Prior Authorization Request (Art Therapy)

Patient Name: [Full name]

Date of Birth: [MM/DD/YYYY]

Member ID: [Alphanumeric / Pending]

Plan Name/Type: [Plan name and product line]

Date of Request: [MM/DD/YYYY]

Request Type: [Initial / Re-authorization / Retroactive]

Review Urgency: [Standard / Expedited] (If expedited, include concise clinical justification supporting urgent review.)

Requested Authorization Period: [Start date – End date]

Rendering Provider: [Name, credentials, NPI, license number/state]

Ordering/Referring Provider: [Name and NPI] (Include only if payer requires.)

Contact for UM Follow-up: [Phone, fax, or secure email]

Request Summary

[Concise 3–6 line summary including: service type and modality, frequency and session duration, total units/visits requested and timeframe, primary diagnosis with ICD-10 code, primary functional impairments, and brief rationale for why outpatient art therapy is indicated at this time.]

Requested Services

Setting/Level: [Outpatient office / Community clinic / School-based / Telehealth]

Service Type: [Individual / Group / Family]

Session Duration: [Minutes per session]

Frequency: [Sessions per week or month]

Total Units Requested: [Total sessions or units]

Authorization Period: [Start date – End date]

CPT/HCPCS Code(s): [List codes if known / Payer-specific coding to be applied]

Unit Calculation: [Minutes/session] × [Sessions per week] × [Number of weeks] = [Total sessions]

[Brief paragraph linking requested intensity to current symptom severity, functional impairment, treatment phase, and time-limited goals.]

Diagnoses and Clinical Summary

Primary Diagnosis (ICD-10): [Code – diagnosis name with specifiers and severity]

Secondary Behavioral Health Diagnoses: [Codes and names] (Include only if they impact treatment.)

Relevant Medical Conditions: [Conditions] (Include only if they affect treatment delivery or outcomes.)

Provisional/Rule-Out Diagnoses: [Diagnosis with clinical basis and plan to confirm] (If applicable.)

Presenting Problems: [Symptom clusters with frequency, intensity, duration, onset; recent changes or triggers informing timing of care.]

Standardized Measures at Baseline: [Measure name, score, date] (Include when available.)

Functional Impairment: [Concrete, behaviorally anchored impacts with quantification: school/work attendance, ADLs, relationships, sleep/appetite/energy, community participation. Include specific counts such as missed days, panic episodes per week, or task completion difficulties.]

Clinical Formulation: [5–10 line synthesis of how symptoms relate to diagnosis; why art therapy is indicated for this patient; and why outpatient level of care is appropriate versus less or more intensive options.]

Medical Necessity Rationale

(Use explicit "because" statements throughout this section.)

Why treatment is needed now: [Current symptom burden, recent escalation or trigger, deterioration or plateau risk without care.]

Why art therapy specifically: [Barriers to talk therapy alone such as alexithymia, avoidance, developmental limitations, or trauma disclosure barriers; evidence-informed rationale for creative arts in this condition/population; prior positive response or clinical indicators for nonverbal/experiential modalities.]

Why this frequency and duration: [Link to symptom severity, treatment phase, and measurable goals. If group or family format requested, include clinical indication.]

Why lower level of care is insufficient: [Specific gaps, risks, or functional needs that would not be met without requested services.]

Prior treatment history and response: [Prior psychotherapy, IOP/PHP, medication trials and outcomes; current medications and prescriber; engagement/adherence factors. If records unavailable, note patient-reported history.]

Risk and Safety

(If no significant risk factors are present, include only a brief statement that risk was assessed and no acute safety concerns were identified. Otherwise include the following fields.)

Current Risk Level: [None / Low / Moderate / High]

Key Acute Risk Factors: [Suicidal ideation/behavior, self-harm, homicidal ideation, abuse/neglect concerns, severe substance use, inability for self-care, recent crises.]

Protective Factors: [Supports, coping skills, reasons for living, engagement in care.]

Safety Plan and Crisis Resources: [Safety plan elements, monitoring approach, crisis contacts.]

Appropriateness of Outpatient Care: [If moderate risk, explain why outpatient art therapy remains safe and appropriate. If high risk, document escalation pathway rather than requesting routine outpatient units.]

Expedited Review Justification: [Brief rationale linking risk to need for expedited authorization.] (If applicable.)

Treatment Plan for Authorization Period

Target Problem 1: [Problem description with associated symptoms, impairment, and risk relevance]

• Goal: [Broad outcome goal]
• Objective(s): [1–2 measurable, time-bound objectives with specific targets such as symptom score change, functional attendance thresholds, or skill demonstration criteria.]

Target Problem 2: [Problem description] (If applicable.)

• Goal: [Broad outcome goal]
• Objective(s): [Measurable objectives]

Target Problem 3: [Problem description] (If applicable.)

• Goal: [Broad outcome goal]
• Objective(s): [Measurable objectives]

Planned Interventions: [Art therapy methods such as structured directives, trauma-informed artmaking, imagery work, narrative integration, mindfulness-based art therapy; skills to be taught; family/group components if applicable.]

Monitoring Approach: [Standardized measures to be used; assessment cadence; how results will guide frequency/intensity adjustments.]

Coordination of Care: [Involvement of PCP, psychiatry, school, or other providers; releases of information status; referral plans for unmet needs.] (If applicable.)

Discharge Criteria and Transition Plan: [Objective improvement thresholds, functional restoration, risk stabilization; step-down plan, linkage to community resources.]

Expected Outcomes

Outcome Domain	Baseline	Target	Measurement Method	Timeframe
[Symptom reduction]	[Score and date]	[Target score or % change]	[PHQ-9 / GAD-7 / PCL-5 / other]	[Within authorization period]
[Functional outcome]	[Current frequency/level]	[Target frequency/level]	[Attendance record / caregiver report / ADL checklist]	[Within authorization period]
[Behavioral regulation]	[Current incidents per week/month]	[Reduced incidents / skill demonstration criteria]	[Behavior logs / session-based demonstrations]	[Within authorization period]
[Safety] (If applicable.)	[Current risk indicators]	[Target reduction / no acute risk]	[Risk screenings / safety plan adherence]	[Within authorization period]

Attachments

• [Intake/diagnostic assessment summary – date]
• [Prior treatment plan or progress summary – date] (Not psychotherapy notes.)
• [Standardized measure score sheets – dates]
• [Risk assessment or safety plan summary – date] (If relevant.)
• [Referral letter or physician order – date] (If payer requires.)

(Patient artwork is not included. Attach only if explicitly required by payer with proper consent and de-identification.)

Provider Attestation

I attest that this prior authorization request contains a clinical summary for coverage determination purposes and does not include psychotherapy notes, session process content, or patient artwork. The information provided is accurate to the best of my knowledge and reflects my professional judgment.

Clinician Signature: [Electronic/handwritten signature]

Name, Credentials, License #/State: [Provider information]

Date: [MM/DD/YYYY]

(If documentation was assisted by a scribe or technology, note that the clinician reviewed and authenticated the content.)

(Meta-instructions: Omit fields that are not applicable rather than including placeholder text, except required administrative identifiers where "Pending" may be used. Do not infer diagnoses solely to meet coverage criteria; include only clinically supported information. Ensure consistency across sections so that diagnosis, symptoms, impairment, risk, goals, and requested frequency align throughout the document.)