Currentblue cross blue shield - tennesseePolicy N/A

Psychiatric Clinical Service Authorization Request Form

Form to request initial or concurrent authorization for psychiatric services (inpatient, outpatient, residential, partial hospitalization, acute, IOP, ECT, and other) from BlueCross BlueShield of Tennessee; includes member, provider, clinical, and utilization review contact information and required clinical details to support authorization decisions.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyPsychiatric Clinical Service Authorization Request Form

Policy CodePolicy N/A

Change TypeInformational form (no material change)

Effective Date

Next Review Date

Key ActionProviders must complete and fax the form to 1-800-496-9600 or submit online via Availity, indicating Initial or Concurrent request and selected service level.

POLICY UPDATE CHANGES

No material clinical/coverage changes — form is informational and used to collect standardized data for authorization decisions.

7Service Types Listed

3Levels of Care w/ Auto-auth

Policy overview

Form used to collect standardized clinical and administrative information necessary for initial and concurrent authorization decisions for psychiatric services provided to BlueCross BlueShield of Tennessee members. Providers are instructed to complete the form for both initial and concurrent requests and either fax it to 1-800-496-9600 or submit online authorization requests and concurrent review updates through Availity.

Service types covered include inpatient, outpatient, psych residential, psych partial hospitalization, psych acute, psych psychiatric intensive outpatient program (IOP), electroconvulsive shock treatment (ECT), and other specified services. The form is intended to ensure complete clinical data for utilization review and decision-making by collecting member, provider, clinical, and utilization review contact information and required clinical details to support authorization decisions.

Document changes

No document-level changes are provided in the brief.

Request form sections and required clinical criteria

Request Type and Required Sections

Complete selected sections depending on request type:

Initial Request - Complete all sections for INITIAL requests.
Concurrent/Continued Stay Review - Complete sections marked with an asterisk (*) and provide updated clinical information; include Reference/Authorization # if available.
Include Reference/Authorization # if available

Service Levels (select one)

Inpatient Request
Outpatient Request
Psych Residential
Psych Partial Hospitalization
Auto-auth available through Availity
Psych Acute
Auto-auth available through Availity
Psych Psychiatric Intensive Outpatient Program (IOP)
Auto-auth available through Availity
Electroconvulsive Shock Treatment (ECT)
Other (Specify)

Required Clinical Information

Provide clinical details to support medical necessity:

Date of evaluation/assessment
Previous treatment history
Presenting problem: Presenting Problem (description of acuity, presenting symptoms, nature of suicide attempts or aggression, need for medical attention for members or others, maladaptive behaviors)
Precipitant (stressors, triggers for behaviors, frequency, date of last occurrence)
Symptoms related to diagnosis

Danger to Self or Others Assessment

Document risk elements:

Suicidal Ideation
- Presence: Yes/No selection for Suicidal Ideation
- Plan (free text)
- Intent (free text)
- Means (free text)
Homicidal Ideation

Psychosocial, Medication and Discharge Planning

Psychosocial factors (home environment, supports, abuse/trauma, occupational/school problems, legal/social service involvement, substance abuse history, UDS results)
Medications (name, dosage, frequency)
Required for concurrent requests
Medication compliance? (Yes/No)
Required for concurrent requests
Barriers (free text)
Treatment plan/goals

Utilization Data

Requested start date for this authorization
Number of days/sessions and frequency requested
Estimated discharge date
Concurrent-review items: For concurrent review: include updated MSE, barriers to discharge, justification for continued stay, individual/family/group session info
Concurrent-review-specific

Actions required of providers

Prior Authorization

Authorization Submission

Complete and submit authorization requests by fax to 1-800-496-9600 or submit online through Availity. Indicate whether this is an Initial Request or a Concurrent/Continued Stay Review and specify the selected service level (e.g., Inpatient, Outpatient, Psych Residential, Psych Partial Hospitalization, Psych Acute, Psych IOP, ECT, Other). For concurrent reviews include Reference/Authorization # if available.

Fax: 1-800-496-9600
Online submission: Availity
Mark request type: Initial or Concurrent/Continued Stay Review
Specify selected service level

Documentation Required

Clinical Documentation Requirements

Supply the clinical documentation listed on the form to support medical necessity. Required elements include date of evaluation/assessment, DSM-5/ICD-10 diagnosis codes, previous treatment history, risk assessment details (suicidal ideation with plan/intent/means; homicidal ideation with intended victim and notification status; psychosis description and MSE/UDS/BAL/baseline), current medications and medication compliance, psychosocial factors, treatment plan/goals, and discharge plan. For concurrent (continued stay) reviews provide sections marked with an asterisk (*): updated MSE, medications (name/dose/frequency), medication compliance, discharge plan, discharge readiness behavior, progress toward stabilization, and a justification for continued stay.

Date of evaluation/assessment
DSM-5/ICD-10 diagnosis codes
Previous treatment history
Risk assessment: suicidal ideation (Yes/No, plan, intent, means); homicidal ideation (Yes/No, intended victim, victim notified, means/access); psychosis (description, baseline, UDS/BAL, MSE)
Medications (name, dosage, frequency) and medication compliance*
Psychosocial factors (supports, abuse/trauma, substance use, UDS results)
Treatment plan/goals
Discharge plan (stepdown plan and disposition)*
For concurrent reviews: updated MSE, barriers to discharge, justification for continued stay, progress toward stabilization*

Billing Rule

Auto-authorization Availability

Auto-authorization is available through Availity for the following levels of care: Psych Partial Hospitalization, Psych Acute, and Psych Psychiatric Intensive Outpatient Program (IOP).

Psych Partial Hospitalization
Psych Acute
Psych Psychiatric Intensive Outpatient Program (IOP)

Documentation Required

Utilization Review Contact Information

Include Utilization Review (UR) contact information with your submission to facilitate review and concurrence. Provide the UR contact name, phone number, contact email address, and UR fax number on the form.

UR contact name
UR contact phone number
UR contact email address
UR fax number

Who and what this form applies to

Providers may fax the completed form to 1-800-496-9600 or submit authorization requests and concurrent review updates online through Availity. Note: auto-authorization is available through Availity for Psych Partial Hospitalization, Psych Acute, and Psych Psychiatric Intensive Outpatient Program (IOP) levels of care.

Background and operational context

The form is used to collect standardized clinical and administrative information to support initial and concurrent utilization review and authorization decisions for psychiatric services for BlueCross BlueShield of Tennessee members, ensuring reviewers have the clinical details needed to determine medical necessity and make timely authorization decisions.

Revision history

N/ACURRENTLatest

Status: CURRENT. No dated revision entries were provided in the brief; form is the current Psychiatric Clinical Service Authorization Request Form for BlueCross BlueShield of Tennessee and includes instructions for initial and concurrent requests, service level options, clinical information and risk assessment fields, and submission methods (fax to 1-800-496-9600 or via Availity).

Policy Summary

Payerblue cross blue shield - tennessee

PolicyPsychiatric Clinical Service Authorization Request Form

Policy CodePolicy N/A

Change TypeInformational form (no material change)

Effective Date

Next Review Date

Key ActionProviders must complete and fax the form to 1-800-496-9600 or submit online via Availity, indicating Initial or Concurrent request and selected service level.

On This Page

DSM-5/ICD-10 Diagnosis Codes

Co-morbidities (medical conditions)

Yes/No selection for Homicidal Ideation

Intended Victim (free text)

Victim Notified? (Yes/No). If No, explain.

Means/Access (free text)

Psychosis

Presence: Yes/No selection for Psychosis
Description: If yes, describe delusions/hallucinations/command hallucinations/thought disorder; if first episode, note whether neurological causes have been ruled out
Baseline (free text)
UDS/BAL (free text)
MSE (free text)

History of attempts/aggression (dates if known)

Other risky behaviors: Other behaviors that constitute risk to self or others

Discharge plan (stepdown plan and disposition)

Required for concurrent requests

Discharge readiness behavior

Required for concurrent requests

Progress toward stabilization and discharge since last review

Required for concurrent requests