CurrentBlue Cross Blue Shield - North CarolinaPolicy N/A

Electroconvulsive Therapy (ECT) prior authorization request

This document governs the information and prior authorization request process for Electroconvulsive Therapy (ECT) for Blue Cross Blue Shield of North Carolina members and applies to NC providers submitting authorization requests.

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyElectroconvulsive Therapy (ECT) prior authorization request

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed ECT Authorization Request form including diagnosis, prior treatment history, standardized suicide risk assessment attachment, comprehensive medical exam documentation, and NC Blue Cross provider ID.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

form-basedAuthorization method

90870Procedure code

NC-onlyProvider scope

requiredSuicide risk

Coverage and Authorization Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Authorization review criteria

Authorization evaluated based on submitted clinical information and documentation; form collects necessary items for review.

ECT Authorization Submission Requirements: Provider must submit: ICD-10 diagnosis and specifier; description of severity/acuity; clinical symptoms necessitating ECT (e.g., catatonia, markers of severity); standardized suicide risk assessment as separate attachment; comprehensive medical exam to rule out contraindications; prior ECT treatment dates and responses; prior pharmacologic trials with duration and response; current medications and psychotherapy details; requested CPT code(s) and units; indication if transition after inpatient ECT; requested start/end dates; provider identification and signatures.

All items are requested on the form for review; omission may delay or prevent authorization.

Submission of this form constitutes a request for Electroconvulsive Therapy (ECT) prior authorization and does not guarantee approval. Complete and accurate documentation is required for timely processing; incomplete forms will delay review and may prevent authorization.

The form itself does not enumerate specific conditions that are not medically necessary. Instead, determinations regarding medical necessity are made after review of the clinical information and supporting records submitted with the authorization request.

Provider Submission and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for ECT. Submit requests using the Blue Cross NC ECT Authorization Request form which lists CPT 90870 (units requested) and allows specification of other procedure codes and requested dates. This form must be completed in full and signed by the requesting/treating provider.

Use the Blue Cross NC ECT Authorization Request form
Include CPT 90870 and number of units or indicate other CPT code
Specify requested ECT start and expected end dates
Indicate Initial or Extension request and prior authorization number for extensions

Denial Risk

Incomplete or Unsupported Documentation May Lead to Denial

Incomplete or unsupported documentation will delay processing and may lead to denial. Submission of the form is only a request and does not guarantee approval. Blue Cross NC may request medical records to verify information and may deny, recover payments, or pursue other remedies if records do not support the request.

Submission does not guarantee approval; incomplete forms will delay processing
Blue Cross NC may request medical records and may deny the request if documentation is not supported
If records do not reflect information provided, Blue Cross NC may request refund of payments or pursue other remedies

Documentation Required

Provider Identification and Attestation Required

Provide complete provider and servicing location information and include required identifiers. The form requires the requesting/ordering provider and servicing provider or facility location details, the state medical license number for the physician in the state where services are rendered, and the 5-digit Blue Cross NC provider ID for all NC providers. The treating provider must sign the attestation certifying authority to request prior authorization and that information is accurate.

Requesting/Ordering Provider name and contact
Servicing Provider or Facility name and location
Provider #, Tax ID #, or NPI for requesting and servicing provider
State medical license number (for state where services are rendered)
BCBS Provider ID & Plan Name (include 5-digit Blue Cross NC provider ID if NC)
Treating provider signature and date for attestation

Documentation Required

Prior Medication and Therapy History Must Be Documented

The form collects comprehensive prior medication and therapy history and responses; include completed pharmacologic trials, medication names, classes, start/end dates, max doses, length of trial, and member response, as well as current medications and psychotherapy history. Prior ECT treatment dates and responses and other treatment history should be documented. Include standardized suicide risk assessments and any medical exam documentation addressing contraindications to ECT.

List psychopharmacologic agents trialed with drug name, class, length of trial, start/end dates, max dose, and member response
Provide current medication (dosage, duration) and current psychological therapy details (type, frequency, duration, provider)
Document prior ECT treatments with dates and response to treatment
Attach other treatment history as needed and standardized suicide risk assessment
Confirm comprehensive medical examination to rule-out or address contraindications to ECT

Background and Definitions

Transition after inpatient ECT — key facts

DefinitionTransition after inpatient ECT: the form asks whether the requested outpatient or subsequent ECT course is a continuation following ECT administered during an inpatient hospitalization (checkbox: 'Is this a transition after IP ECT?').

Form locationCaptured on the Authorization Details section alongside request type, place of service, and requested start/end dates.

Implication for reviewMust be indicated on the request so reviewers know treatment is a post‑inpatient continuation when assessing prior ECT treatments and responses.

Related documentationPrior ECT treatment dates and responses should be listed on the form; extension requests require prior reference/authorization number when applicable.

Use in authorization logicSelecting 'Yes' signals reviewers to consider recent inpatient course and acute response when evaluating need for extension or maintenance ECT.

Electroconvulsive therapy (ECT) is a treatment option for certain severe psychiatric conditions, typically considered when patients have not responded to other interventions or present with urgent clinical features such as severe suicidality or catatonia. The authorization form requests clinical history, treatment response, and provider attestation to support medical review and to identify any contraindications prior to performing ECT.

OpenPayer

Electroconvulsive Therapy (ECT) prior authorization request

Coverage and Authorization Criteria

Procedure and Billing Codes

Provider Submission and Documentation Requirements

Indication of Inpatient vs Outpatient Care

Procedure-Specific Treatment Details

Background and Definitions