Prior Authorization Request (Behavioral Health Services)

Administrative and Request Information

• Request Type: [initial / continuation] — [standard / urgent-expedited]
• Requested Start Date: [date]
• Authorization Period: [start date – end date or total units/visits requested] (State total authorized hours/week for program-level requests.)
• Service Level and Setting: [outpatient / IOP / PHP / residential / inpatient] — [in-person / telehealth / hybrid] (Include program days/week and hours/day for IOP/PHP.)
• CPT/HCPCS Codes and Place of Service: [codes, units, POS] (Include modifiers if applicable.)
• Patient: Name: [full name] | DOB: [DOB] | Member ID: [ID] | Plan: [payer/plan name] (If Member ID pending, state reason and resolution plan.)
• Rendering Provider: Name: [name] | Credentials: [credentials] | NPI: [NPI] | Tax ID: [Tax ID] | Facility: [name] | Address: [address]
• UM Contact: Phone: [number] | Fax: [number] | Email: [email] | Peer-to-peer availability: [days/times and time zone] | Best callback times: [times]
• Referring Provider: [name, credentials, NPI, contact] (Only include if applicable.)
• Clinical Documentation Date Range: [dates of evaluation and most recent contact informing this request]

(Do not leave required fields blank. If any required payer element is unavailable, explicitly document why, current status, and plan/timeline to obtain.)

Executive Clinical Summary

[Concise narrative (5–10 sentences) covering in order: (1) primary diagnosis with ICD-10 code and presenting syndrome; (2) severity and trajectory; (3) key functional impairments across work/school, ADLs, relationships, housing; (4) current risk level for suicide/self-harm, violence, grave disability, or substance-related harm with brief supporting factors; (5) clinical rationale for requested level of care now and why lower intensity is insufficient; (6) what will be delivered including modality, frequency, duration, and hours/week if program-level; (7) measurable goals for this authorization period; (8) risk mitigation already in place including safety plan status and crisis supports] (Use objective, clinically focused language without boilerplate.)

Clinical Presentation and Diagnosis

• Chief Complaint: [one-line statement] (Use patient's words only if it clarifies clinical need.)
• Symptom Profile: [onset, duration, triggers, pattern, current severity; key symptoms supporting primary diagnosis] (Label any provisional diagnoses explicitly.)
• Diagnostic Formulation: Primary: [ICD-10 code – diagnosis] | Comorbid: [ICD-10 code – diagnosis(es)] (Include differential only if it impacts level-of-care selection.)
• Mental Status Examination:
  • Appearance/Behavior: [description]
  • Speech: [description]
  • Mood/Affect: [description]
  • Thought Process/Content: [description; include SI/HI/psychosis content if present]
  • Perception: [description]
  • Cognition: [orientation, attention, memory]
  • Insight/Judgment: [description]
• Standardized Measures:
  • [Measure name]: [score] ([date]) — [severity band]; Trend from baseline: [improved / stable / worsened]
  • (Repeat for each measure; if none administered, state how severity was assessed and why standardized scales were not used.)
• Co-occurring Conditions Affecting Risk or Treatment Intensity: [medical, psychiatric, SUD, neurodevelopmental conditions] (Include pregnancy status if relevant.)

Functional Impairment and Psychosocial Context

• Occupational/Educational: [attendance, productivity, disciplinary actions, accommodations, leave status]
• ADLs/IADLs: [hygiene, meals/nutrition, sleep, medication adherence, finances, transportation]
• Interpersonal/Family: [isolation, conflict, caregiving capacity, parenting concerns]
• Housing Stability: [stable / unstable / at risk]; [safety concerns in environment]
• Barriers to Care: [transportation, childcare, finances, technology, language]
• Support System: [who is available outside treatment hours and their reliability]
• Intensity Justification: [explicit linkage of functional impairment to requested level of care; why this intensity is required]

(If a domain was not assessed, state "Not assessed" with plan and timeline; consider time-limited authorization pending completion.)

Risk Assessment and Mitigation Plan

• Suicide/Self-Harm:
  • Ideation: [denied / passive / active]; Frequency: [frequency]
  • Plan: [none / vague / specific]; Intent: [denied / ambivalent / present]
  • Behaviors: [NSSI / preparatory acts / attempts]; Past attempts: [details, dates]
  • Lethal Means Access: [firearms / medications / other]; Status: [secured / removed / unknown]
  • Protective Factors: [factors] | Aggravating Factors: [factors]
• Violence/Homicide:
  • Ideation/Threats: [none / present]; Targets: [identified targets if any]
  • Access to Weapons: [yes / no / unknown]
  • History of Violence: [summary]
• Grave Disability:
  • Ability to Meet Basic Needs: [food, shelter, medical care]
  • Impact of Psychosis/Mania/Cognitive Disorder: [description]
• Substance-Related Risk:
  • Use Pattern: [substances, frequency, amount, last use]
  • Overdose/Intoxication Risk: [low / moderate / high] with rationale
  • Withdrawal Potential: [none / mild / moderate / severe]; Medical management needed: [yes / no]
• Overall Risk Level: [low / moderate / high] — [acute / chronic] (Provide concise justification tied to findings; distinguish passive ideation vs. active plan/intent.)
• Risk Mitigation Plan:
  • Safety Plan: [completed / reviewed / updated] on [date]; Patient has copy: [yes / no]; Key steps reviewed: [steps]
  • Means Safety: [specific steps taken—firearms secured, meds locked, sharps removed, etc.]
  • Crisis Resources: [988/911 and local crisis line provided; instructions reviewed]
  • Monitoring: [frequency of reassessment; scheduled check-ins]
  • Care Coordination: [communications with supports/PCP/psychiatry; consent status]
  • Escalation Criteria: [explicit indicators for ED referral or higher level of care]

(If risk could not be assessed, document reason and request provisional/time-limited authorization pending completion. Never infer low risk without documented assessment.)

Prior Treatment History and Response

• Levels of Care: [inpatient / residential / PHP / IOP / outpatient / ED] — [dates, outcomes] (List in reverse chronological order.)
• Medications: [names, doses, start/stop dates, adherence, adverse effects, response] (Include current and relevant past trials.)
• Psychotherapy Modalities: [type, duration, frequency, response]
• Engagement Barriers: [missed appointments, access issues, motivation, cultural/linguistic factors]
• Lower-Intensity Trials and Insufficiency: [what was tried and why it was inadequate for safety/functional recovery]

(For continuation requests: include attendance/compliance in current episode, response to date with updated measures and function, and updated risk trends.)

Medical Necessity and Level-of-Care Rationale

• Why Now: [precipitant and current acuity]
• Why This Level of Care: [link symptoms, functional impairment, and risk to required structure/intensity; include hours/week if program-level]
• Why Not a Lower Level: [specific deficits in safety/monitoring/skill acquisition that outpatient alone cannot address]
• Why Not a Higher Level: [patient can be managed safely; supports available; no imminent danger] (Include only if requesting non-24-hour care.)
• Expected Benefit: [functional improvement targets; relapse/hospitalization prevention]
• Time-Limited Need: [why requested duration is reasonable; what will change by end of period]
• Program Eligibility: [able to participate cognitively/emotionally; adequate supports outside program hours; not dangerous in program setting] (Include only for IOP/PHP requests.)

Treatment Plan

• Problem 1: [highest-priority problem, e.g., suicidality/acute risk]
  • Goal(s): [measurable goal with baseline → target and timeframe]
  • Interventions: [specific modalities/skills/coaching/medication strategies]
  • Frequency/Dose: [sessions per week, minutes per session; program hours/week if applicable]
  • Measurement: [standardized scales and/or behavioral anchors; reassessment cadence]
  • Target Date: [date or week number]
• Problem 2: [next priority problem]
  • Goal(s): [measurable goal]
  • Interventions: [specific interventions]
  • Frequency/Dose: [details]
  • Measurement: [details]
  • Target Date: [date]

(Add additional problem blocks as needed, prioritized by risk and severity.)

• Planned Services:
  • Individual Therapy: [modality] — [minutes] [x/week] — [in-person / telehealth]
  • Group Therapy: [type(s)] — [x/week]
  • Family/Collateral: [indicated / not indicated]; [frequency if indicated]
  • Medication Management: [prescriber type] — [cadence]; Monitoring: [labs/scales/side effects]
  • Case Management/Peer Support: [focus areas] (Only include if part of requested services.)
  • Total Program Intensity: [hours/day], [days/week], total [hours/week] (Only include for IOP/PHP.)
• Care Coordination: ROI status: [obtained / pending] for [parties]; Planned communications: [who, what, when]

Discharge and Step-Down Plan

• Anticipated Step-Down Level: [e.g., PHP → IOP → weekly outpatient]
• Discharge Criteria: [symptom thresholds, functional milestones, risk stabilization, adherence benchmarks]
• Relapse Prevention and Follow-Up: [skills plan, crisis plan review, scheduled follow-ups]
• Barriers to Discharge: [barriers]; Mitigation: [steps]

(For continuation requests: indicate progress toward discharge and remaining needs with timeframe.)

Attestation

Clinician Signature: [name, credentials, license state]

Date/Time: [date/time]

Attestation: "I attest that the information provided is accurate and reflects the patient's current clinical need. This disclosure is limited to information necessary for coverage determination and excludes psychotherapy process notes."

Peer-to-Peer Contact: [direct phone and availability]

(Include supervising physician signature and attestation if required by payer or service type.)

Conditional Addenda

Continuation/Concurrent Review Addendum

(Only include for continuation requests.)

• Services Delivered Since Last Authorization: [services with dates and doses]
• Attendance/Compliance: [attendance percentage; reasons for any misses]
• Clinical Response: [updated measures, functional status changes, risk trends]
• Revised Goals/Plan: [changes to plan; expected duration for remaining treatment]

Urgent/Expedited Request Addendum

(Only include if request type is urgent/expedited.)

• Serious Jeopardy Justification: [specific risk to health, safety, or function if standard timeframe used]

SUD (ASAM) Addendum

(Only include for SUD-focused requests.)

• ASAM Dimensions: [Dimension 1: withdrawal risk; Dimension 2: biomedical conditions; Dimension 3: emotional/behavioral; Dimension 4: readiness to change; Dimension 5: relapse/continued use potential; Dimension 6: recovery environment]
• Withdrawal Management Need/Setting: [none / ambulatory / residential / inpatient] with rationale
• Relapse/Continued Use Potential: [low / moderate / high] with supporting factors
• Recovery Environment: [supports and barriers]
• Consent Statement: Patient consent for disclosure of SUD treatment records is on file per 42 CFR Part 2; scope: [parties and information disclosed]

Child/Adolescent Addendum

(Only include for patients under 18.)

• Developmental Considerations: [relevant developmental factors affecting presentation or treatment]
• Education: [school, grade; IEP/504 status; attendance and performance; school coordination plan]
• Custody/Guardianship: [legal guardian; custody arrangement; consent status]
• Family Involvement: [caregiver participation capacity; training needs; supervision adequacy]

Privacy Statement

This document contains only information necessary for coverage determination. Psychotherapy process notes are excluded per HIPAA standards. (For SUD services, add: Patient consent for disclosure of SUD records is on file per 42 CFR Part 2 requirements.)