Currentblue cross blue shield - tennesseePolicy N/A

Controlled Substance Prescribing

This policy defines documentation and monitoring requirements that network practitioners should follow when prescribing controlled substances chronically (>90 days) across all BlueCross BlueShield of Tennessee lines of business. It outlines specific clinical records, monitoring, and follow-up actions expected and consequences for noncompliance.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyControlled Substance Prescribing

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionFor chronic controlled substance prescriptions (>90 days), maintain individualized findings, complete history and exams, risk assessments, treatment goals, informed consent, signed annual controlled substance contract, medication list, reason for concurrent controlled substances, and documentation of conservative treatments.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes reported.

20Required Documentation Items Listed

>90 daysDefinition of Chronic Prescribing

>= every 90 daysPDMP Query / In-person Eval Frequency

>= once every 6 monthsUrine Drug Testing Frequency

Coverage Summary

Required Provider Actions and Risks

Documentation Required

Maintain detailed member documentation for chronic controlled substances

For chronic controlled substance prescriptions (>90 days), keep accurate, individualized, legible records that document clinical findings, course of treatment, history, exams, risk assessments, treatment goals, informed consent, annual signed controlled substance contract, medication list with full prescribing details, reasons for concurrent controlled substances, conservative treatment use/contraindications, and documentation of discussions of risks.

Individualized specific findings and course of treatment
Legible, non‑cloned entries
History, physical exam (including pain site if opioids), and mental status exam when appropriate
Initial and periodic validated risk assessments
Treatment goals and pain/function outcomes
Informed consent and annually signed controlled substance contract
Current medication list with name, dose, frequency, quantity, and date
Statement of reasons for concurrent controlled substances
Documentation of conservative treatments and contraindications

Documentation Required

Urine drug testing

Perform and document random urine drug testing for members on chronic controlled substances and record any discussions related to aberrant results.

Frequency: at least once every 6 months
Document test results and any discussion of aberrant findings

Documentation Required

Pill counts

Conduct and document pill counts for each controlled substance prescribed, including the medication name and quantity remaining.

Record medication name and quantity remaining for each controlled substance

Documentation Required

PDMP/CSMD queries

Query and document the Controlled Substance Monitoring Database (PDMP/CSMD) regularly, noting presence or absence of discrepancies and documenting any discussions about discrepancies.

Frequency: at least every 90 days
Document presence/absence of discrepancies and any discussions

Documentation Required

In-person evaluation

Perform an in‑person evaluation for members receiving chronic controlled substances and document the evaluation; avoid issuing prescriptions for more than 90 days without an evaluation at the time of the prescription.

Frequency: at least every 90 days
Do not issue prescriptions for >90 days without an in‑person evaluation at the time of prescribing

Denial Risk

Noncompliance consequences

Network practitioners who do not comply with these guidelines may face disciplinary actions by BCBST.

Credentialing revocation
Network contract termination
Report to the National Practitioner Data Bank (NPDB) or other mandated entities

Background

BCBST provides guidelines to ensure the safe, documented, and monitored use of controlled substances. The policy applies to prescriptions of controlled substances for a duration of >90 days and is intended for network practitioners who prescribe controlled substances chronically. Practitioners should keep accurate and complete records including specific clinical documentation, monitoring, and follow-up actions to support ongoing use and to mitigate risks.

Chronic controlled substance prescribing: Prescription of controlled substances for a duration greater than 90 days.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyControlled Substance Prescribing

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Controlled Substance Prescribing

Coverage Summary

Documentation and Monitoring Requirements (Chronic >90 days)

Required Provider Actions and Risks

Background

Revision History