Currentblue cross blue shield - tennesseePolicy CPCP028

Chronic Controlled Substance Prescribing

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Standards governing documentation and practice expectations for practitioners prescribing controlled substances chronically (>90 days) to BlueCross BlueShield of Tennessee members; applies to all BCBST lines of business and is intended for Clinical Risk Management and network practitioners.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyChronic Controlled Substance Prescribing

Policy CodePolicy CPCP028

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionFor chronic prescribing (>90 days), maintain complete individualized records including history, treatment goals, annual controlled substance contract, regular PDMP queries, urine drug testing, and in-person evaluations per policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>90 daysDefinition of chronic prescribing

>=90dPDMP query frequency

6 moUrine drug testing

90dIn-person evaluation

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Currentblue cross blue shield - tennesseePolicy CPCP028

Chronic Controlled Substance Prescribing

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Policy Summary

Payerblue cross blue shield - tennessee

PolicyChronic Controlled Substance Prescribing

Policy CodePolicy CPCP028

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>90 daysDefinition of chronic prescribing

>=90dPDMP query frequency

6 moUrine drug testing

90dIn-person evaluation

Coverage Criteria for Chronic Controlled Substance Prescribing

Documentation and monitoring requirements for chronic controlled substance prescribing

Covered when ALL of the following documentation and monitoring actions are performed for chronic controlled substance prescribing (>90 days):

Documentation elements: Individualized findings and course of treatment; legible non-cloned entries (no copy/paste of identical statements); history (medical, surgical, social, family), chief complaint, HPI, and review of systems; physical examination including the body part of pain when opioids are prescribed; mental status exam where psychotropic drugs are prescribed; treatment goals; underlying pathology to support chronic controlled substance prescribing; informed consent; controlled substance contract signed and dated annually; current medication list with medication name, dose, frequency, quantity, and date prescribed for each controlled substance; statement of reasons for concurrent controlled substances

These items are required documentation

Consults and assessments: Behavioral Health consult when controlled substances are prescribed on a chronic basis or when benzodiazepines are prescribed >2 weeks with other controlled substances; Pain Management consult when controlled substances are prescribed on a chronic basis for pain; initial and periodic validated risk assessments for aberrant behavior

Consultation and risk assessment requirements

Monitoring: Random urine drug testing at least once every 6 months with documentation and discussion of aberrant results; Controlled Substance Monitoring Database (PDMP) query at least every 90 days with notation and discussion of discrepancies; in-person evaluation at least every 90 days

Monitoring frequency requirements

Safety and counseling: Discussion of risks of chronic controlled substance use; discussion of pregnancy possibility at each visit for women of child-bearing age; naloxone prescribed for patients at increased overdose risk

Safety counseling and overdose prevention

Prescribing practice: Do not write controlled substance prescriptions in advance without evaluation at the time of the prescription; telemedicine is inappropriate for treatment of chronic non-malignant pain using controlled substances

Practice restrictions

Telemedicine is inappropriate for the treatment of chronic non‑malignant pain when management includes prescribing controlled substances. This policy explicitly states that telemedicine should not be used as the modality for chronic controlled substance treatment of non‑malignant pain.

Coding and Monitoring Intervals

No codes listedmixed

No codes listed

inv-04: Urine drug testing interval

RequirementRandom urine drug testing at least once every 6 months with documentation and discussion of aberrant results

PurposeMonitor for aberrant drug use and document results and discussions

ApplicabilityApplies to chronic controlled substance prescribing (>90 days)

inv-05: PDMP query interval

RequirementControlled Substance Monitoring Database (PDMP) query at least every 90 days with notation of discrepancies and discussion

PurposeIdentify prescription discrepancies and potential misuse

Provider Actions, Documentation and Consequences

Prior Authorization

Prior authorization not specified

This policy does not list any specific prior authorization requirements or affected billing codes for chronic controlled substance prescribing.

Step Therapy

Document conservative treatments or contraindications

Document use of, or reasons conservative modalities are contraindicated, before or during chronic controlled substance prescribing; this must be included in the member record.

Policy item 12: "Use of or contraindications to ongoing conservative treatment modalities" must be documented.

Background and Purpose

This policy defines expectations for safe chronic prescribing of controlled substances for members, emphasizing documentation, risk assessment, monitoring, and coordination with Behavioral Health and Pain Management specialists to mitigate misuse and overdose. Chronic prescribing is defined as use for >90 days and requires specific documentation elements (history, physical exam including body part of pain when opioids are prescribed, mental status where appropriate, treatment goals, informed consent, annual controlled substance contract, and a current medication list), consults and validated risk assessments, and ongoing monitoring.

Required monitoring includes random urine drug testing at least once every 6 months, query of the Controlled Substance Monitoring Database (PDMP) at least every 90 days, and an in‑person evaluation at least every 90 days. The policy also requires safety counseling such as discussion of overdose risk, naloxone prescribing for patients at increased overdose risk, and discussion of pregnancy risk at each visit for women of child‑bearing potential.

Network practitioners who do not comply with these standards are subject to disciplinary actions, which may include credentials revocation, network contract termination, and reporting to the National Practitioner Data Bank or other mandated entities.

Definitions

inv-13: Chronic controlled substance prescribing

DefinitionPrescribing of a controlled substance on a chronic basis defined in this document as greater than 90 days.

Documentation requirementMaintain accurate, complete, individualized records including history, physical exam (including body part of pain if opioids prescribed), mental status exam where appropriate, treatment goals, informed consent, and controlled substance contract signed annually.

Monitoring requirementAdhere to monitoring frequencies (urine drug testing, PDMP queries, in-person evaluations) specified for chronic prescribing.

Conservative Treatment Documentation Requirements

Follow-up and Monitoring Frequency Limits

inv-15: chronic controlled substance follow-up

RequirementIn-person evaluation at least every 90 days for chronic controlled substance follow-up

Frequency labelPer 90 days

PurposeDocument ongoing response to therapy, risks, and need for continued controlled substances

Imaging Requirements

Billing Rule

Required monitoring: UDT, PDMP, and in-person evaluation intervals

The policy requires monitoring steps tied to clinical follow-up: random urine drug testing at least once every 6 months, Controlled Substance Monitoring Database (PDMP) queries at least every 90 days with notation of discrepancies and discussion, and in‑person evaluations at least every 90 days.

Policy item 18: Random urine drug testing results (at least once every 6 months) and discussion of aberrant results.
Policy item 19: Controlled Substance Monitoring Database query at least every 90 days with notation and discussion of discrepancies.
Policy item 20: In person evaluation at least every 90 days.

Not Covered

Telemedicine for the management of chronic non‑malignant pain when that management includes prescribing controlled substances is explicitly listed as not covered and is deemed inappropriate under this policy.