Prior Authorization Request (Psychotherapy)

Date: [Submission date]

To: [Payer name], Utilization Management Department

Request Type: [initial / continuation / retroactive]

Prior Authorization/Reference #: [Previous authorization number and authorized dates/units, if continuation]

Patient: [Full name], DOB: [DOB], Member ID: [Member ID], Group #: [Group number]

Rendering Provider: [Provider name], [Credentials], [License type and state], NPI: [NPI]

Practice: [Practice name], [Address], Phone: [Phone], Fax: [Fax]

Contact for Clinical Questions: [Name], [Phone or email]

Request Summary

Primary Diagnosis: [ICD-10-CM code and description]

Secondary Diagnoses: [Comorbid conditions affecting complexity, if applicable]

Service Requested: [CPT code(s)], [Session length in minutes], [Frequency], [Total sessions or date range requested]

Modality: [individual / family / group] psychotherapy

Medical Necessity Statement: [One sentence linking diagnosis, symptom severity, functional impairment, and expected benefit of continued grief-focused psychotherapy at requested frequency]

Index Loss and Clinical Context

[Relationship to deceased and approximate date of loss; circumstances affecting clinical complexity; pre-loss baseline functioning compared to current functioning; time elapsed since loss and why symptoms exceed culturally normative grief] (3–5 sentences; describe circumstances generally without graphic detail.)

Current Clinical Presentation

[Brief narrative synthesis of current presentation emphasizing severity, frequency, and persistence of grief symptoms and their functional impact] (1–3 sentences.)

• Grief Symptoms: [Core symptoms such as intense yearning, preoccupation with deceased, difficulty accepting death, avoidance, emotional numbness—with frequency and intensity noted] (Include only symptoms currently present and clinically significant.)
• Associated Symptoms: [Sleep disturbance, appetite changes, concentration problems, anxiety, depressive symptoms] (Include only if present and clinically significant.)
• Functional Impairment:
  • [Occupational or academic impact with specific examples]
  • [Social or interpersonal impact with specific examples]
  • [Self-care, ADLs, or health behavior impact with specific examples]
  (Provide 2–3 concrete examples with baseline vs. current comparison when available; this anchors medical necessity.)
• Mental Status Highlights: [Affect, mood, relevant thought content, attention or concentration issues] (Include only elements supporting severity; not a full MSE unless payer requires.)
• Risk and Safety: [Suicidal ideation or self-harm present or denied; protective factors; safety plan status; rationale for outpatient vs. higher level of care] (If no acute concerns: "Patient denies suicidal/homicidal ideation; no acute safety concerns identified.")

Treatment History and Response

Treatment Course: [Date range of current episode], [Total sessions completed], [Typical frequency], [Attendance and adherence summary], Modality: [Therapeutic approach, e.g., complicated grief treatment / grief-focused CBT / interpersonal therapy for grief] (Do not include session dialogue or process note content.)

Outcome Measures: [Measure name: baseline score (date), most recent score (date), interpretation] (If no standardized measures used: "Progress tracked clinically; plan to introduce [measure name] at [interval].")

Response Summary: [Improvements achieved including symptom reduction, functional gains, skills acquired; remaining symptoms and impairments; complexity factors affecting progress such as comorbidities, ongoing stressors, limited supports, anniversary reactions]

Other Treatments: [Psychiatric medications with response and adherence; prior higher levels of care; support groups tried] (Include only if relevant to authorization request.)

Treatment Plan

Approach: [Grief-focused interventions to be used, e.g., grief exposure, imaginal revisiting, cognitive restructuring of grief-related beliefs, behavioral activation, meaning-making, relapse prevention] (State why this approach matches the patient's presentation.)

Goals:

• [Symptom goal with target and timeframe]
• [Functional goal with target and timeframe]
• [Additional functional or safety goal with target and timeframe]

(List 3–5 measurable goals in priority order.)

Monitoring: [Outcome measures or clinical metrics to be used, reassessment interval, criteria for treatment modification]

Medical Necessity Rationale

Requested Services: [Frequency], [Session length], [Total sessions or duration requested]

Why Continued Treatment Is Necessary: [Rationale for why discontinuation or step-down is premature—unfinished treatment phase, persistent impairment, high-risk period; expected functional and symptom changes by end of requested period]

Why This Intensity: [Clinical rationale for requested frequency tied to severity or risk; if higher than weekly, include time-limited plan to step down]

Why Alternatives Are Insufficient: [Why lower frequency, group-only care, self-guided resources, medication alone, or watchful waiting would not meet this patient's needs at this time]

Prognosis: [Favorable / Guarded] with continued treatment; [Key factors influencing outlook]

Care Coordination

[Coordination with PCP, psychiatrist, or other providers; releases of information on file; relevant collateral obtained] (Omit this section entirely if not applicable.)

Discharge Planning

• Planned Reassessment: [Date or session number]
• Step-Down Plan: [Planned frequency reduction, e.g., weekly to biweekly to monthly]
• Discharge Criteria: [Functional restoration targets, sustained symptom reduction metrics, relapse prevention plan in place]

Attachments

• [Treatment plan summary, if attached]
• [Outcome measure score reports, if attached]
• [Payer-required prior authorization form, if attached]

(Omit this section if no attachments.)

Attestation

Clinician Signature: ________________________________

Printed Name and Credentials: [Name, Credentials]

License Number and State: [License number], [State]

NPI: [NPI]

Date: [Date signed]

(This document follows HIPAA minimum necessary standards. Do not include psychotherapy process notes or session dialogue. Include only information necessary to establish medical necessity.)