SUD Clinical Service Authorization Request Form - Coverage Criteria
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Form and instructions for submitting prior authorization requests for Substance Use Disorder (SUD) services (initial and concurrent) to Blue Cross Blue Shield of Tennessee; applies to providers requesting authorization for various SUD levels of care.
No material clinical or coverage changes in this revision.
Coverage Criteria and Form Scope
Authorization submission criteria
Authorization is contingent on submission of required clinical and administrative information to support level-of-care decisions.
Complete all sections for initial requests; complete sections marked with * for concurrent/continued stay reviews. Authorization may be submitted online via Availity or faxed to 1-800-496-9600.
The SUD Clinical Service Authorization Request Form functions as the mechanism to request prior authorization for the SUD service types listed on the form (for example: SUD Residential, Inpatient Detox ASAM 4.0, SUD Residential Detox 3.7, Outpatient, Partial Hospitalization, and IOP). The form itself does not enumerate explicit service exclusions; instead, providers must select the requested service type and supply the required clinical and administrative information to support level-of-care determination.
Utilization decisions will be made based on the clinical and administrative information submitted with the request. The form includes an attestation that, by submitting the request, the provider is confirming they have provided all available pertinent clinical information and are requesting a decision based on that submission. Absence of required data (for example, missing vitals, withdrawal assessment scores, UDS/BAL results, or an adequate treatment plan) may delay review or result in denial.
Diagnosis, Assessment Codes and Scores
| DSM-5/ICD-10 | Diagnosis codes field for substance use and comorbid conditions |
How Providers Submit Requests and Required Documentation
How to submit authorization requests
Submit authorization requests online through Availity or fax the completed form to 1-800-496-9600. For initial requests complete all sections of the form; for concurrent/continued stay reviews complete sections marked with an asterisk and indicate request type, requested start date, number of days/sessions, frequency, and estimated discharge date.
- Online submission channel: Availity
- Fax number: 1-800-496-9600
- Initial requests: complete all sections
- Concurrent reviews: complete sections marked with * and provide requested start date, number of days/sessions, frequency, and estimated discharge date
Document whether MAT was considered
The form asks whether Medication Assisted Treatment (MAT) has been considered and, if yes, requests an explanation and medication details; the form does not impose a specific step-therapy algorithm but requires documentation of MAT consideration.
- Question on form: "Has Medication Assisted Treatment been considered?" with Yes/No checkbox
- If yes, the form instructs: "If yes, explain:" and requests medication information elsewhere on the form
Required clinical and administrative documentation
Providers must submit the completed SUD Clinical Service Authorization Request Form (initial or concurrent) including member demographics, DSM-5/ICD-10 diagnosis codes, treating provider and facility information, clinical evaluation/assessment, vitals, CIWA and COWS scores, UDS/BAL results, withdrawal symptoms, treatment plan/goals, medications and medication adherence, and discharge/step-down plan as applicable.
- Member demographics and DSM-5/ICD-10 diagnosis codes
- Ordering clinician and facility identifiers (Provider ID/NPI, Tax ID, contact info)
- Clinical evaluation: date of evaluation, presenting problem, SUD history, mental status exam
- Vitals: date, BP, pulse, temperature, respirations, CIWA and COWS scores
- UDS/BAL date and results, documented withdrawal symptoms
- Treatment plan/goals, medications (name, dosage, frequency) and medication adherence
- Concurrent reviews: updated MSE, vitals, CIWA/COWS, UDS, withdrawal symptoms, justification for continued stay, and discharge plan
Incomplete clinical information may delay or result in denial
By submitting the request you confirm that all available clinical information pertinent to the request has been provided; missing or incomplete clinical data (e.g., absent vitals, CIWA/COWS, UDS/BAL, treatment plan) may delay the review or result in denial.
- Submission statement on form: confirmation that submitter provided all available clinical information
- Incomplete or missing required sections (especially those required for concurrent reviews) can delay or lead to denial
Key Definitions for Request Types
Level of Care Options and Selection Criteria
Mixed (Inpatient/Residential/PHP/IOP/Outpatient)
Requested level(s) of care must be selected on the form and supported by the clinical information provided.
Requested start date, number of days/sessions, frequency, and estimated discharge date should be provided on the form.
Complete sections marked with * for concurrent reviews.
Treatment Modalities and Considerations
Medication Assisted Treatment (MAT)
Form documents whether Medication Assisted Treatment (MAT) has been considered and requests details when applicable.
The form requests MAT documentation but does not specify a mandatory MAT requirement or step-therapy algorithm.
Background and Clinical Rationale
Authorization requests must include documentation of the member’s substance use and treatment history, a mental status exam and vital signs, and formal withdrawal assessments. The form explicitly collects vitals and records for CIWA and COWS scores, UDS/BAL date/results, withdrawal symptoms, psychosocial factors, treatment history, the treatment plan and goals, current medications and medication adherence, and discharge/step-down planning as applicable.
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