ECT continuation/maintenance prior authorization
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Requirements and form for requesting prior authorization of continuation or maintenance electroconvulsive therapy (ECT) for Bluecross Idaho members; applies to providers submitting authorization requests and supports clinical review for ongoing ECT services.
No material clinical or coverage changes in this revision.
Coverage criteria for Continuation / Maintenance ECT
Continuation/Maintenance ECT coverage criteria
Covered when ALL of the following are met:
Authorization period may not exceed three months without review of medical records.
Submission by fax or phone alone does not constitute authorization. All information requested on the form must be complete; missing data may result in authorization delay and may prevent authorization. The plan will notify providers of the decision by secure email, mail, phone, or fax. Providers must fax the completed form along with supporting medical records; telephone or fax transmission of the request alone is insufficient to authorize services.
Codes and timing considerations
| CPT code(s) requested | Place to list CPT code(s) requested for ECT services as provided by the requester |
What providers must do to obtain authorization
Prior authorization required — submit ≥10 days before service; 3-month authorization limit
Prior authorization is required for continuation/maintenance ECT. Submit elective prior authorization requests at least 10 days before the scheduled date of service. Authorization period may not exceed three months without review of medical records; include explanation if medical necessity justifies special handling. For expedited requests when delay could seriously jeopardize the member, provider attestation per PAP 241 is required.
- Submit elective prior authorization requests at least 10 days prior to the scheduled date of service.
- Authorization period may not exceed three months without review of medical records.
- For expedited review when delaying service could seriously jeopardize the member, provider must sign the attestation per PAP 241.
Pre-ECT workup required when >90 days since acute series
If the requested maintenance ECT occurs more than 90 days after the acute/short-term series, the provider must submit proof that a pre-ECT workup and clearance was completed or that an annual workup and clearance for ongoing ECT has been completed.
- Include documentation showing a pre-ECT workup with clearance, or an annual workup with clearance, when maintenance ECT is >90 days after the acute series.
Required documentation — form plus supporting medical records and rating scales
Submit the completed continuation/maintenance ECT request form along with medical records documenting clinical indications or medical necessity, including the most current psychiatric evaluation or progress note and completed rating scales tracking treatment response.
- Completed request form (all required fields).
- Most current psychiatric evaluation or progress note.
- Completed rating scales used to track the patient's response to treatment.
- Documentation of total prior ECT treatments and number requested, adverse effects/events, current medications, and requested CPT codes as applicable.
Incomplete submissions risk delay or non-authorization
Incomplete or missing data on the form may result in authorization delay; submission by fax or phone alone does not constitute authorization. Blue Cross of Idaho will notify providers of decisions by secure email, mail, phone or fax.
- All information requested on the form must be complete; missing data may result in authorization delay.
- Submission by fax or phone alone does not constitute authorization.
Background and purpose
This form is used to request continuation or maintenance electroconvulsive therapy (ECT) and to document prior ECT series, current clinical status, and treatment details. It collects the total number of treatments previously given in the series, the number of additional treatments requested, requested dates and frequency, diagnoses, current medications, adverse effects, and completed rating scales to track response. The completed form must be submitted with medical records demonstrating clinical indications or medical necessity, and elective prior authorization requests should be submitted at least 10 days before the scheduled date of service. If delaying service could seriously jeopardize the member’s life, health, or ability to regain maximum function, the provider may request expedited prior authorization with an attestation per the form.
Key definitions
ECT modalities referenced
ECT
Use the service request fields on the form to provide these items.
Authorization period and visit limits
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