CurrentBlue Cross Blue Shield - North CarolinaPolicy N/A

Authorization Request Form for Non-Hospital Medical Detox and Behavioral Health Services

This document is an authorization request form used by Blue Cross Blue Shield of North Carolina for commercial members to request prior authorization for non-hospital medical detoxification and related rapid-response behavioral health services. It governs submission requirements and required clinical information from NC providers.

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyAuthorization Request Form for Non-Hospital Medical Detox and Behavioral Health Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization in advance for initial admissions and submit required clinical records including serial vital signs and withdrawal scale scores from the prior 72 hours.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

866-987-4161submission fax number

Commercialmember population

071122document version

5-digitprovider ID req

72-hr vitals

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Authorization Documentation and Clinical Criteria

Authorization documentation and clinical criteria

Covered when the documentation and clinical information below are provided to justify authorization for Non‑Hospital Medical Detox and associated rapid‑response behavioral health services.

Advance authorization required for initial admissions; approval must be obtained in advance of admission or failure may result in reimbursement denial.

Reference: initial authorization requirement

Required submission of service and timing fields: requested authorization start date, anticipated length of stay, and service requested (e.g., Non‑Hospital Medical Detox).

Service/date fields

Clinical records must be submitted for initial requests, including serial vital signs and withdrawal scale scores from the prior 72 hours, current treatment plans, and a complete discharge summary upon discharge.

Documentation requirement for initial authorization

ALL of the following

Does the patient currently require, or is the patient anticipated to require physical restraint or seclusion? (YES/NO)
Does the patient require around‑the‑clock medical or nursing monitoring for treatment of withdrawal or other medical conditions? (YES/NO)
If around‑the‑clock monitoring is required, indicate whether intensive inpatient hospital treatment and resources are anticipated (YES/NO).

Pertinent clinical history and treatment information must be included, such as pertinent medical history (active co‑occurring medical conditions), current medications (dosages and duration), current psychological therapy (type, frequency, duration), and detailed prior treatment history with response (service category, dates, reason for admission, response).

Clinical background and treatment history

Assessment of patient risk or severity must document relevant items, including: imminent danger to self (details of suicidal ideation/intent/means and risk factors), imminent danger to others (details of intent/means and prior acts if applicable), inability to care for self (impact on ADLs, work/school), and support assessment (home/social resources and coping skills).

Risk and support assessment

Provide evidence why outpatient treatment (partial hospitalization, intensive outpatient, or regular outpatient) is not a sufficient or safe alternative to rapid‑response care, including documentation of behavioral health disorder severity, rating scales (e.g., PHQ‑9, GAD, Columbia), and severe dysfunction in daily living if applicable.

Justification for higher level of care

Documentation of current treatment goals, proposed interventions and rationale/benefits of rapid‑response level of care versus a less intensive level, expected patient participation and anticipated discharge plan and needs must be included.

Treatment plan and discharge planning

URGENCY: Requesting provider may indicate that the review should be URGENT when routine timeframes could seriously jeopardize life, health, or safety; include rationale if URGENT review is selected.

Urgent review option and required rationale

Provider attestation: signature certifying authority to request prior authorization, that the medical records reflect the information provided, understanding that BCBSNC may request records and pursue refunds or other remedies if information is unsupported, and acknowledgement that incomplete forms may delay processing.

Attestation and audit risk

Diagnosis and Service Codes

Diagnosis coding (ICD-10)ICD-10

ICD-10 diagnosis codes and diagnosis names are requested; form provides fields for multiple ICD-10 codes and specifiers.

Service code placeholdermixed

Form has a placeholder for service code for Non-Hospital Medical Detox (labeled 'Code').

Submission Requirements and Provider Responsibilities

Prior Authorization

Authorization Request — General Submission Instructions

Submission of this form is only a request for services and does not guarantee approval. Incomplete forms may delay processing. All North Carolina providers must provide their 5-digit Blue Cross NC provider ID number on the request. This form, supporting clinical records, and required attachments should be submitted to Blue Cross NC for review; failure to obtain approval in advance of admission for Initial Authorization Requests may result in reimbursement denial.

Date of Request
Patient Name
Patient Blue Cross NC Member ID number
Patient Date of Birth
Facility UR/DC Planner Contact
Phone #
Fax #
All NC Providers must provide their 5-digit Blue Cross NC provider ID#

Prior Authorization

Initial Authorization Requirements

Key Terms

inv-09: Non-Hospital Medical Detox Services — definition and scope of the service level

TermNon-Hospital Medical Detox Services

ScopeLevel of care involving medical/nursing monitoring for treatment of withdrawal or other medical conditions outside a hospital setting

Key clinical elementsAcuity assessment (need for restraints/seclusion, need for around-the-clock monitoring), pertinent medical history, current medications, treatment history, psychopharmacologic trials

Assessment requirementsDocument evidence why outpatient care is insufficient and assess risk (imminent danger to self/others, inability to care for self, support assessment)

Planning fieldsCurrent treatment goals, proposed treatment plan interventions and rationale, anticipated discharge plan and needs

inv-10: URGENT review — definition and requester responsibilities for urgent/expedited review

Documentation Required

Clinical Information to Support Authorization

For Non-Hospital Medical Detox authorization, provide detailed clinical information to support medical necessity and appropriate level of care. Include acuity assessment, need for physical restraint or seclusion, need for around-the-clock medical/nursing monitoring, pertinent medical history, current medications (dosages and duration), current psychological therapy, prior treatment history and responses, psychopharmacologic trials (drug, class, dates, max dose, member response), assessment of suicide or violence risk, ability to care for self, support assessment, and documentation why lower levels of care are not sufficient or safe. Also document current treatment goals, anticipated discharge plan and needs, and whether the overseeing physician considers the request URGENT with supporting rationale.

Acuity assessment (including need for restraints/seclusion)
Does the patient require around-the-clock medical or nursing monitoring? If yes, state whether inpatient-level resources are anticipated
Pertinent medical history (active co-occurring medical conditions)
Current medications — list dosages and duration (attach separate sheet if needed)
Current psychological therapy — type, frequency, duration
Treatment history — prior service categories, dates, reason for admission, and response (attach if needed)
Psychopharmacologic trials — drug, class, trial dates, max dose, member response
Assessment of risk/severity: imminent danger to self (suicidal ideation/intent/plan), imminent danger to others, inability to care for self, support assessment
Clinical findings and rating scales for co-occurring conditions (e.g., PHQ-9, GAD-7, Columbia)
Documentation of why outpatient or lower levels of care are insufficient or unsafe
Current treatment goals and proposed interventions
Anticipated discharge plan and ongoing needs
If urgent review requested, include rationale why routine timeframes could seriously jeopardize life, health, or safety