Documentation and clinical criteria required to support authorization requests for specific services.
Complete all member, submitter, and provider sections on the prior authorization form (member demographics, PCP, current primary and secondary DSM-5 diagnoses and codes, facility NPIs/TINs, attending physician for inpatient).
Only include medically necessary documentation and follow HIPAA guidelines; limit additional faxed documentation to 4–8 pages; do not fax extraneous or old chart documentation.
Include current attending psychiatrist's notes and current medication list when applicable.
INPATIENT (mental health): For inpatient mental health hospitalization include admission date, voluntary/involuntary status, court orders if applicable, date of next court hearing, and ensure a follow-up appointment is scheduled within 7 days post-discharge.
PSYCHOLOGICAL TESTING: Provide diagnoses and neurological/cognitive condition (suspected or demonstrated), description of presenting symptoms and impairment, member and family psychological/medical history, documentation that medications/substance use have been ruled out as contributing factors, tests to be administered with number of hours and visits requested, any past testing results, and how results will affect the treatment plan.
ECT (Electroconvulsive Therapy): Document acute symptoms warranting ECT, ECT indications (refractory to medication or contraindication), informed consent, personal and family medical and psychiatric history, medication review, review of systems and baseline vitals, anesthesia evaluation, ECT-privileged psychiatrist evaluation (update within last month for continuation), any additional workups for medical complications, and documentation of response for continuation/maintenance.
ASAM / SUD-specific: Submit a completed ASAM assessment addressing all dimensions, including MAT considerations, urine drug screen/BAL, withdrawal symptoms/vitals, seizure history, CIWA/COWS scores as applicable; if assessment is over 2 weeks old, redo the assessment (if within 2 weeks but not current, send assessment plus brief updates or addendum).
OUT-OF-NETWORK OUTPATIENT: Provide rationale for out-of-network use, known or provisional diagnosis and current symptoms, barriers to in-network care, treatment plan and discharge supports; document that out-of-network outpatient services are covered per benefits as applicable.
KING COUNTY FIELD: King County only: indicate if member-delegated SMI/SED status applies.
PROCEDURAL/CLAIM CODING: Ensure the procedure code matches the requested level of care (map ASAM levels to procedure codes where indicated) and include CLIP/notification codes when required.
COURT ORDERS / SBC: If court-ordered (involuntary care or single-bed certification), fax the court order and related documentation to the specified court-order fax number and attach progress/results on placement in a psychiatric unit and date of next court hearing.