Psychiatric Clinical Service Authorization Request Form / Prior Authorization Guidance
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This document is the prior authorization/request form and process guidance for psychiatric clinical services (outpatient, residential, partial hospitalization, acute, IOP) for Blue Cross Blue Shield - Tennessee; it governs providers submitting initial and concurrent/continued stay authorization requests for Tennessee members.
No material clinical or coverage changes in this revision.
Authorization and Coverage Criteria
Authorization Criteria
Authorization is covered when the provider submits a completed request form with required clinical information supporting the level of care requested.
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The form does not list any explicit clinical exclusions. Instead, it includes an "Other (Specify)" option allowing providers to request services outside the predefined categories when appropriate. Use the "Other (Specify)" selection to provide supporting clinical detail for requests that do not fit the listed levels of care.
The form does not present a named list of conditions that are "not medically necessary." However, the form requires submission of the clinical information specified; lack of required clinical information or failure to demonstrate need for the requested level of care may lead to denial or a determination based on the information available at the time of review.
Diagnosis and Procedure Codes
| DSM-5/ICD-10 | DSM-5/ICD-10 Diagnosis Codes (as requested on form) |
Provider Submission & Documentation Requirements
Use the Authorization Request Form and Include Dates/Duration
Submit all prior authorization requests (initial and concurrent/continued stay) using the Psychiatric Clinical Service Authorization Request Form. The form must include requested start date, number of days/sessions, frequency, estimated discharge date, and the clinical information outlined on the form. Tennessee providers may submit via Availity; out-of-state providers via their provider portal or Cohere. For questions, call (423) 535-5717, option 2.
- Indicate Initial Request or Concurrent/Continued Stay and include Reference/Authorization Number for concurrent reviews.
- Provide Requested Start Date, Number of Days/Sessions, Frequency Requested, and Estimated Discharge Date on the form.
- Attach all required clinical information as outlined on the form when submitting.
Document Treatment Plan and Address Concurrent Review Requirements
Document a treatment plan and prior treatments on the form; for concurrent reviews include updated MSE, progress toward stabilization and discharge readiness, justification for continued stay, updated medications and discharge plan, and describe how the treatment plan will be changed if there is no progress toward stabilization and discharge readiness.
- Complete Treatment Plan/Goals and Discharge Plan (stepdown plan and disposition).
- For concurrent reviews provide updated MSE, barriers to discharge, what progress has been made toward stabilization, and justification for continued stay.
- If no progress toward stabilization and discharge readiness, describe planned changes to the treatment plan.
Submit Required Clinical Documentation and Member Identifiers
Provide required clinical and member information on the form including member demographics/identifiers, DSM-5/ICD-10 diagnosis codes, prior treatment history, presenting problem details, risk assessment elements, mental status exam, psychosocial factors, medications (name/dose/frequency) and discharge plan.
- Member Name, Member ID, Date of Birth, Member Phone Number, and (if applicable) Parent/Guardian Name.
- DSM-5/ICD-10 Diagnosis Codes and co-morbid medical conditions.
- Previous Treatment History, Presenting Problem (including suicide/ aggression details), Precipitants, and Symptoms related to diagnosis.
- Danger to Self or Others: suicidal/homicidal ideation, plan, intent, means, history of attempts/aggression, psychosis description, UDS/BAL, and MSE.
- Medications: name, dosage, frequency, and medication compliance; include Discharge Plan.
Risk of Decision Based on Incomplete Documentation
Incomplete or partial submissions may result in the decision being made based on the information available; providers must submit all pertinent clinical information to avoid delays or adverse decisions.
- Complete sections marked with an asterisk for concurrent requests and attach additional clinical documentation as needed.
- By submitting the request you confirm all available pertinent clinical information has been provided and that the decision may be made on the submitted information.
Levels of Care Definitions
Criteria by Level of Care
Inpatient/Residential/PHP/IOP/Outpatient (as requested)
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Medication Management and Psychosocial Treatment Planning
Medication management / Psychosocial treatment planning
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Background and Purpose
This request form is designed to collect the clinical, risk, and treatment information necessary to support utilization review decisions across psychiatric levels of care. It requires documentation of presenting problem, prior treatment history, psychosocial factors, medications (name, dosage, frequency, compliance), risk assessment (e.g., suicidal/homicidal ideation, plan, intent, means, history), mental status findings, treatment plan and goals, and a discharge/step-down plan. For concurrent reviews the form requests updated mental status, barriers to discharge, justification for continued stay, progress toward stabilization and specific changes to the treatment plan if there has been no progress.
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