Referrals to Specialty Treatment

Alcohol and Drug Abuse Treatment Centers (ADATC)

Partners’ Utilization Management has a referral process and forms for Alcohol and Drug Abuse Treatment Center (ADATC) services. Providers should follow the ADA Referral Procedure.

The following documents are required for all ADATC referrals and need to be faxed to the attention of the ADATC Utilization Management Care Manager at 704-884-2701.

If you have questions, please contact the Mental Health and Substance Use Utilization Management Unit at 1-877-864-1454.

Electro Convulsant Therapy (ECT)

Electro Convulsant Therapy is managed the Partners Utilization Management (UM) Department. ECT Service Authorization Requests (SARs) will be reviewed by UM Medical Doctors.

ECT Limits and Documentation Requirements

ADULT ECT REQUESTS; 901, 90870

Initial Treatment Requests:

  • There are six Unmanaged ECT sessions, per episode of treatment (Episode of Care). The six Unmanaged ECT sessions per Episode of Care, include treatment given in an Inpatient setting, Outpatient setting, or combination of both.
  • Providers must submit a Notification SAR. No clinical documentation or review is required with Notification SARs.
  • Providers can request up to a maximum of six units/sessions in a six-day timeframe.

Continued Treatment Requests:

  • Prior authorization is required before the seventh or more sessions in an Episode of Care.
  • Providers can request up to three units/sessions in a five-day timeframe.
  • All continued ECT SARs must provide the information requested on the Electroconvulsive Therapy (ECT) Continuation Form.

Maintenance ECT Requests:

  • Prior authorization is required before the seventh or more session in an Episode of Care.
  • Providers can request up to six units/sessions in a six-month timeframe for maintenance ECT.
  • All maintenance ECT SARs must provide the information requested on the Electroconvulsive Therapy (ECT) Continuation Form.

CHILD ECT REQUESTS; 901HA, 90870HA

Initial Treatment Requests:

  • There are No Unmanaged ECT sessions for children.
  • Prior authorization is required before the first session.
  • Providers can request up to three units/sessions in a five-day timeframe.
  • All initial Child ECT SARs must provide the information requested on the Electroconvulsive Therapy (ECT) Continuation Form.

Continued ECT Requests:

Maintenance ECT Requests: 

  • Prior authorization is required.
  • Providers can request up to six units/sessions in a six-month timeframe for maintenance ECT.
  • All maintenance ECT SARs must provide the information requested on the Electroconvulsive Therapy (ECT) Continuation Form.

Psychological Testing Guidelines

Partners recognizes the importance and value of psychological testing to address specific diagnostic questions necessary for an individual’s treatment that cannot be answered through the diagnostic interview and psychiatric evaluation.

Psychological testing is the use of formal procedures employing reliable and valid instruments to measure intellectual, cognitive, emotional and behavioral functioning. Psychological testing may be used to identify intelligence, psychopathology, personality style, interpersonal processes, and adaptive skills. Neuropsychological testing is a specialized area of psychological testing that can identify the presence of brain damage, injury or dysfunction, and associated functional deficits. Before conducting psychological testing, it is important to obtain current clinical information through a Comprehensive Clinical Assessment and/or Psychiatric Evaluation. It is also important to inquire about additional psychological testing that may have been conducted with the individual, and obtain copies of such evaluations before conducting psychological testing. Before referring for or administering psychological testing, it is important to answer the following questions:

1. What clinical information about the individual is already available?

Available clinical information should be reviewed before conducting psychological testing.

2. What questions will be addressed by psychological testing?

Specific questions to be addressed should be identified before referring for psychological testing.

3. Can these questions be addressed through diagnostic interviewing, including a psychiatric evaluation? 

Most information needed for the treatment of mental health and substance use disorders can be obtained as well or better through skillful diagnostic interviewing. However, some issues such as intellectual functioning, adaptive functioning, and the presence of possible thought disorders may be better identified and understood through formal psychological testing.

Limitations

Psychological Testing is not covered in the following situations:

  1. Testing conducted primarily for educational purposes, including for cognitive abilities, learning disabilities and academic achievement. Testing for qualifying for services that are covered under applicable State or Federal Special Educational laws.
  2. Vocational referrals, including the need for Vocational Rehabilitation services, job placement, vocational interests, and aptitudes, or fitness for duty.
  3. Legal referrals from attorneys in preparation for criminal or civil court proceedings. Court-ordered evaluations that would not be otherwise considered medically necessary under these guidelines.  (Note: Multidisciplinary Evaluations to determine the need for guardianship and Forensic Evaluations to determine competence to participate in legal proceedings have alternative referral and funding mechanisms through the LME-MCO )
  4. Requests for information about parenting skills or the capacity to parent from the Department of Social Services or courts
  5. Testing for the routine diagnosis of Attention Deficit/Hyperactivity Disorder (ADHD). Suspected ADHD can be diagnosed or ruled out in most situations through careful diagnostic interviewing and gathering of information from collateral resources such as parents and teachers. ADHD questionnaires are often useful in obtaining such input and do not require psychologists to administer.
  6. Testing for basic screens or other self-report inventories that are normally completed as part of a comprehensive clinical evaluation
  7. Testing conducted primarily for the titration of medication
  8. Repeated testing on a routine or periodic basis that does not otherwise meet the requirements of these guidelines. An exception is repeated intellectual and adaptive testing for minors with previously identified intellectual or developmental disabilities in order to determine continued eligibility for IDD treatment services every three years.

Directions for Requesting Prior Authorization for Psychological Testing:

  • Assure that the individual has had a recent Comprehensive Clinical Assessment and/or Psychiatric Evaluation. Exception: individuals believed to have an intellectual or developmental disability that need to qualify to receive IDD services may be referred to intellectual ability and adaptive functioning before completion of a Comprehensive Clinical Assessment.
  • Inquire about, obtain and review prior Psychological Test Reports and other relevant clinical assessments, treatment summaries, etc.
  • Identify whether and how Psychological Testing will enhance and facilitate the individual’s treatment.
  • Complete and submit a service authorization request (SAR) and the Partners Psychological Test Authorization Request Form [Psychological Testing Form] to Partners 10 or more days before the proposed test date(s).
  • Follow directions on the form to submit to Partners for review.
  • To ensure coverage, request and obtain authorization before performing testing. Psychological Testing can be conducted under Medicaid enrollees’ Unmanaged Outpatient Basic Benefit. Psychological Testing must have prior authorization once unmanaged basic benefits are exhausted to determine medical necessity as defined in this guideline, and is subject to post service review.