Psychiatric Clinical Service Authorization Request Form
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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.
No material clinical/coverage changes — form is informational and used to collect standardized data for authorization decisions.
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
- DSM-5/ICD-10 Diagnosis Codes
- Co-morbidities (medical conditions)
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
- Presence: 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
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
- 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
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
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
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*
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)
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
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).
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