Partial Hospitalization Program (PHP) and Intensive Outpatient Program (IOP) Prior Authorization Form
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Form and clinical criteria governing prior authorization requests for Partial Hospitalization Program (PHP) and Intensive Outpatient Program (IOP) services for mental health, substance use disorder, and eating disorder treatment; applies to providers submitting authorization requests to Bluecross Idaho.
No material clinical or coverage changes in this revision.
Level-of-Care Clinical Criteria
InterQual-based level-of-care criteria
Clinical criteria by condition and level of care (Mental Health, Substance Use Disorder, Eating Disorder):
MH PHP
- Can tolerate a structured therapeutic program at least 15 hours per week
- Clinical assessment at least once a day
- Personalized goal-directed treatment plan
- Weekly psychiatric evaluation by a licensed clinical practitioner
- Psychosocial assessment
- Medication reconciliation
MH IOP
- Can tolerate programming at least six contact hours for child/adolescent or nine contact hours for adults per week
- Personalized goal-directed treatment plan
- Psychosocial assessment
- Medication reconciliation
SUD PHP
- Individual, group or family therapy at least 20 hours per week
- Personalized recovery-focused treatment plan
- Weekly psychiatric evaluation by a licensed clinical practitioner
- Psychosocial assessment
- Medication reconciliation
- Toxicology screen or breathalyzer as needed
SUD IOP
- Can tolerate programming at least six contact hours for child/adolescent or nine contact hours for adults per week
- Personalized recovery-focused treatment plan
- Medication reconciliation
- Recovery or education group at least one hour per day, at least two times per week
Eating Disorder PHP
- Can tolerate a structured therapeutic program at least 30 hours per week
- Clinical assessment at least once a day
- Personalized goal-directed treatment plan
- Nutritional assessment with weight measurement
- Weekly psychiatric evaluation by a licensed clinical practitioner
- Psychosocial assessment
- Medication reconciliation
Eating Disorder IOP
- Can tolerate programming at least 6 contact hours for child/adolescent or 9 contact hours for adults per week
- Personalized goal-directed treatment plan
- Psychosocial assessment
- Medication reconciliation
Service and Contact Hour Requirements
| Other | Other (specified by provider) |
Authorization Submission & Documentation Requirements
Submission, timing, and decision communication
Submit the completed prior authorization form; sending the form by fax or phone alone does not constitute authorization. Blue Cross of Idaho will notify the provider of the decision by fax, mail, phone, or the provider portal. Submit elective prior authorization requests at least 10 days before the scheduled date of service. Authorization periods may not exceed one month without review of medical records. Expedited requests are allowable if the provider attests that delay could seriously jeopardize the member and follows PAP 241. Behavioral Health fax: 208-387-6840; questions: 208-331-7535 or 800-743-1871.
- Faxing or phoning the form does not authorize services.
- Decision communicated via fax, mail, phone, or provider portal.
- Elective requests must be submitted ≥10 days before service.
- Authorization period normally ≤1 month without medical record review.
- Expedited requests require provider attestation per PAP 241.
Attach medical records documenting clinical indications and planned InterQual-based interventions
Fax the completed prior authorization form together with medical records that document the clinical indications, medical necessity, and the planned interventions as outlined by the InterQual criteria on the form.
- Include supporting medical records demonstrating InterQual criteria and medical necessity.
- Provide documentation of planned interventions referenced on the form.
Use the required CPT/HCPCS codes to identify the requested service
Indicate the requested service using the applicable CPT/HCPCS/service codes on the form: commercial and Medicare options are listed and must be selected to identify the service requested.
Program Definitions
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