Prior authorization: submit required assessment/plan for initial and continuation

Prior authorization requests must include the required clinical documentation for either initial or continued treatment: initial requests need an initial assessment and treatment plan; continued requests need treatment goals, interventions (including frequency/duration), patient response and discharge planning.

• Initial authorization: submit initial assessment and treatment plan (diagnosis, relevant psychosocial history, substance use evaluation, current functioning and risk factors, initial treatment goals and interventions) or referral information indicating patient is reasonably likely to meet program criteria.
• Continued authorization: submit treatment goals; treatment interventions including frequency and duration; patient response to treatment including engagement and progress toward identified goals; and discharge planning.

Include complete prior authorization packet per policy

Ensure a complete prior authorization packet is provided as described in the policy; include either the initial assessment/treatment plan or the continued-treatment documentation depending on whether the request is for an initial or ongoing authorization.

• If requesting initial authorization, include diagnosis, psychosocial history, substance use evaluation, functioning and risk factors, and initial goals/interventions (or referral information).
• If requesting continued authorization, include explicit treatment goals, interventions with frequency/duration, patient response/progress, and discharge planning.

Information to include with initial prior authorization

When submitting an initial authorization request, include the initial assessment and treatment plan details listed in the policy: diagnosis, relevant psychosocial history, substance use evaluation, current functioning and risk factors, and initial treatment goals and interventions.

• Diagnosis and relevant psychosocial history
• Substance use evaluation
• Current functioning and risk factors
• Initial treatment goals and planned interventions

Missing documentation may cause denial

Failure to submit the required information with the prior authorization request (initial assessment/treatment plan for initial requests; treatment goals, interventions, patient response, and discharge planning for continued requests) may result in denial of the request.

• Omitting the initial assessment and treatment plan or the continued-treatment documentation can trigger denial.