CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

Behavioral Health Out of Network Outpatient Treatment Request Form

Forms and instructions for out-of-network behavioral health outpatient authorization requests for Medi-Cal members; used by non-contracted outpatient BH providers to request authorization from Anthem/Blue Cross Blue Shield - Wisconsin.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyBehavioral Health Out of Network Outpatient Treatment Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionOut-of-network outpatient behavioral health providers must complete and submit this request form to Anthem for authorization for Medi-Cal members.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

phone & faxauthorization contact methods provided

member, provider, clinicalsections included on form

risk assessmentcontains current risk/lethality fields

treatment requestrequests details on services

Required Information for Authorization Decisions

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Required clinical and administrative information

Form fields that must be completed to support authorization decisions include clinical history, diagnoses, treatment goals, risk assessment, coordination of care, medications, and specific services requested.

ALL of the following

Member and clinical history
- Previous behavioral health and substance use treatment (none, outpatient, inpatient, other); list names and dates including hospitalizations if applicable.
- Medical history and substance use history; current/active status and details of substances used (type, amount, frequency, last used).
- Tobacco use (none, by history, current/active).
- DSM-5 / DSM-5-TR and/or ICD-10 diagnoses; if substance use and/or HIV diagnosis, documentation of consent to release information for these conditions.
Treatment plan and goals
- Primary complaint/problem to be addressed.
- List measurable treatment goals, standardized assessments used, and scores.
- Discharge goals describing how you will know the patient is ready to terminate treatment.
Risk and safety assessment
- Current risk/lethality assessment for suicidal ideation (None, Low, Moderate, High, Extreme).
- Current risk/lethality assessment for homicidal ideation (None, Low, Moderate, High, Extreme).
- Current risk/lethality assessment for assault/violent behavior (None, Low, Moderate, High, Extreme).
- Interventions for current risk/lethality (for levels 2–5).
Coordination of care and supports
- Indicate whether information has been shared with the PCP (initial evaluation, updated evaluation and treatment plan) and provide PCP name, phone, and date last notified; if not shared, explain.
- Family/support involvement in treatment (Yes/No).
- Coordination of care with other behavioral health providers (Yes/No) and with medical providers (Yes/No).
- Whether the member has received services at the county and whether the member has been evaluated by a psychiatrist (Yes/No).
Medications and progress
- List current medications and dosages and indicate prescriber (Psychiatrist, PCP, Nurse practitioner/PA).
- Overall progress toward goals (None, Minimum, Moderate, Maximum, Met).
- Compliance with treatment (None, Minimum, Moderate, Maximum, Met); if low, provide explanation.
Requested service details (administrative)
- Services requested (Individual therapy, Group therapy, etc.).
- Total sessions requested (provider to complete).
- Frequency of visits and number of visits per CPT/HCPCS code; CPT codes to be provided by requester.
- Estimated number of sessions to complete treatment episode; requested start date; provider signature and date.

ref63b3f3a9a1f4d1b2c4d8e9f0ef1a2b3c4d5e6f7a8b9c0d1e2f3a4b5c6d7e8f9g0h1i2j3k4l5m6n7o8p9q0r1s2t3u4v5w6x7y8z9a0b1c2d3e4f5g6h7i8j9k0

title64a2e1b3c4d5e6f7g8h9i0j1k2l3m4n5o6p7q8r9s0t1u2v3w4x5y6z7a8b9c0d1

Provider and Contracting Status Fields

DEFINITIONS — Requesting provider

Direct servicing provider name/credentialsForm field: 'Direct servicing provider name/credentials'

Provider NPIForm field: 'Provider NPI'

Contact (phone/fax/email/physical address)Form fields: 'Phone', 'Facsimile #', 'Provider email', 'Physical address' — submission contact: Phone 888-831-2246, Fax 855-473-7902

DEFINITIONS — Continuity/contracting status

Continuity of care (yes/no)Form captures 'Continuity of care: Yes / No'

Provider contracting status (pending) (yes/no)Form captures 'Provider pending completion of contracting with Anthem for BH Medi‑Cal: Yes / No'

Reason for requestForm field: 'Specify reason requested (such as, in‑network provider not in area, language, clinical specialty)'

OpenPayer

Behavioral Health Out of Network Outpatient Treatment Request Form

Required Information for Authorization Decisions

Requested Services and Session Details

Submission and Contact Instructions

Provider and Contracting Status Fields