ModifiedPremera Blue Cross of WashingtonPolicy 3.01.521

Psychiatric and Other Specified Evaluations for Behavioral Health Treatment

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This policy supplements InterQual medical-necessity criteria by specifying evaluation types, timing, and eligible clinician types for inpatient, residential, and partial hospital behavioral health treatment, including mental health, substance use disorder, withdrawal management, eating disorder, and PHP services.

Policy Summary

PayerPremera Blue Cross of Washington

PolicyPsychiatric and Other Specified Evaluations for Behavioral Health Treatment

Policy CodePolicy 3.01.521

Change TypeModified

Effective DateNovember 16, 2026

Last ReviewSep 8, 2026

Next Review DateN/A

Key ActionApply InterQual criteria together with this policy when reviewing inpatient, residential, or PHP treatment.

SourceLink

POLICY UPDATE CHANGES

The policy title was expanded to include partial hospital program behavioral health treatment, and PHP evaluation criteria were added for psychiatric, substance use disorder, and eating disorder services.

The terminology for detoxification was changed to withdrawal management (detoxification).

For residential mental health and eating disorder treatment, the initial psychiatric evaluation may be completed within two calendar days after admission.

Subsequent residential psychiatric evaluations for mental health and eating disorder treatment may occur at least once every 10 days rather than being limited to a once-weekly interval.

Subsequent nutritional assessments by a registered dietitian during residential eating disorder treatment may occur at least once every 10 days rather than being stated as once every seven days.

The effective date was changed from October 9, 2026, to November 16, 2026.

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ModifiedPremera Blue Cross of WashingtonPolicy 3.01.521

Psychiatric and Other Specified Evaluations for Behavioral Health Treatment

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Sign up for premerabluecrossofwashington Policy 3.01.521 alerts

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Policy Summary

PayerPremera Blue Cross of Washington

PolicyPsychiatric and Other Specified Evaluations for Behavioral Health Treatment

Policy CodePolicy 3.01.521

Change TypeModified

Effective DateNovember 16, 2026

Last ReviewSep 8, 2026

Next Review DateN/A

Key ActionApply InterQual criteria together with this policy when reviewing inpatient, residential, or PHP treatment.

SourceLink

POLICY UPDATE CHANGES

The terminology for detoxification was changed to withdrawal management (detoxification).

For residential mental health and eating disorder treatment, the initial psychiatric evaluation may be completed within two calendar days after admission.

Subsequent residential psychiatric evaluations for mental health and eating disorder treatment may occur at least once every 10 days rather than being limited to a once-weekly interval.

Subsequent nutritional assessments by a registered dietitian during residential eating disorder treatment may occur at least once every 10 days rather than being stated as once every seven days.

The effective date was changed from October 9, 2026, to November 16, 2026.

3Treatment levels addressed

24 hoursInitial inpatient evaluation window

7 daysStandard recurring evaluation interval

10 daysPermitted recurring interval

DailyInpatient follow-up frequency

Behavioral Health Coverage Criteria

Inpatient mental health and eating disorder treatment

In addition to other InterQual criteria, inpatient mental health and eating disorder treatment is medically necessary when all applicable evaluation requirements are met.

Inpatient mental health and eating disorder evaluation requirements: A psychiatric evaluation is completed within 1 day after admission and at least daily thereafter by an eligible provider. A medical history and physical examination is completed within 1 day after admission, or in an emergency department or hospital medical unit before direct transfer.Initial psychiatric and medical evaluations within 1 day; psychiatric evaluation at least daily

Eligible psychiatric providers include a psychiatrist, psychiatric nurse practitioner, psychiatric physician assistant, qualifying licensed clinical psychologist, or physician, nurse practitioner, or physician assistant specializing in eating disorder treatment. For inpatient mental health treatment on a medical unit or in an emergency department while awaiting a psychiatric bed, a non-psychiatric physician, nurse practitioner, or physician assistant may qualify when daily consultation or daily evaluation by a master's-level, doctoral-level, or licensed mental health clinician is documented.

Inpatient substance use disorder treatment

In addition to other InterQual criteria, inpatient substance use disorder treatment is medically necessary when all applicable evaluation requirements are met.

Inpatient substance use disorder evaluation requirements: A psychiatric evaluation is completed within 1 day after admission and at least daily thereafter by an eligible provider. A medical history and physical examination is completed within 1 day after admission, or in an emergency department or hospital inpatient medical unit before direct transfer.Initial psychiatric and medical evaluations within 1 day; psychiatric evaluation at least daily

Substance use disorder inpatient rehabilitation

In addition to other InterQual criteria, substance use disorder inpatient rehabilitation is medically necessary when the following requirement is met.

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.Within 1 day before or after admission

This requirement applies in addition to other InterQual criteria.

Residential mental health and eating disorder treatment

In addition to other InterQual criteria, residential mental health and residential eating disorder treatment are medically necessary when all applicable requirements are met.

Residential psychiatric evaluation requirements: An initial psychiatric evaluation by a licensed clinical practitioner is completed within 1 business day of admission, within 2 calendar days after admission, or within 3 calendar days before direct transfer from appropriate inpatient or PHP treatment in the same facility. A psychiatric or psychiatric-medication evaluation by a licensed clinical practitioner is then completed at least once every 7 days, with a permitted exception allowing an interval of at least once every 10 days.Initial evaluation: within 1 business day, within 2 calendar days, or within 3 calendar days before qualifying same-facility transfer; recurring evaluation: every 7 days, permitted exception every 10 days

Evaluations must be additional to nursing, psychosocial or biopsychosocial, substance-use, nutritional, daily clinical, therapy, and other assessments or treatment activities. For eating disorder treatment, psychiatric evaluations must also be additional to nutritional assessments.

Residential substance use disorder treatment

In addition to other InterQual criteria, substance use disorder residential treatment is medically necessary when all applicable requirements are met.

Residential substance use disorder evaluation requirements: A psychiatric evaluation by a licensed clinical practitioner is completed within 7 days after admission, or within 3 calendar days before direct transfer from inpatient or residential/subacute withdrawal management in the same facility.Within 7 days after admission or within 3 calendar days before qualifying same-facility transfer

The psychiatric evaluation must be additional to nursing, psychosocial or biopsychosocial, substance-use, ASAM dimension, daily clinical, therapy, and other assessments or treatment activities.

Inpatient withdrawal management

In addition to other InterQual criteria, inpatient withdrawal management is medically necessary when all applicable requirements are met.

Withdrawal management evaluation requirements: A medical history and physical examination 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. Thereafter, a psychiatric evaluation or a medical evaluation that includes an assessment of withdrawal status and management is completed at least daily by an eligible provider.Medical and psychiatric evaluations within 1 day; daily follow-up evaluation

Eligible follow-up providers include a psychiatrist, psychiatric nurse practitioner, psychiatric physician assistant, qualifying licensed clinical psychologist, or physician, nurse practitioner, or physician assistant specializing in addiction medicine.

Residential eating disorder nutritional assessments

In addition to other InterQual criteria, eating disorder residential treatment is medically necessary when either nutritional-assessment pathway is met.

Nutritional assessment pathway

Treatment-staff pathway: Treatment staff complete a nutritional assessment daily during eating disorder residential treatment.Daily
Registered dietitian pathway: A registered dietitian completes a nutritional assessment within 2 days of admission and then at least once every 7 days, with a permitted exception allowing an interval of at least once every 10 days.Initial assessment within 2 days; recurring assessment every 7 days, permitted exception every 10 days

Mental health and eating disorder PHP psychiatric evaluations

In addition to other InterQual criteria, mental health and eating disorder PHP treatment is medically necessary when all applicable requirements are met.

Mental health and eating disorder PHP psychiatric evaluation requirements: A psychiatric or psychiatric-medication evaluation by a licensed clinical practitioner is completed within the first 7 calendar days of program treatment and then at least once every 7 days, with a permitted exception allowing an interval of at least once every 10 days.Initial evaluation within 7 calendar days; recurring evaluation every 7 days, permitted exception every 10 days

Evaluations must be additional to nursing, psychosocial or biopsychosocial, substance-use, nutritional, daily clinical, therapy, program-activity, and other evaluations or treatment activities. Registered or certified clinicians without the required license do not satisfy the licensed-clinical-practitioner requirement.

Substance use disorder PHP psychiatric and substance-use evaluations

In addition to other InterQual criteria, substance use disorder PHP treatment is medically necessary when all applicable requirements are met.

Substance use disorder PHP evaluation requirements

Psychiatric evaluation: A psychiatric or psychiatric-medication evaluation by a licensed clinical practitioner is completed within the first 7 calendar days of treatment.Within the first 7 calendar days
Substance-use evaluation: A substance-use evaluation is completed on admission, within 1 program day after admission, or within 3 calendar days before qualifying same-facility direct transfer, and is then completed at least once every 7 days, with a permitted exception allowing an interval of at least once every 10 days.On admission, within 1 program day, or within 3 calendar days before qualifying transfer; recurring evaluation every 7 days, permitted exception every 10 days
The substance-use evaluation may be performed by a licensed clinical practitioner, licensed or certified substance use disorder professional, or certified alcohol and drug counselor. An ASAM dimension assessment may serve as the substance-use evaluation.

Eating disorder PHP nutritional assessments

In addition to other InterQual criteria, eating disorder PHP treatment is medically necessary when the nutritional-assessment requirement is met.

Eating disorder PHP nutritional assessment requirements: A dietitian completes a nutritional assessment within the first 7 calendar days of treatment and then at least once every 7 days, with a permitted exception allowing an interval of at least once every 10 days.Initial assessment within 7 calendar days; recurring assessment every 7 days, permitted exception every 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 addressed under this policy. Refer to policy 3.01.515, Behavioral Health: Residential/Sub-Acute Withdrawal Management (Detoxification), which specifies the clinician types required to conduct the evaluations.

Wilderness therapy and Outdoor Behavioral Healthcare Residential Wilderness programs are not addressed under this policy. Refer to policy 3.01.522, Wilderness Therapy/Outdoor Behavioral Healthcare Residential Wilderness Programs, which specifies the clinician types required to conduct the evaluations.

Coding Information

Codingmixed

N/A	No procedure, diagnosis, or billing codes specified

Documentation and Provider Requirements

Documentation Required

Apply InterQual Plus This Policy

Apply the applicable InterQual criteria together with this policy. This policy adds supplemental requirements for the provider type, timing, and documentation of psychiatric, medical, substance-use, and nutritional evaluations; meeting this policy alone does not replace other InterQual medical-necessity criteria.

Documentation Required

Use Dated Evaluation Documentation

Document each required evaluation as a dated evaluation performed on the applicable date by the required qualifying clinician. Weekly or periodic summaries of a member’s clinical status do not substitute for the required evaluation documented on a specific date.

For residential mental health, eating disorder, and substance use disorder treatment, document the initial evaluation within the required admission or direct-transfer timeframe and subsequent evaluations at least every 7 days, with no interval longer than 10 days when the policy exception applies.
For PHP treatment, document evaluations within the first 7 calendar days and subsequently at least every 7 days, with no interval longer than 10 days when the policy exception applies.

Purpose of Required Evaluations

Psychiatric evaluations support diagnosis, determine the appropriate treatment, assess the effects of medication, and guide treatment adjustments across behavioral health levels of care. These evaluations must be distinct from routine nursing, therapy, clinical-review, and other treatment activities so that an appropriately qualified clinician performs the required psychiatric assessment.

Key Definitions

Once every week

Standard intervalAt least once every 7 days

Permitted exceptionAt least once every 10 days when the policy exception applies

Minimum frequencyEvaluations may not occur less frequently than once every 10 days

First week and program-day timing

First weekWithin the first 7 calendar days starting with the day of admission

On admissionDuring the first day in the treatment program

Within one program day after admission

Treatment Levels Addressed

Evaluation Frequency and Timing

Psychiatric evaluation; withdrawal management may use a qualifying daily medical evaluation

Initial evaluationComplete the initial psychiatric evaluation within 1 day after admission

Ongoing frequencyAt least once every day after the initial evaluation

Withdrawal management alternativeFor withdrawal management, a psychiatric evaluation or a medical evaluation that includes withdrawal-status and management assessment may be completed daily

Psychiatric or psychiatric-medication evaluation

Applicable settingResidential treatment

Standard frequencyAt least once every 7 days

Policy Summary

PayerPremera Blue Cross of Washington

PolicyPsychiatric and Other Specified Evaluations for Behavioral Health Treatment

Policy CodePolicy 3.01.521

Change TypeModified

Effective DateNovember 16, 2026

Last ReviewSep 8, 2026

Next Review DateN/A

Key ActionApply InterQual criteria together with this policy when reviewing inpatient, residential, or PHP treatment.

SourceLink

On This Page

Identify the clinician who performed each evaluation and retain documentation supporting the required licensure or certification.

Documentation Required

Document Admission and Transfer Timing

Record the admission date, evaluation date, clinician type, and applicable transfer details so the evaluation can be verified against the policy’s timing requirements. Evaluations completed before admission are acceptable only where expressly permitted, including qualifying evaluations completed before a direct transfer in the same facility.

For inpatient psychiatric evaluations, document completion within one day after admission and then at least daily, as applicable to the service.
For residential treatment, document completion within one business day or the permitted calendar-day window after admission, or within the permitted period before a direct transfer, followed by periodic evaluations.
For required medical histories and physical examinations, document completion within one day after admission or, when permitted, in the emergency department or inpatient medical unit before direct transfer.
For substance-use PHP treatment, document the admission or first-program-day timing and any qualifying evaluation completed before a direct transfer.

Documentation Required

Maintain Nutritional Assessment Records

For eating disorder treatment, retain a true nutritional assessment—not merely meal-related observation or intake charting. The policy distinguishes nutritional assessments from documentation of food or fluid choices, intake, or behavior during meals and snacks.

Residential treatment: document the applicable daily treatment-staff assessment or the Registered Dietitian assessment within two days of admission and at least weekly thereafter, subject to the permitted 10-day exception.
PHP treatment: document a dietician nutritional assessment within the first 7 calendar days and at least weekly thereafter, subject to the permitted 10-day exception.
Food and fluid observation, choices, intake records, and meal or snack behavior charting do not constitute nutritional assessments.

Documentation Required

Periodic Clinical Reviews Do Not Replace Evaluations

Do not use Clinical Reviews, Clinical Updates, Concurrent Reviews, Utilization Reviews, Progress Reviews, or similar periodic documents as substitutes for required psychiatric or psychiatric medication evaluations in residential treatment. Retain the underlying evaluation documented for its specific date.

A periodic clinical review may summarize a week or other treatment period, but it is not itself a dated psychiatric or psychiatric medication evaluation.
The evaluation record must show that the required clinical service occurred on the documented date and identify the evaluating clinician.

Documentation Required

Document Evaluations Separately

Document psychiatric evaluations separately from nursing assessments, psychosocial or biopsychosocial assessments, substance-use or ASAM dimension assessments, daily clinical assessments, and other required evaluations. A psychiatric evaluation must also be performed in addition to—not as a substitute for—therapy sessions or other treatment activities.

For residential mental health and eating disorder treatment, psychiatric evaluations must be separate from nursing, psychosocial, substance-use, and nutritional assessments, as applicable.
For substance-use disorder treatment and PHP services, document psychiatric and substance-use evaluations separately unless the policy expressly permits an ASAM dimension assessment to serve as the substance-use evaluation.
Keep separate documentation for each required evaluation and service so reviewers can verify that each requirement was met.

Denial Risk

Incomplete Evaluation Documentation Risks Non-Coverage

Failure to complete a required evaluation, failure to complete it within the specified timing window, or failure to document the required clinician and service separately may mean the treatment does not meet the policy’s medical-necessity criteria, even if other clinical records are present.

Verify every required initial, daily, weekly, nutritional, medical, psychiatric, and substance-use evaluation against the applicable service requirements.
Do not rely on undated summaries, incomplete clinician identification, or documentation of another service to establish that a required evaluation occurred.
Apply this policy in addition to all other applicable InterQual criteria.

Denial Risk

Verify Required Licensure

Registered or certified status does not equal licensure. A registered or certified clinician who is not a licensed clinical practitioner does not satisfy a requirement that a psychiatric or psychiatric medication evaluation be performed by a licensed clinical practitioner.

Identify the evaluator’s license and qualifying provider type in the record.
Do not treat registration or certification alone as evidence that the clinician meets a specified licensed-clinical-practitioner requirement.
For substance-use evaluations, use only the clinician types expressly allowed for that service.

Documentation Required

Perform Evaluations in Addition to Other Services

Perform and document each required evaluation in addition to other clinical services and their documentation. Therapy, treatment-program activities, nursing or daily clinical assessments, psychosocial or substance-use assessments, ASAM assessments, and nutritional assessments do not replace a separately required psychiatric, psychiatric medication, medical, or substance-use evaluation unless the policy expressly states otherwise.

Schedule the required evaluation as a distinct clinical service, not merely as part of an individual, group, or family therapy session or treatment activity.
For residential eating disorder treatment, perform psychiatric evaluations in addition to nutritional assessments.
For substance-use PHP treatment, document psychiatric evaluations separately from substance-use evaluations; ASAM dimension assessments may serve as substance-use evaluations only where expressly permitted.

On the second day in the treatment program

Licensed clinical practitioner

Required statusThe evaluating clinician must be a licensed clinical practitioner when the policy requires one

Registration or certificationRegistration or certification does not establish licensure

Registered or certified cliniciansRegistered and certified clinicians are not licensed clinical practitioners unless they independently hold the required license

At least once every 10 days, and not less frequently than once every 10 days

Psychiatric, psychiatric-medication, or substance-use evaluation

Applicable settingPartial hospital program treatment

Standard frequencyAt least once every 7 days

Permitted exceptionAt least once every 10 days, and not less frequently than once every 10 days

Nutritional assessment

Applicable settingEating disorder residential or partial hospital program treatment

Standard frequencyAt least once every 7 days

Permitted exceptionAt least once every 10 days, and not less frequently than once every 10 days