505-816-4902.

Use the BCBSNM ECT Request Form for benefit verification/prior authorization
Report visits with CPT 90870
Fax completed form to 505-816-4902

Note

Complete and include all sections of the ECT Request Form. Ensure the form contains patient demographics, subscriber and group information, facility/provider and ordering MD details (including NPI), UR/contact with phone number, and indication whether request is Initial, Concurrent, or Discharge.

Indicate request type: Initial Request, Concurrent, or Discharge
Provide full patient demographics and subscriber information
Include facility/provider name and NPI, and ordering MD name and NPI
Provide UR/Contact name and phone number

Documentation Required

Required Documentation on Form

Required documentation on the ECT Request Form includes: current diagnoses (include DSM-5 codes and specifiers), ECT history (any past ECT, ECT in the last b months and brief details), whether this is a transition after inpatient ECT, current ECT treatment plan and frequency, requested start/tentative treatment dates, number of visits requested, current medications, clinical presentation and risk factors (including last date of substance use), prior mental health/chemical dependency treatment, treatment goals, and discharge plan/summary. Sign and date the form; additional clinical information may be faxed with the form.

Document current DSM-5 diagnoses with codes and specifiers
Provide full ECT history and details of prior treatments
Specify current ECT plan (frequency) and number of visits requested
Include requested authorization start date and tentative treatment dates
List current medications and relevant clinical/risk information
Attach/disclose prior mental health or chemical dependency treatment
Include treatment goals, discharge plan/summary, signature and date

Denial Risk

Incomplete or Unsubmitted Form

Incomplete or unsubmitted forms, or forms missing required sections or signatures, may result in processing delays or denial of the request. Ensure all required fields are completed and any supporting clinical documentation is included or faxed with the form to avoid denial or delay.

Missing required sections (demographics, diagnosis, ECT history, treatment plan, signature) may lead to denial or processing delay
Attach any additional clinical information as needed and fax with the form

Definitions and Current Plan

Current ECT Plan (form fields)

Planned frequencyCurrent ECT Plan — Frequency: free-text field (e.g., per week / month) to be completed by treating clinician.

Tentative treatment datesRequested ECT Authorization Start Date and Tentative Date of treatment — date fields are provided on the form.

Visits requestedVisits Requested (CPT Code) field accompanies the plan to specify billing code(s).

Clinical details to includeForm requests current DSM‑5 and/or medical diagnoses, medications, clinical presentation/risk factors, previous mental health/chemical dependency treatment, treatment goals, and discharge plan alongside the plan details.

CPT code for ECT visit

CPT code listed90870 — listed in the 'Visits Requested (CPT Code)' field on the request form.

Purpose on formUsed to identify the ECT visit/management code when requesting authorization/benefit verification.

Submission instructionList of visits requested should reference CPT 90870 when completing the form for prior authorization/benefit verification via fax to BCBSNM.

Background

The purpose of this form is to support prior authorization and benefit verification for electroconvulsive therapy (ECT) for Blue Cross Medicare Advantage HMO and PPO members in New Mexico. It requests patient and subscriber demographics, provider and facility information (including NPI), DSM‑5 and/or medical diagnoses, prior ECT history and timing, the current ECT plan (frequency and tentative start date), requested CPT code(s) (including 90870), clinical presentation and risk factors, current medications, prior mental health/substance use treatment, treatment goals, discharge plan, and the treating physician’s signature. Completed forms and any additional clinical information should be faxed to the number provided for benefit verification.

OpenPayer

Electroconvulsive Therapy (ECT) Request Form — Prior Authorization / Benefit Verification

Coverage Criteria

Coding

Provider Actions and Submission Requirements

Definitions and Current Plan

Background