CurrentBlue Cross Blue Shield - North CarolinaPolicy N/A

Inpatient Psychiatric Care — Authorization Request Coverage Criteria

Governs prior authorization and concurrent review requests for inpatient psychiatric level of care for Blue Cross NC members, specifying required clinical documentation for initial, concurrent, and SUD-specific admissions.

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyInpatient Psychiatric Care — Authorization Request Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionRequest authorization for emergent admissions within 2 business days of admission; elective admissions require approval before admission.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 business daysauth request timeframe (emergent)

48 hoursconcurrent review window

336-794-1557submission fax (MA BH)

NCstate

Coverage and Medical Necessity Criteria

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Medical necessity and documentation criteria

Covered when documentation demonstrates medical necessity for inpatient psychiatric level of care and required documentation is provided.

Initial admission requirements: Provider submits completed authorization form with current ICD-10 diagnosis, clinical rationale and treatment plan, justification for inpatient level versus less intensive care, prior treatment history and response (service categories), pertinent history including co-occurring medical/behavioral conditions, current medications (dose, duration, frequency), current psychotherapy details (type, frequency, duration), and discharge plan/support systemall items documented

See chunks 3 and 2 for details

Acuity criteria supporting inpatient care: At least one of the following must be present and documented: imminent danger to self (include details of current suicidal thoughts/intent/plan/means and prior attempts), imminent danger to others (include intent/plan/means), inability to care for self (document impact on ADLs, work/school, hygiene, weight), or severe psychiatric/substance use/co-occurring conditions requiring inpatient resourcesat least one must be present and documented

See chunk 2 for required acuity documentation and examples

SUD-specific inpatient need: For admissions for substance use disorder (SUD) or when SUD is actively occurring, provide withdrawal assessments (CIWA, COWS, BAWS) with serial scores and vital signs, ASAM score, and documentation whether around-the-clock medical or nursing monitoring or intensive inpatient resources are requireddocumentation of withdrawal scores, serial vital signs, ASAM score, and monitoring needs

See chunk 4 for SUD-specific required fields

Concurrent review/continuation of stay: To continue inpatient coverage submit updated clinical records and an updated treatment plan within 48 hours of the last covered day demonstrating continued need; include current medications and any dose adjustments, and active discharge planning with anticipated discharge date (attach discharge summary when available)updated clinicals within 48 hours of last covered day

See chunks 2 and 5 for concurrent review timing and required documentation

The form itself does not enumerate discrete coverage criteria on the face of the document. Instead, coverage is determined when clinical documentation supplied with the request demonstrates medical necessity for inpatient psychiatric level of care and meets the documentation requirements described elsewhere on the form (e.g., initial admission rationale, treatment plan, and acuity evidence).

The form does not list specific conditions that are automatically not medically necessary. Determinations about medical necessity or noncoverage depend on the clinical information submitted with the request and validation against the member's medical record; incomplete or inconsistent submissions may delay processing or lead to denial or other remedies.

Diagnosis, Codes and Assessment Data

Requested diagnosis codesICD-10

ICD-10 Code

Placeholders for patient diagnosis ICD-10 codes; form requests current ICD-10 code(s) and diagnosis name

Withdrawal assessment scores — CIWA/COWS/BAWS serial scores and vital signs as documented

Required measurementsSerial withdrawal assessment scores (CIWA, COWS, or BAWS) and serial vital signs (heart rate, blood pressure, temperature) as documented for SUD admissions

Documentation formatDates/times and at least three serial entries for symptoms, scores, heart rate, blood pressure, and temperature are requested on the form

Assessment instruments acceptedCIWA, COWS, or BAWS may be used to document withdrawal severity

Attachment optionForm indicates withdrawal scores and vital signs may be included as a separate attachment if necessary

Monitoring indicationForm asks whether around-the-clock medical or nursing monitoring is required and whether intensive inpatient resources are anticipated

Authorization, Documentation, and Submission Requirements

Prior Authorization

Prior authorization and timing

Authorization must be requested for emergent admissions within 2 business days of admission; elective admissions require prior approval before admission. For concurrent review or extension requests, updated clinical records and treatment plans must be received within 48 hours of the last covered day and a complete Discharge Summary must be sent upon discharge.

Emergent admission: authorization requested within 2 business days of admission.
Elective admission: approval required prior to admission.
Concurrent review/extensions: updated clinical records and treatment plans received within 48 hours of the last covered day; send complete Discharge Summary upon discharge.

Documentation Required

Level-of-care justification

Providers must document the clinical rationale why inpatient level of care is necessary compared with less intensive levels (e.g., outpatient, PHP, IOP). Documentation should describe acuity, risk (imminent danger to self or others), inability to care for self, co-occurring conditions, prior treatment history and response, and expected benefit of inpatient care. Include the proposed treatment interventions and goals, expected patient participation, and discharge planning/support system.

Describe why outpatient, PHP, IOP, or residential care are insufficient.
Document current risk factors: suicidal/homicidal intent, plans, means, prior attempts/acts, and withdrawal assessment scores if applicable.
Include prior treatment history (service types and responses) and expected benefit/goal of inpatient stay.

Documentation Required

Concurrent review required documentation

For concurrent review or request to extend an inpatient stay, submit an updated clinical assessment and treatment plan that justifies continued inpatient care. Include current clinical status, changes in medications (with doses and adjustments), progress toward treatment goals, ongoing risks, continued need for inpatient resources, anticipated discharge date, and any attached or forthcoming Discharge Summary. Updated records must be provided within 48 hours of the last covered day.

Concurrent review: clinical rationale and updated treatment plan for continuation of inpatient level of care.
Provide current medications and note any changes or dose adjustments.
Include anticipated discharge date and attach Discharge Summary if available.

Denial Risk

Incomplete or inaccurate submission

Incomplete or inaccurate submissions may delay processing. Blue Cross NC may request medical records to verify information; if records do not support the submitted information, Blue Cross NC may request refund of payments made and pursue other remedies. A signature of an authorized requester is required when this form is used as clinical substitution. Ensure the form is completed in its entirety and include the Blue Cross NC provider ID.

Incomplete forms may delay processing.
Blue Cross NC may request medical records and pursue refund or other remedies if information is not supported.
Signature required if form used as clinical substitution; include 5-digit Blue Cross NC provider ID.

Purpose and Scope

This authorization request form is intended to collect the clinical elements needed to support admission and continued stay decisions for inpatient psychiatric care. Required information includes the current ICD-10 diagnosis; documentation of acuity such as imminent danger to self or others, inability to care for self, or severe co-occurring psychiatric/substance-use conditions; and an initial treatment plan with interventions, goals, and the rationale for inpatient level of care versus less intensive options. For substance use disorder (SUD) admissions, the form requires serial withdrawal assessments (for example, CIWA, COWS, or BAWS), serial vital signs, ASAM scoring, and documentation of whether around-the-clock medical or nursing monitoring is needed. For concurrent reviews, updated clinical records and a treatment plan demonstrating continued need must be submitted within 48 hours of the last covered day. The form also requires the signature of an authorized requester when used as clinical substitution and notes that incomplete or inaccurate submissions may delay processing and could lead Blue Cross NC to request medical records or seek refund/remedies if records do not support the request.

Assessment Tools

Withdrawal assessment tools — CIWA, COWS, and BAWS are accepted withdrawal assessment instruments; scores and serial vital signs should be provided for SUD admissions

Accepted toolsCIWA, COWS, and BAWS are accepted withdrawal assessment instruments for SUD admissions

Required supporting dataProvide serial vital signs (heart rate, blood pressure, temperature) alongside withdrawal scores

When requiredComplete this section only for SUD admission or if SUD is actively occurring as a comorbid diagnosis

Monitoring and resource documentationDocument whether around-the-clock medical/nursing monitoring or intensive inpatient resources are required

Submission noteWithdrawal scores and serial vital signs should be included with the authorization request; can be attached separately if needed

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