CurrentUnitedHealthcarePolicy N/A

Behavioral health prior authorization form for Washington Apple Health

This document provides the UnitedHealthcare Community Plan prior authorization form and instructions for behavioral health services for Washington Apple Health members; it governs what information providers must submit (including clinical documentation and ASAM assessments) to request authorization. It applies to providers submitting authorizations for Washington Apple Health through UnitedHealthcare Community Plan.

Policy Summary

PayerUnitedHealthcare

PolicyBehavioral health prior authorization form for Washington Apple Health

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form, include only medically necessary documentation (limit 4-8 pages), and fax to 844-747-9828.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4-8 pagesrecommended maximum additional documentation to fax

844-747-9828fax number to send completed form

6ASAM dimensions documented (1-6)

Jan. 15, 2021effective date noted in this section

Authorization and Assessment Criteria

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Authorization documentation criteria

Clinical content and criteria to include with authorization requests.

Complete all required member, submitter, provider, and service location fields on the prior authorization form.

For inpatient requests include attending physician name and phone; provide follow-up appointment date/time within 7 days of discharge.

Only include medically necessary documentation; follow HIPAA guidelines; limit additional faxed documentation to 4-8 pages.

Include with the request the current attending psychiatrist's notes and current medication list, current primary and secondary DSM-5 diagnoses (name and code).

Provide clinical details: active medical conditions; precipitant/circumstances that led to admission; additional event details; whether substance use contributed and details if yes; current acute symptoms; psychosocial stressors and functional impairments; current living situation (including household and supports); barriers/issues related to medication regimen; current treatment interventions; planned discharge level of care and barriers to discharge; outpatient providers (prescriber, case manager, and/or therapist).

If requesting specific services include the following as applicable:

Psychological testing requests: provide diagnoses/neuro conditions or cognitive impairment, description of presenting symptoms and impairment, member and family psych/medical history, tests to be administered with number of hours and visits requested, prior psych testing results, and the clinical question the testing will answer.
ECT requests: document acute symptoms warranting ECT, indications (refractory or contraindication to medication), informed consent, updated personal and family medical and psychiatric history, medication review, review of systems and baseline BP, evaluation by anesthesia provider, evaluation by ECT-privileged psychiatrist (update within last month for continuation), any additional workups for medical complications, and documentation of positive response when requesting continuation/maintenance per benefit coverage.
Out-of-network outpatient: include rationale for using out-of-network provider, known or provisional diagnosis and current symptoms, known barriers to treatment, treatment plan including estimated length of care and discharge plan, and additional supports needed to implement the discharge plan.

For SUD-related requests submit a completed ASAM assessment (address all ASAM dimensions and MAT considerations); if the ASAM assessment is over 2 weeks old, redo it; if within 2 weeks but not current, submit it with brief updates or an addendum; if it cannot be completed due to the member's condition, provide explanation and consider calling for authorization.

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ASAM assessment documentation requirements

Required ASAM assessment elements to be provided with authorization requests include the following dimension-specific items and assessor ratings.

Follow HIPAA; include only medically necessary documentation; limit extra documentation to 4-8 pages.

Address Medication Assisted Treatment (MAT) considerations and indicate whether the member is currently on MAT and whether continuing or initiating MAT is contraindicated.

If unable to complete the ASAM assessment because of the member's condition, include an explanation; consider calling for authorization instead.

If the ASAM assessment is over 2 weeks old, redo the assessment; if within 2 weeks but not current, submit the assessment with brief updates or an addendum.

Dimension 1 (Acute intoxication or withdrawal potential): Document substance use history (substance/amount/frequency/route/first use/last use), urine drug screen, blood alcohol level, current withdrawal symptoms and vitals, history of seizures/blackouts/DTs, supporting assessment scores (CIWA or COWS), and assessor ASAM rating for dimension 1.

Submission Instructions and Required Clinical Documentation

Documentation Required

ASAM Dimension 2 assessment — Biomedical conditions and complications

Complete an ASAM Dimension 2 assessment (Biomedical conditions and complications). Document current medical issues and diagnoses, relevant past medical history, active medical conditions, recent vital signs or laboratory abnormalities that impact treatment, current acute medical symptoms, and any medical complications requiring monitoring or specialty consultation.

List current primary and secondary medical diagnoses
Include comorbid chronic conditions (e.g., diabetes, hepatitis, HIV) and acute medical problems
Note any recent hospitalizations, surgeries, or emergency visits relevant to current presentation
Describe medical monitoring needs (e.g., cardiac monitoring, wound care) and any required medical consultations

Documentation Required

Dimension 2 — additional required fields

Provide the Dimension 2 additional fields: include the member’s PCP, complete home medication list, current medications including detox/withdrawal protocols or MAT (medication-assisted treatment) details, and the assessor’s ASAM rating for Dimension 2.

PCP name and contact
Home medications (pre-admission) — include doses and frequencies or attach med list
Current medications and any detox protocol or MAT details (agents, doses, start date)
Assessor’s ASAM rating for Dimension 2 with brief rationale

Documentation Required

ASAM Dimension 3 assessment — Emotional, behavioral or cognitive conditions

Document ASAM Dimension 3 elements: mental health diagnoses, current psychiatric symptoms, outpatient mental health provider(s), cognitive or behavioral concerns, history of trauma/abuse or risk factors, current mental status exam findings, and medication adherence issues. Include the assessor’s ASAM rating for Dimension 3 with rationale.

Current DSM-5 primary and secondary mental health diagnoses with codes
Outpatient mental health provider(s) and contact information
Home and current psychiatric medications (include PRN)
Relevant history (abuse, trauma, suicidality, violence, noncompliance) and current mental status exam findings
Assessor ASAM rating for Dimension 3 and clinical justification

Documentation Required

ASAM Dimension 4 assessment — Readiness to change

Assess and record readiness to change (ASAM Dimension 4). State the member’s stage of change, observable evidence supporting that stage, internal and external motivators (legal, family, employer, DCFS, etc.), and any barriers to engagement. Provide the assessor’s ASAM rating for Dimension 4 with supporting comments.

Stage of change (e.g., precontemplation, contemplation, preparation, action, maintenance) and evidence (self-report, behavior)
Internal motivators (personal goals) and external motivators (legal, family, employment) — explain why now/precipitant
Barriers to readiness (denial, ambivalence, lack of supports)
Assessor ASAM rating for Dimension 4 and brief rationale

Documentation Required

ASAM Dimension 5 assessment — Relapse potential

Document relapse potential (ASAM Dimension 5). Describe identified triggers, severity of relapse risk, relapse prevention skills demonstrated or in progress during treatment, and the member’s treatment history including prior levels of care, facilities, and dates. State the longest period of sobriety outside a structured environment and provide the assessor’s ASAM rating for Dimension 5.

Relapse potential assessment and factors increasing risk
Specific triggers identified (people, places, emotions, situations)
Relapse prevention skills and progress made during current treatment
Treatment history: prior levels of care, facilities, and dates
Longest period of sobriety outside structured environment
Assessor ASAM rating for Dimension 5 with rationale

Documentation Required

ASAM Dimension 6 assessment — Recovery and living environment

Assess recovery and living environment (ASAM Dimension 6). Document current living situation, household members, safety concerns, availability of sober supports, family history of mental health or substance use disorders, and community resources/supports. Provide the assessor’s ASAM rating for Dimension 6 and how the environment affects discharge planning and level-of-care decisions.

Current living situation (address, who they live with, stability)
Sober supports (family, peers, recovery groups) and engagement level
Family history of mental health/substance abuse
Environmental risks (homelessness, unsafe housing, exposure to substances)
Assessor ASAM rating for Dimension 6 and implications for treatment/discharge planning

Terms and ASAM Dimension Definitions

ASAM assessment

DefinitionAn ASAM assessment documents multidimensional needs related to substance use disorder and must succinctly address all six ASAM dimensions or use an ASAM checklist

PHI and relevanceOnly include medically necessary documentation; follow HIPAA and do not fax extraneous/old chart documentation

TimelinessIf assessment is over 2 weeks old, redo; if within 2 weeks include updated dimension sections or an addendum

Electroconvulsive therapy (ECT) requirements

IndicationAcute symptoms that warrant ECT (e.g., specific symptoms of depression, acute mania, psychosis)

Informed consentInformed consent from patient/guardian is required for both acute and continuation ECT

Clinical evaluationsEvaluation by an anesthesia provider and evaluation by an ECT‑privileged psychiatrist (update within last month for continuation) are required

Documentation for continuation/maintenanceDocument medical/psychiatric history updates, medication review, review of systems and baseline BP, any additional workups, and evidence of positive response to acute/short‑term ECT to justify continuation/maintenance

ASAM Dimension 2 — Biomedical conditions and complications

DefinitionASAM Dimension 2 — Biomedical conditions and complications: document medical issues and diagnoses relevant to level of care planning

PurposeIdentify acute or chronic medical problems that affect treatment needs and safety

Link to assessmentInclude Dimension 2 information as part of the completed ASAM assessment submitted with authorization requests

ASAM Dimension 3 — Emotional, behavioral or cognitive conditions

DefinitionASAM Dimension 3 — Emotional, behavioral or cognitive conditions and complications: document mental health diagnoses and relevant behavioral information

Required detailsInclude mental health diagnosis, outpatient mental health provider, home and current medications, and current mental status or risk factors

ASAM Dimension 4 — Readiness to change

DefinitionASAM Dimension 4 — Readiness to change: documents the member's stage of change and motivators for treatment

Required detailsInclude stage of change evidence and internal/external motivators (legal, family, DCFS, employer, precipitant)

ASAM Dimension 5 — Relapse potential

DefinitionASAM Dimension 5 — Relapse, continued use or continued problem potential: documents relapse potential and related history

Required detailsInclude identified triggers, relapse prevention skills/progress, treatment history (levels of care, facility, dates), and longest period of sobriety outside structured environment

ASAM Dimension 6 — Recovery and living environment

DefinitionASAM Dimension 6 — Recovery and living environment: documents living situation and supports that affect recovery

Required detailsInclude living situation, sober supports, and family history of mental health/substance abuse

OpenPayer

Behavioral health prior authorization form for Washington Apple Health

Authorization and Assessment Criteria

Procedure Codes and Documentation Limits

Submission Instructions and Required Clinical Documentation

Terms and ASAM Dimension Definitions