ModifiedPremera Blue Cross of WashingtonPolicy 3.01.521
Psychiatric and Specified Evaluations in Behavioral Health Treatment
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This policy supplements InterQual medical-necessity criteria by specifying provider types, timing, frequency, and distinct documentation requirements for psychiatric, medical, substance use, and nutritional evaluations during inpatient, residential, withdrawal-management, and partial hospital behavioral health treatment.
Policy Summary
PayerPremera Blue Cross of Washington
PolicyPsychiatric and Specified Evaluations in Behavioral Health Treatment
Policy CodePolicy 3.01.521
Change TypeModified
Effective DateNovember 16, 2026
Last ReviewSep 8, 2026
Next Review DateNot specified
Key ActionDocument each required evaluation as an actual psychiatric, psychiatric medication, substance use, medical, or nutritional evaluation performed on a specific date.
Added InterQual criteria for partial hospital program behavioral health treatment.
Expanded the policy scope to include partial hospital program behavioral health treatment.
Added an option allowing the initial residential psychiatric evaluation within two calendar days after admission.
Revised the permitted interval for subsequent residential psychiatric evaluations to include once every 10 days.
Revised the permitted interval for subsequent residential eating disorder nutritional assessments to include once every 10 days.
Replaced detoxification with withdrawal management (detoxification).
Removed separate review sections for psychosocial and substance use evaluations during substance use disorder residential treatment.
Removed the psychiatric evaluation requirement during substance use disorder inpatient rehabilitation.
Clarified that review summaries are not substitutes for date-specific psychiatric, psychiatric medication, or substance use disorder psychiatric evaluations.
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24 hoursInitial psychiatric evaluation in inpatient treatment
4Treatment settings addressed
7 daysStandard recurring evaluation interval
10 daysLongest permitted exception interval
3 daysPre-transfer evaluation look-back period
Behavioral Health Coverage Criteria
Inpatient mental health and eating disorder treatment
In addition to other InterQual criteria, coverage requires all of the following:
Inpatient mental health or eating disorder psychiatric evaluation
Eligible evaluating provider
Psychiatrist.
Psychiatric nurse practitioner.
Psychiatric physician assistant.
Licensed clinical psychologist, where functioning as the attending clinician is within the psychologist's legally permitted scope of licensure.
Physician, nurse practitioner, or physician assistant who specializes in eating disorder treatment.
For inpatient mental health treatment on a medical unit or in an emergency department while waiting for a psychiatric bed: a non-psychiatric physician, nurse practitioner, or physician assistant with documentation of daily consultation or daily evaluations by a master's-degree or doctoral-degree clinician or licensed mental health clinician.
Inpatient substance use disorder treatment
In addition to other InterQual criteria, coverage requires all of the following:
Inpatient substance use disorder psychiatric evaluation
Eligible evaluating provider
Psychiatrist.
Psychiatric nurse practitioner.
Psychiatric physician assistant.
Licensed clinical psychologist, where functioning as the attending clinician is within the psychologist's legally permitted scope of licensure.
Physician, nurse practitioner, or physician assistant who specializes in addiction medicine.
Inpatient medical evaluations
In addition to other InterQual criteria, the applicable medical evaluation requirement must be met:
Inpatient mental health or eating disorder medical evaluation: A medical history and physical examination is completed by a physician, nurse practitioner, or physician assistant within 1 day after admission, or was completed in an emergency department or hospital inpatient medical unit before direct transfer to the inpatient mental health or eating disorder unit or facility.Within 1 day after admission or before direct transfer
Inpatient substance use disorder medical evaluation: A medical history and physical examination is completed by a physician, nurse practitioner, or physician assistant within 1 day after admission, or was completed in an emergency department or hospital inpatient medical unit before direct transfer to the inpatient substance use disorder unit or facility.Within 1 day after admission or before direct transfer
Substance use disorder inpatient rehabilitation medical evaluation: A medical history and physical examination is completed by a physician, nurse practitioner, or physician assistant within 1 day before or 1 day after admission.
Residential mental health and eating disorder treatment
In addition to other InterQual criteria, residential mental health and eating disorder treatment requires all applicable criteria below:
Residential psychiatric evaluations: A psychiatric evaluation by a licensed clinical practitioner is completed within 1 business day of admission, within 2 calendar days after admission, or during inpatient or partial hospitalization treatment within 3 calendar days before direct transfer to residential treatment in the same facility. A psychiatric or psychiatric medication evaluation by a licensed clinical practitioner is then completed at least once every week.Initial: within 1 business day, within 2 calendar days, or within 3 days before same-facility direct transfer; recurring: at least every 7 days, with a permitted exception not beyond 10 days
The exception to the weekly interval may apply because of the patient's clinical condition or availability, mandatory activities or conflicting appointments, or evaluating or covering clinician schedules.
Residential mental health distinct services: Psychiatric evaluations are additional to nursing, psychosocial or biopsychosocial, substance use, and other evaluations; individual, group, or family therapy; and daily clinical assessments.
Residential eating disorder distinct services:
Residential substance use disorder treatment
In addition to other InterQual criteria, coverage requires all of the following:
Residential substance use disorder psychiatric evaluation: A psychiatric evaluation is completed within 1 week after admission, or during inpatient or residential/subacute withdrawal management within 3 calendar days before direct transfer to residential treatment, and the individual transfers to substance use disorder residential treatment in the same facility.Within 7 days after admission or within 3 days before same-facility direct transfer
The psychiatric evaluation must be additional to nursing, psychosocial or biopsychosocial, substance use, ASAM dimension, and other evaluations, as well as individual, group, or family therapy and daily clinical assessments.
Inpatient withdrawal management
In addition to other InterQual criteria, coverage requires all of the following:
Inpatient withdrawal management evaluations: A medical history and physical examination assessment is completed within 1 day of admission by a physician, nurse practitioner, or physician assistant; a psychiatric evaluation is completed within 1 day of admission; and thereafter, at least once every day, a psychiatric evaluation or a medical evaluation that includes assessment of withdrawal status and management is completed by an eligible provider.Medical history and physical plus psychiatric evaluation within 1 day; daily psychiatric or withdrawal-focused medical evaluation thereafter
Eligible recurring providers are a psychiatrist, psychiatric nurse practitioner, psychiatric physician assistant, licensed clinical psychologist where legally permitted to function as attending clinician, or physician, nurse practitioner, or physician assistant who specializes in addiction medicine.
Treatment staff complete a nutritional assessment daily.Daily
This is an alternative to the registered dietitian pathway.
A nutritional assessment is completed within 2 days of admission and then at least once every week by a registered dietitian.Within 2 days of admission; at least every 7 days, with a permitted exception not beyond 10 days
Observation or charting of food and fluid choices, intake, or behavior during meals and snacks does not constitute a nutritional assessment.
Mental health and eating disorder PHP treatment
In addition to other InterQual criteria, coverage requires all of the following:
Mental health and eating disorder PHP psychiatric evaluation: A psychiatric or psychiatric medication evaluation by a licensed clinical practitioner is completed within the first week of treatment in the program and then at least once every week.Initial within the first 7 calendar days; recurring at least every 7 days, with a permitted exception not beyond 10 days
The evaluations must be additional to nursing, psychosocial or biopsychosocial, substance use, nutritional, and daily clinical assessments; individual, group, or family therapy; program activities; and other evaluations or treatment activities.
Substance use disorder PHP treatment
In addition to other InterQual criteria, coverage requires all of the following:
Substance use disorder PHP evaluations
A psychiatric or psychiatric medication evaluation by a licensed clinical practitioner is completed within the first week of treatment in the program.Within the first 7 calendar days
A substance use evaluation is completed on admission, within 1 program day after admission, or during another level of substance use disorder treatment within 3 calendar days before direct transfer in the same facility.Day 1, day 2, or within 3 days before same-facility direct transfer
On admission means during the first day in the program; within 1 program day after admission means the second day in the program. A licensed clinical practitioner, licensed or certified substance use disorder professional, or certified alcohol and drug counselor may perform the substance use evaluation.
Substance use evaluations are then completed at least once every week.
Eating disorder PHP nutritional assessments
In addition to other InterQual criteria, coverage requires all of the following:
Eating disorder PHP nutritional assessment: A nutritional assessment by a dietician is completed within the first week of treatment in the program and then at least once every week.Initial within the first 7 calendar days; recurring at least every 7 days, with a permitted exception not beyond 10 days
Observation or charting of food and fluid choices, intake, or behavior during meals and snacks does not constitute a nutritional assessment.
Residential/sub-acute withdrawal management is not covered under this policy. The clinician requirements for these services are specified in Policy 3.01.515, Behavioral Health: Residential/Sub-Acute Withdrawal Management (Detoxification).
Wilderness therapy and outdoor behavioral healthcare residential wilderness programs are not covered under this policy. The applicable clinician requirements are specified in Policy 3.01.522, Wilderness Therapy/Outdoor Behavioral Healthcare Residential Wilderness Programs.
When the policy requires an evaluation by a licensed clinical practitioner, the evaluation must be performed by a clinician who meets the applicable licensure requirement. Registration or certification alone does not equal licensure; therefore, an evaluation by a registered or certified clinician who is not licensed does not satisfy the requirement.
A Clinical Review, Clinical Update, Concurrent Review, Utilization Review, Progress Review, or similar summary describes clinical status or treatment over a period of time, but it is not the required evaluation. These summaries do not replace a required psychiatric, psychiatric medication, or substance use evaluation because the evaluation must be documented as performed on a specific date.
Meal observation and documentation of food or fluid choices, intake, or behavior during meals and snacks do not constitute a nutritional assessment. These records may document treatment activity, but they do not replace the separately required nutritional assessment by the applicable treatment staff or dietician.
Documentation and Denial Risks
Documentation Required
Document Each Required Evaluation
Document each required psychiatric, medical, substance use, nutritional, or other qualifying evaluation as an actual evaluation performed for the member—not merely as a summary of care or a general progress note.
Record the evaluation type, date performed, treatment setting, admission or transfer date, and evaluating clinician.
When an evaluation is completed before a direct transfer, document the prior level of care, transfer date, and that the transfer occurred within the policy’s permitted timeframe.
Documentation Required
Identify Setting, Timing, and Clinician
For every required evaluation, clearly identify the setting and timing and name the clinician who performed it. Documentation must allow the reviewer to determine whether the evaluation occurred within the required admission, transfer, program-day, business-day, calendar-day, or weekly interval.
Inpatient psychiatric evaluations generally require completion within one day after admission and then at least daily; applicable residential and PHP requirements commonly require an initial evaluation within the first week and subsequent evaluations at least every 7 days, with limited allowance for no less frequent than every 10 days.
Policy Scope and Purpose
This policy supplements InterQual medical-necessity criteria by establishing evaluation requirements for behavioral health treatment in inpatient, residential, inpatient withdrawal-management, and partial hospital program (PHP) settings. Depending on the level of care and condition treated, required evaluations include psychiatric, psychiatric medication, medical, substance use, and nutritional assessments. The requirements address the provider type, timing, frequency, and separate documentation needed to support medical necessity. Inpatient evaluations may be required within 1 day of admission and daily thereafter, while residential and PHP evaluations generally begin within the applicable admission or treatment-start period and recur at least every 7 days, with specified exceptions allowing intervals no longer than 10 days.
Timing and Clinician Definitions
Once every week
Standard weekly intervalAt least once every 7 days.
Permitted exceptionWhere specified, evaluations may occur at least once every 10 days because of clinical condition, patient availability, conflicting appointments or activities, clinician scheduling, or covering-clinician schedules.
Maximum intervalEvaluations must never occur less frequently than once every 10 days.
Within the first week of treatment
Time periodThe first 7 calendar days.
Starting pointThe count starts with the day of admission or the day treatment begins, as applicable.
Treatment Settings Covered
Inpatient, Residential, Inpatient Withdrawal Management, and Partial Hospital Program
The policy addresses four behavioral health treatment settings. In addition to the applicable InterQual medical-necessity criteria, the required evaluation criteria for each setting are:
Inpatient treatment: For inpatient mental health, eating disorder, substance use disorder, and withdrawal management treatment, complete the applicable initial psychiatric, medical, and withdrawal-management evaluations within 1 day of admission and continue required psychiatric or medical evaluations daily.Initial evaluations within 1 day; daily thereafter where specified
Residential treatment: For residential mental health, eating disorder, and substance use disorder treatment, complete the applicable psychiatric evaluation within the specified admission or direct-transfer timeframe and repeat required psychiatric, psychiatric medication, substance use, or nutritional evaluations generally at least every 7 days, with specified exceptions not beyond 10 days.Initial timing varies by treatment type; recurring evaluations generally every 7 days, never less frequently than every 10 days
Evaluation Frequency and Timing
Inpatient psychiatric evaluation frequency
Initial psychiatric evaluationFor inpatient mental health, inpatient substance use disorder, and inpatient withdrawal management, the initial psychiatric evaluation is completed within 1 day after admission.
Subsequent psychiatric evaluationsAfter the initial evaluation, a psychiatric evaluation is completed at least once every day during inpatient mental health and inpatient substance use disorder treatment.
Withdrawal-management alternativeDuring inpatient withdrawal management, a psychiatric evaluation or a medical evaluation that includes assessment of withdrawal status and management is completed at least once every day.
Residential psychiatric and substance use evaluations
Residential mental health and eating disorder treatmentAfter the initial evaluation, a psychiatric or psychiatric medication evaluation by a licensed clinical practitioner is completed at least once every 7 days.
Policy Summary
PayerPremera Blue Cross of Washington
PolicyPsychiatric and Specified Evaluations in Behavioral Health Treatment
Policy CodePolicy 3.01.521
Change TypeModified
Effective DateNovember 16, 2026
Last ReviewSep 8, 2026
Next Review DateNot specified
Key ActionDocument each required evaluation as an actual psychiatric, psychiatric medication, substance use, medical, or nutritional evaluation performed on a specific date.
Physician assistants working in substance use disorder settings are considered to specialize in addiction medicine.
Within 1 day before or after admission
Psychiatric evaluations are additional to nursing, psychosocial or biopsychosocial, substance use, and other evaluations; individual, group, or family therapy; daily clinical assessments; and nutritional assessments.
At least every 7 days, with a permitted exception not beyond 10 days
ASAM dimension assessments are acceptable as substance use evaluations.
Document medical history and physical examinations within the applicable one-day admission window, including whether they were completed in an emergency department or medical unit before direct transfer.
For substance use disorder PHP, separately identify the psychiatric or psychiatric medication evaluation and the substance use evaluation, including the program admission or transfer date and each subsequent evaluation date.
Documentation Required
Keep Assessment Records Separate
Maintain distinct records for each required assessment. A psychiatric or psychiatric medication evaluation must remain separate from nursing, psychosocial or biopsychosocial, substance use, ASAM dimension, medical, nutritional, daily clinical, therapy, treatment-activity, or meal-observation documentation.
Residential psychiatric evaluations must be in addition to nursing, psychosocial, substance use, other assessments, therapy sessions, and daily clinical assessments; eating disorder services also require separation from nutritional assessments.
Substance use evaluations must be distinct from nursing, psychosocial, psychiatric, daily clinical, therapy, and other treatment records, except that ASAM dimension assessments may qualify as substance use evaluations when permitted.
A nutritional assessment is distinct from observation or charting of food or fluid intake, choices, or behavior during meals and snacks.
Documentation Required
Document the Specific Evaluation Date
Every submitted evaluation record must identify the specific date on which the evaluation was performed. Do not rely on undated entries, date ranges, or a weekly record that does not establish a qualifying evaluation on a particular date.
Use the actual service date for each psychiatric, psychiatric medication, substance use, medical, or nutritional evaluation.
Ensure the documented dates demonstrate compliance with the applicable admission, transfer, program-day, weekly, or daily frequency requirement.
Denial Risk
Timing, Frequency, and Provider Compliance
Failure to meet the required timing, frequency, or clinician qualification can create a medical-necessity denial risk even when other clinical records are present. Review each episode against the applicable setting-specific requirements before submitting the claim.
Late initial evaluations, evaluations performed outside the permitted pre-transfer window, or evaluations not completed within the required first day, first week, or program day may fail the criteria.
Weekly evaluations generally must occur at least every 7 days; an allowed exception may extend the interval to no more than 10 days, and never less frequently than every 10 days where the policy permits it.
Daily requirements must be met each day, and evaluations must be performed by the provider type specified for the service.
Do not treat nursing notes, therapy notes, daily clinical assessments, meal observations, or other treatment documentation as satisfying a required evaluation unless the policy expressly identifies that record as an acceptable evaluation.
Denial Risk
Use a Qualified Evaluating Clinician
Verify that each evaluating clinician meets the policy’s licensed or otherwise specified provider requirement. Registration or certification alone does not establish licensure as a licensed clinical practitioner.
Registered or certified clinicians do not satisfy requirements for psychiatric or psychiatric medication evaluations that must be performed by a licensed clinical practitioner.
For applicable services, document the qualifying role, such as psychiatrist, psychiatric nurse practitioner or physician assistant, licensed clinical psychologist within the permitted scope, physician, nurse practitioner, physician assistant specializing in eating disorder treatment or addiction medicine, dietician, or other expressly permitted professional.
A nursing, psychosocial, therapy, substance use, or other clinician’s record cannot substitute for a required psychiatric or psychiatric medication evaluation unless that clinician independently meets the policy’s provider and evaluation requirements.
Denial Risk
Do Not Substitute Other Clinical Records
Do not submit nursing assessments, psychosocial or biopsychosocial assessments, therapy notes, daily clinical assessments, treatment-program records, meal observations, or similar documentation as substitutes for a required evaluation. Each required evaluation must be separately performed and documented by a qualifying clinician.
Food and fluid observation or charting does not constitute a nutritional assessment.
ASAM dimension assessments may qualify as substance use evaluations only where the policy expressly permits it; they do not replace required psychiatric evaluations.
A record that mentions symptoms, medications, treatment participation, or clinical status is not necessarily a psychiatric, medical, substance use, or nutritional evaluation.
Note
Confirm the Service Is Within Policy Scope
Residential or sub-acute detoxification and wilderness therapy/outdoor behavioral healthcare residential wilderness programs are outside the scope of this policy. Apply the separate policy governing the applicable service when determining required clinician types and documentation.
Residential/sub-acute withdrawal management (detoxification) is governed by policy 3.01.515.
Wilderness Therapy/Outdoor Behavioral Healthcare Residential Wilderness Programs are governed by policy 3.01.522.
Denial Risk
Summary Reviews Are Not Evaluations
Clinical Reviews, Clinical Updates, Concurrent Reviews, Utilization Reviews, Progress Reviews, and similar summaries do not satisfy a required evaluation merely because they describe the member’s status or treatment during a week or other period.
Submit documentation of the specific qualifying psychiatric, psychiatric medication, or substance use evaluation performed on the identified date.
A summary review may accompany the evaluation record, but it cannot replace the dated evaluation or establish compliance by itself.
Applicable settings
This definition applies to specified residential and partial hospital program psychiatric, substance use, and nutritional evaluations.
On admission / within one program day
On admissionDuring the first day in the treatment program.
Within one program day after admissionOn the second day in the treatment program.
Use in substance use PHPA substance use evaluation must be completed on admission, within one program day after admission, or within 3 calendar days before direct transfer from another level of substance use disorder treatment in the same facility.
Licensed clinical practitioner
Licensure requirementThe evaluator must independently meet the applicable clinical licensure requirement when the policy requires a licensed clinical practitioner.
Registration or certificationRegistration and certification are not the same as licensure.
Effect on coverage criteriaA registered or certified clinician who is not licensed does not satisfy an evaluation requirement for a licensed clinical practitioner.
Inpatient withdrawal management: Complete the medical history and physical examination and psychiatric evaluation within 1 day of admission, followed by a daily psychiatric evaluation or medical evaluation that assesses withdrawal status and management.Within 1 day of admission; daily thereafter
Partial hospital program treatment: For mental health, eating disorder, and substance use disorder PHP treatment, complete the applicable psychiatric, psychiatric medication, substance use, and nutritional evaluations within the specified first-week, admission, or transfer timeframe and repeat required evaluations generally at least every 7 days, with specified exceptions not beyond 10 days.Initial timing varies by treatment type; recurring evaluations generally every 7 days, never less frequently than every 10 days
Residential exceptionFor specified clinical, patient-availability, activity, or clinician-schedule reasons, the interval may be extended to at least once every 10 days, but not longer.
Residential substance use disorder treatmentThe psychiatric evaluation is completed within 1 week (7 days) after admission, or within 3 calendar days before direct transfer from withdrawal management to residential treatment in the same facility.
Partial hospital program evaluation frequency
Mental health and eating disorder PHPA psychiatric or psychiatric medication evaluation by a licensed clinical practitioner is completed within the first 7 calendar days and then at least once every 7 days; a specified exception may permit once every 10 days.
Substance use disorder PHPSubstance use evaluations are completed at least once every 7 days after the required initial evaluation; a specified exception may permit once every 10 days.
Eating disorder PHPA nutritional assessment by a dietician is completed within the first 7 calendar days and then at least once every 7 days; a specified exception may permit once every 10 days.