CurrentBlue Cross Blue Shield - North CarolinaPolicy N/A

Commercial Residential Treatment Behavioral Health Form (PDF)

Authorization request form for commercial Blue Cross NC members seeking Residential Treatment Center (RTC) behavioral health services (excluding substance or eating disorders). Governs information and documentation required for prior authorization, facility licensure requirements for out-of-network RTCs, and attestation statements.

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyCommercial Residential Treatment Behavioral Health Form (PDF)

Policy CodePolicy N/A

Change TypeAdministrative form (no material changes)

Effective Date

Next Review Date

Key ActionObtain advance authorization before admission and submit complete clinical records and required facility licensure/accreditation documents as applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes reported

Excludes substance/eatingScope Exclusion

RTC licenseLicensure Requirement

Prior authAuthorization Requirement

Policy Summary and Scope

This form is an authorization request for commercial Blue Cross NC members seeking Residential Treatment Center (RTC) behavioral health services. It excludes admissions for substance use and eating disorders, which require separate request processes. Submission of this form is an informational/administrative prior-authorization request only and does not guarantee approval.

Submission, Documentation, and Signatures

Authorization Submission Requirements

Submission of this form is a request only; incomplete submissions may delay processing:

ALL of the following

Form must be filled out in entirety
Approval must be obtained in advance of admission for initial authorization; failure may result in reimbursement denial
For initial authorization: send current clinical records including serial vital signs and withdrawal scale scores from prior 72 hours, treatment plans, and complete Discharge Summary upon discharge
Requested authorization start date and anticipated length of stay must be provided
If urgent review requested, include rationale why routine timeframe could seriously jeopardize life, health, or safety

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Prior Authorization

Advance Authorization Required for Initial Admission

Approval must be obtained in advance of admission for initial authorization. Failure to obtain prior authorization may result in denial of reimbursement.

Risk: Claims may be denied or not reimbursed if authorization is not obtained before admission.

Documentation Required

Required Clinical Documentation for Initial Authorization

Submit current clinical records for initial authorization. Required documentation includes serial vital signs and withdrawal scale scores from the prior 72 hours, treatment plans, complete discharge summary upon discharge, current medications and prior psychopharmacologic trials, treatment history and response, proposed treatment plan, and risk assessments.

Serial vital signs and withdrawal scale scores from the prior 72 hours
Treatment plans and proposed treatment plan interventions and goals
Complete Discharge Summary upon discharge
Current medications and list of psychopharmacologic agents trialed (drug, class, dates, max dose, response)
Prior treatment history and response
Assessment of patient risk/severity (self-harm, harm to others, inability to care for self, support assessment)

Documentation Required

Provider Signatures and Attestations

Treating provider and the requestor must sign and date the attestation statements certifying the information is complete, accurate, and that the requested level of treatment is medically necessary.

Treating provider must sign and date the attestation
Requestor must sign and date certifying authority to request prior authorization
Blue Cross NC may request medical records to verify information and may seek refunds or other remedies if records do not support the submission

Prior Authorization

Urgent Review Option

An urgent review may be requested when applying routine timeframes could seriously jeopardize life, health, or safety. When requesting an urgent review, include the physician's rationale describing why the routine timeframe would jeopardize life, health, or safety.

Include physician rationale explaining urgency when requesting an urgent review

Clinical Documentation and Risk/Severity Criteria for RTC Care

Clinical Criteria / Documentation to Support RTC Care

Behavioral health disorder present and appropriate for residential care; provide documentation:

ALL of the following

Evidence of risk/severity (select as applicable)
- Imminent danger to SELF: include details of current thoughts/actions for suicide attempt and/or self-harm; current intent, plans, and/or means; current risk factors; dates/summary of prior acts if applicable
- Imminent danger to OTHERS: include details of current thoughts/actions for harm to others; intent, plans, means; current risk factors; dates/summary of prior acts if applicable
- Inability to care for self: description of missed work/school obligations; inability to attend to activities of daily living; changes in weight/hygiene
- Support assessment: resources and relationships available at home/social networks and coping skills
- Evidence why outpatient treatment (partial hospitalization, intensive outpatient, or regular outpatient) is not sufficient or safe alternative
Behavioral health disorder reasons (check all applicable)
- Psychiatric, substance use, or other co-occurring conditions (include severity descriptions and standard rating scales e.g., PHQ-9, GAD, Columbia)
- Severe dysfunction in daily living (including self-care assessment and functional status in home, school/work and social settings)
Documentation must include proposed treatment plan interventions and goals; rationale/benefits of residential level of care versus less intensive level of care; expected patient participation and adherence
Provide prior treatment history and response including service category type
List current psychopharmacologic agents trialed including drug, class, dates, max dose, response, frequency

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Out-of-Network RTC Licensure and Accreditation

Out-of-Network RTC Licensure and Accreditation Requirements

If facility is out-of-network, submit licensure and meet RTC criteria or there is no benefit:

ALL of the following

Facility is considered out-of-network if not participating with Blue Cross NC or Host state's Blue Card network
ALL of the following
- Facility operational 24/7 must be indicated
- Does licensure require licensed clinical staff to be present 24/7? must be indicated
- Does licensure require licensed clinical staff during day hours but on call during sleep hours? must be indicated
- Is your facility accredited? must be indicated
- Do you have a copy of facility State License and Accreditation to submit and attach with this request?

Documentation Required

Facility Licensure Documentation for Out-of-Network RTCs

For out-of-network RTCs, submit a copy of the facility's current state licensure (and accreditation if applicable). If current licensure is not provided, it is implied the facility does not have an active license for RTC level of care and there is no benefit.

Attach a copy of current facility state license
Indicate whether facility is operational 24/7 and staffing/licensure requirements
Attach accreditation documentation if available

Required Signatures and Attestations

Provider Attestations

Signatures required for authorization processing:

ALL of the following

Treating provider attests they are licensed to provide requested services in the state where services performed and that information is complete and accurate
Attestation that level of treatment requested is medically necessary and appropriate
Signature certifying authority to request prior authorization; acknowledgment Blue Cross NC may request medical records and may seek refund or other remedies if records do not support information

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Documentation Required

Provider Signatures and Attestations (Reminder)

Both the treating provider and the requestor must sign and date the attestation statements. Blue Cross NC may request medical records to verify the information and may request refunds or pursue other remedies if the information is not supported by records.

Ensure signatures and dates are provided on attestation statements
Be prepared to provide medical records if requested to support the submission

Definitions

TermResidential Treatment Center (RTC)

DefinitionAn RTC is a facility providing residential treatment for behavioral health; considered out-of-network if not participating with Blue Cross NC or the Host state's Blue Card network; non-participating facilities must provide a copy of current licensure for review, otherwise no RTC benefit

This is a commercial prior authorization form used by Blue Cross Blue Shield of North Carolina for Residential Treatment Center behavioral health services. It is not to be used for substance or eating disorder admissions. The form must be completed in full; submission is a request only and incomplete forms will delay processing. For initial admissions, approval must be obtained in advance and required clinical documentation (including recent clinical records, treatment plans, discharge summary, and other supporting clinical information) should be provided. Out-of-network facilities must submit a copy of current licensure and meet RTC licensure and accreditation criteria. Treating providers must sign attestation statements certifying accuracy and medical necessity.

OpenPayer

Commercial Residential Treatment Behavioral Health Form (PDF)

Policy Summary and Scope

Submission, Documentation, and Signatures

Clinical Documentation and Risk/Severity Criteria for RTC Care

Out-of-Network RTC Licensure and Accreditation

Required Signatures and Attestations

Definitions

Revision History