Required documents for RTC and Detoxification admissions
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Lists clinical documentation Bluecross Idaho requires for prior authorization and medical necessity determinations for admissions to Residential Treatment Centers and Detoxification levels of care; applies to providers submitting admission requests for Blue Cross of Idaho members.
No material clinical or coverage changes in this revision.
Coverage Criteria for RTC and Detoxification Admissions
inv-01: Required Documents for Determination
Requests for admission to RTC or Detoxification will be pended until ALL of the following documents are submitted:
Submit all documents together in one fax to 208-519-3960. Determination made within two business days after receipt.
None specified in this policy. The document does not list any specific exclusions or additional coverage criteria beyond the required-document checklist for admissions to Residential Treatment Centers (RTC) and Detoxification levels of care.
The policy does not enumerate conditions that are explicitly considered not medically necessary. It states that all admissions to RTC and Detoxification must be determined to be medically necessary, but provides no list of specific diagnoses or scenarios that would be classified as not medically necessary.
Provider Submission and Prior Authorization Requirements
Prior authorization / medical necessity requirement
Prior authorization/medical necessity determination for Residential Treatment Center (RTC) and Detoxification admissions requires submission of the specified clinical documents; requests will be pended awaiting timely submission and the insurer will make a determination within two business days after receipt.
High-priority: complete documentation required before determination
Do not submit admission requests without the full required documentation — requests are pended until all specified documents are received and determinations are made within two business days after receipt.
Required clinical documentation checklist
Provide clinical information documenting the need for the member's admission including: initial assessment or psychiatric evaluation, history and physical, documentation of anticipated length of stay to complete treatment at the requested level of care; and for Detoxification requests include CIWA and/or COWS scores.
- Initial assessment or psychiatric evaluation that reflects member diagnosis and level of care recommendation
- History and Physical
- Documentation of anticipated length of stay required to complete treatment at the requested level of care
- If Detoxification: Clinical Institute Withdrawal Assessment (CIWA) and/or Clinical Opiate Withdrawal Scale (COWS) scores
Submission instructions — one fax
Submit all required documents together in a single fax to 208-519-3960.
Pending status and potential denial if documents missing
Admission requests will be pended and may be denied or delayed if required documentation is not submitted in a timely manner.
Residential Treatment Center (RTC) and Detoxification Criteria
inv-11: Residential Treatment Center (RTC) and Detoxification
Requests are pended until received; determination made within two business days after receipt.
Detoxification Monitoring and Treatment Modalities
inv-12: Detoxification monitoring/scoring
Include these scores with the other required documents in a single fax to 208-519-3960; determination within two business days after receipt.
Definitions and Scales
Background
Minimal clinical background is provided. The policy is administrative in scope and requires that all admissions to Residential Treatment Centers (RTC) and Detoxification levels of care be determined to be medically necessary. It mandates submission of a completed initial assessment or psychiatric evaluation that documents the member’s diagnosis and recommended level of care; requests will be pended while required documentation is pending.
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