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.
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.
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