Currentblue cross blue shield - tennesseePolicy N/A

Chronic Controlled Substance Prescribing Documentation Requirements

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Requirements for providers prescribing controlled substances chronically (>90 days) to maintain specific documentation and monitoring; applies to all BCBST lines of business and network practitioners.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyChronic Controlled Substance Prescribing Documentation Requirements

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionMaintain complete, individualized documentation and monitoring (including annual controlled substance contract, CSMD queries at least every 90 days, urine drug testing at least every 6 months, and in‑person evaluation at least every 90 days) when prescribing controlled substances for >90 days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>90 daysdefinition of chronic prescribing

≥90 daysCSMD query frequency

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Currentblue cross blue shield - tennesseePolicy N/A

Chronic Controlled Substance Prescribing Documentation Requirements

Customize your policy alerts

Sign up for all blue cross blue shield - tennessee policy alerts

Know when blue cross blue shield - tennessee releases new policies or updates existing guidance.

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Policy Summary

Payerblue cross blue shield - tennessee

PolicyChronic Controlled Substance Prescribing Documentation Requirements

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>90 daysdefinition of chronic prescribing

≥90 daysCSMD query frequency

Chronic Controlled Substance Prescribing Criteria

Requirements for chronic (>90 days) controlled substance prescribing — documentation and monitoring must include ALL of the following elements unless not applicable:

Documentation and monitoring requirements: 1. Individualized specific findings and course of treatment; 2. Legible entries that are not cloned and do not use copy and paste of similar or identical statements from visit to visit or member to member; 3. History (medical, surgical, social, family), Chief Complaint, History of Present Illness, Review of Systems; 4. Physical Examination, including examination of the body part where the pain is located if prescribing opioids for pain; 5. Mental Status Examination where appropriate if psychotropic drugs are prescribed; 6. Behavioral Health consult when controlled substances are prescribed on a chronic basis or when benzodiazepines are prescribed for >2 weeks to a member receiving other controlled substance prescriptions; 7. Pain Management consult when controlled substances are prescribed on a chronic basis for pain; 8. Initial and periodic validated risk assessment(s) for aberrant behavior associated with controlled substance misuse; 9. Treatment goals related to controlled substance use and discussion of those goals; 10. Pain reduction and/or improvement in functional abilities related to controlled substance prescribing; 11. Underlying pathology to support chronic controlled substance prescribing; 12. Use of or contraindications to ongoing conservative treatment modalities; 13. Informed Consent signed by the member; 14. Discussion of the risks of chronic controlled substance use; 15. Controlled substance contract signed and dated by the member annually outlining member responsibilities and consequences; 16. Current and continuously updated medication list that includes full prescribing information (name, dose, frequency, quantity, and date prescribed) for each controlled substance; 17. Statement of the reason(s) for prescribing different controlled substances concurrently; 18. Random urine drug testing results at least once every 6 months with discussion of all aberrant results; 19. Pill counts for each controlled substance showing medication name and quantity remaining; 20. Controlled Substance Monitoring Database (CSMD) query at least every 90 days with notation and discussion of any discrepancies; 21. In-person evaluation at least every 90 days (advance writing of controlled substance prescriptions for >90 days without evaluation at the time of prescription is inappropriate).

All elements listed must be documented for chronic (>90 days) controlled substance prescribing.

No explicit clinical exclusions are listed in this policy.

The policy does not list specific conditions that are considered not medically necessary; instead it states that network practitioners who do not comply with these documentation and monitoring guidelines are subject to disciplinary action, which may include credentials revocation, network contract termination, and reporting to the National Practitioner Data Bank or other mandated entities.

Provider Requirements and Documentation

Prior Authorization

Prior authorization

No prior authorization statements are provided in this policy document.

Step Therapy

Conservative treatment documentation

Document the use of, or documented contraindications to, ongoing conservative treatment modalities when prescribing controlled substances chronically (>90 days).

Policy lists “Use of or contraindications to ongoing conservative treatment modalities” as a required element of the medical record for chronic prescribing.

Documentation Required

Policy Background

This policy outlines expectations when controlled substances are prescribed chronically (defined as >90 days). For chronic prescribing, providers must document all of the required elements including individualized findings and course of treatment; legible, non-cloned entries; complete history and relevant physical exam (including the pain site when opioids are prescribed); appropriate mental status exam; validated initial and periodic risk assessments; discussion of treatment goals and functional outcomes; documentation of underlying pathology; informed consent; and an annually signed controlled substance contract. In addition, monitoring requirements include random urine drug testing at least once every 6 months, Controlled Substance Monitoring Database (CSMD) query at least every 90 days with notation and discussion of discrepancies, pill counts, and a in-person evaluation at least every 90 days (the policy states that advance writing of controlled substance prescriptions for >90 days without evaluation is inappropriate).

Key Definitions

inv-09: Definition — Chronic prescribing: >90 days

DefinitionPrescribing a controlled substance for greater than 90 days.

Applies toAll BCBST Lines of Business.

PurposeGuidelines for documentation and monitoring when controlled substances are prescribed chronically.

Conservative Treatment and Documentation

Monitoring and Follow-up Frequency

inv-11: Follow-up frequency — in-person evaluation at least every 90 days

Required intervalIn-person evaluation at least every 90 days.

Prescription practiceAdvance writing of controlled substance prescriptions for >90 days without an evaluation at the time of prescription is inappropriate.

Consequence for noncomplianceNetwork practitioners who do not comply may face disciplinary action including credential revocation, contract termination, and NPDB reporting.

inv-12: Urine drug testing frequency — random urine drug testing at least once every 6 months

Minimum frequencyRandom urine drug testing at least once every 6 months.

Follow-up actionDiscussion of all aberrant urine drug test results must be documented.

Imaging Requirements

Note

Opioid prescribing for pain — imaging requirement

No imaging requirement is specified for opioid prescribing for pain; the policy requires a physical exam of the pain site when opioids are prescribed but does not mandate imaging.

Physical examination of the body part where the pain is located is required if prescribing opioids for pain; no imaging requirements are listed.