Optum behavioral health prior auth form

Coverage and Medical Necessity Criteria

Initial Authorization Submission

Coverage determinations rely on submission of required clinical information and are considered when ALL of the following are provided:

Required submission elements: Practical form completion: practitioner identification (name, practice/facility, phone, fax, practitioner ID/TAX ID), patient demographics (name, date of birth, membership number), authorization number (if applicable), date first seen for this episode, level of care being requested (benefit type), primary and secondary diagnosis codes, current treatment modalities, medication types, current symptoms and functional impairments (including risk/ideation fields), treatment plan (objectives, goals, interventions), and requested CPT/HCPCS/revenue codes with number of units for each.

Supports authorization decision.

Modality-specific Criteria

Modality-specific supporting evidence required for authorization:

ECT/rTMS: Provide clinical rationale including medical suitability and history of failed treatments, and list requested revenue/HCPC/CPT codes and units.

Required for device-based neuromodulation authorization.

ABA: Provide supervising BCBA name, documentation that Autism Spectrum Disorder was validated by an MD/DO or Psychologist, and for initial requests list specific ABA treatment goals; for continuing requests provide assessments of functioning (e.g., FBA, ABLLS, VB-MAPP) and documentation of progress and targeted behaviors.

Required when carrier classifies ABA as mental health benefit.

Psychological Testing: Document symptoms/impairments prompting testing, purpose (differential diagnosis, treatment planning), prior testing history, names and hours of requested tests, substance use status, and justification for additional testing time if needed.

Supports testing authorization.

Biofeedback: List requested CPT/HCPC/Reven ue codes and number of units; provide presenting problems and rationale for biofeedback.

Form provides dedicated fields for codes/units.

Telehealth: List requested CPT/HCPC/CPT codes and units and indicate presenting problems or reasons telehealth is suitable.

Form provides dedicated fields for telehealth codes/units.

Substance Use Disorder Criteria

For Substance Use Disorder higher-level care requests include a multidimensional assessment and clinical history:

SUD dimensional assessment: Rate and describe each of the six ASAM-style dimensions: (1) acute intoxication and/or withdrawal potential, (2) biomedical conditions and complications, (3) emotional/behavioral/cognitive conditions and complications, (4) readiness to change, (5) relapse/continued use or continued problem potential, and (6) recovery/living environment; provide explanatory details for each rating.

Used to determine level of care intensity.

SUD history and monitoring: Provide type of substance use disorder, onset (recent past 12 months vs >12 months), frequency of use, last use, consequences of relapse (medical, social, housing, work/school, legal, other), urine drug screen status, current vital signs, withdrawal score (CIWA/COWS) or symptoms, and history of seizures/DTs/blackouts if applicable.

Required for higher level SUD authorization.

Eating Disorder Medical Criteria

For eating disorder higher-level care, provide medical monitoring and severity data:

Eating disorder medical criteria: Provide height, current weight, percent of NBW, highest and lowest weight, weight change over time (e.g., pounds lost in 1 month), if purging specify type and frequency, serum potassium and sodium values, current vital signs, presence of abnormal EKG, and documentation of medical evaluation; include current symptoms, behaviors, diagnosis, and any medical/physiological pathologic manifestations.

Used to determine medical necessity for higher-level eating disorder care.

This form is a standardized data-collection template used to gather the clinical, safety, functional and billing details needed to support a treatment authorization request. It does not itself enumerate policy-level exclusions or list services that are specifically excluded from coverage; rather, it provides the structured fields (practitioner information, diagnoses, treatment rationale, requested procedure codes and units, modality-specific details, etc.) that reviewers use to evaluate requests against applicable coverage policies.

The form does not define or list conditions that are explicitly not medically necessary. Instead, it collects the information (member demographics, clinical history, symptoms, prior treatments, testing results, and requested CPT/HCPCS/revenue codes with units) that enables utilization review clinicians to determine medical necessity or to identify services that do not meet medical necessity criteria under the applicable policy.

Criteria by Level of Care (Outpatient, IOP, PHP, Residential, Inpatient)

Inpatient, Residential, PHP, IOP, Outpatient

Level-of-care determinations (Inpatient, Residential, PHP, IOP, Outpatient) require clinical justification and ongoing documentation:

Higher-level care admission: Provide primary reason for request/admission (self/other lethality, violent/uncontrolled behavior, safety issues, eating disorder, detox/withdrawal, substance use, psychosis, mania, depression, or other) AND describe frequency, intensity, and duration of impairing behaviors and symptoms, medication adjustments during the level of care, barriers to adherence, prior treatment in past 6 months, relevant medical issues, support system/home environment, treatment plan (objectives, goals, interventions) and discharge plan (including anticipated discharge date).

Admission requires detailed clinical rationale and data.

Continued stay/Concurrent review: Document progress since the last review and justify continued need for the level of care using objective changes and treatment response, including updates to the treatment plan and discharge planning.

Used to evaluate ongoing medical necessity.

Specialty Modalities (ECT, rTMS, ABA, Testing, Telehealth, Biofeedback)

ECT, rTMS, ABA, Psychological Testing, Biofeedback, Telehealth

Top-level modality-specific criteria (details as required above):

ECT/rTMS: Clinical rationale including medical suitability and history of failed treatments plus requested CPT/HCPCS codes and units.

Device-based neuromodulation authorization.

ABA: Supervising BCBA name provided and ASD validation by MD/DO or Psychologist; initial requests must list specific ABA treatment goals; continuing requests require functional assessments (FBA, ABLLS, VB-MAPP) and documentation of progress.

ABA authorization requirements.

Psychological Testing: Symptoms/impairment prompting testing, purpose, prior testing history within 12 months, names and hours of requested tests, substance use status, and justification for additional time if required.

Testing justification required.

Requested Codes and Billing Information

Requested CPT/HCPC/Revenue Codes (form field)mixed

Requested Revenue/HCPC/CPT Code(s)

Placeholder field in the form where provider lists procedure or billing codes for requested services (applies across modalities: ECT, rTMS, ABA, psychological testing, biofeedback, telehealth, higher levels of care).

inv-08: Weight change

Requested metricWeight change over time (exact numeric entry requested; example field: 'Weight change over time (e.g. lbs lost in 1 month)')

Related fields to reportHeight, Weight, % of NBW, Highest/Lowest weight

Context of useCollected when request is related to treatment of an eating disorder for higher level of care

Required Documentation and Submission Instructions

Billing Rule

List CPT/HCPCS/Revenue codes and units

List the CPT/HCPCS/Revenue code(s) and the number of units requested for each service. Providers must include codes and units for ALL services being requested (e.g., ECT, rTMS, ABA, psychological testing, biofeedback, telehealth, higher level of care).

Requested Revenue/HCPC/CPT Code(s) and Number of Units for each service must be provided
Include separate line items for modality-specific codes (ECT, rTMS, ABA, psychological testing, biofeedback, telehealth, etc.)

Denial Risk

Incomplete form risks denial

Incomplete or missing information can lead to processing delays or denial. Ensure all required fields on the submission form are completed before sending.

Definitions and Modality Requirements

inv-15: ABA requirements

ASD validationHas Autism Spectrum Disorder been validated by MD/DO or Psychologist? (Yes/No checkbox)

Supervising clinicianSupervising BCBA name required for ABA requests

Initial request documentationFor initial requests, list specific ABA treatment goals (3 goal fields) and date of evaluation by MD/DO

Continuing request documentationFor continuing requests, provide assessment of functioning using FBA, ABLLS, VB-MAPP, etc., and documentation of progress over the last year plus current treatment goals and targeted behaviors

inv-16: Eating disorder medical requirements

Core medical monitoring fieldsHeight, Weight, % of NBW, Highest weight, Lowest weight

Visit/Unit Limits and Quantity Details

inv-20: Units requested

Units entry on formForm requests 'Number of Units for each' alongside Requested Revenue/HCPC/CPT Code(s)' for modality-specific and other services

No explicit visit limits on formThe form does not set explicit visit or session limits; visit/unit limits are determined elsewhere

Applies to multiple modalitiesUnits field provided for ECT/rTMS, ABA, psychological testing, biofeedback, telehealth and other modalities

Form Purpose and Scope

This Uniform Treatment Plan Form is intended as a standardized form to collect the clinical, safety, and functional information needed to authorize and monitor behavioral health services across levels of care and treatment modalities. It captures practitioner identification and contact data, patient demographics, current symptoms and functional impairment, treatment history and rationale, modality-specific sections (for example ABA supervisory details, psychological testing purpose and tests requested, biofeedback/telehealth CPT codes and units), and focused medical monitoring fields for higher-level needs such as substance use and eating disorder care.

OpenPayer

Uniform Treatment Plan Form for Mental Health and Substance Use Services — Authorization Template