Clinical Forms

Outpatient Treatment Report Forms

For most efficient and timely service – use of authorization request flow on our provider portal is the preferred method of submitting requests. Faxed or mailed forms should only be submitted to the specific fax or address. Please confirm for a specific contract that forms are allowed. Some contracts allow only telephonic review if web service is not utilized. Some contracts require that requests only be submitted via the web.

• Outpatient Review
• Florida Outpatient Treatment Review Form (FL-OTR form)
• Instructions
  Use for Outpatient Reviews
• Provider Tip Sheet – Florida
• Esketamine Form
• Medication Management Registration Form
  Only use this form if you are credentialed to offer medication management services.
• New York State OASAS Notification of Admission for Inpatient and Residential Substance Use Disorder (SUD) Services
  Required for New York Medicaid, CHP, Essential, and Commercial plans.
• New York State OASAS Notification of Admissions for Outpatient Substance Use Disorder (SUD) Services
  Required for New York Medicaid, CHP, Essential, and Commercial plans.

Inpatient and Higher Levels of Care Authorization Requests

For most efficient and timely service — use of authorization request flow on our provider portal is the preferred method of submitting requests. Beacon Health Options is no longer accepting faxed Inpatient Treatment Review (ITR) requests for Acute Mental Health or Acute Detox Services for its commercial contracts.

Please submit requests via our secure HIPAA-compliant provider portal. Alternatively, you may contact us by dialing the toll-free number on the member’s health benefit insurance card to complete a telephonic review during normal business hours Monday through Friday. After hour requests, occurring past normal business hours on Friday or Saturday, may be called in as well.

Continue to submit Residential, Partial, and Intensive Outpatient service requests online. If you are unable to complete the request online, please contact customer service by dialing the toll-free number on the member’s health benefit insurance card to obtain information on the correct procedure to utilize.

Faxed or mailed forms should only be submitted to the specific fax or address. Please confirm for a specific contract that forms are allowed. Some contracts allow only telephonic review if web service is not utilized. Some contracts require that requests only be submitted via the web.

• Inpatient Treatment Report
• Instructions
  Use for authorization requests for inpatient and all alternative/higher levels of care.

Electroconvulsive Therapy (ECT) Forms

• Request to Authorize ECT

Repetitive Transcranial Magnetic Stimulation (rTMS) Form

• Beacon Health Options (Fallon, WellSense, Unicare) rTMS Authorization Request Form
• Beacon NY Health Plan (Affinity, MetroPlus, IHA) rTMS Authorization Request Form
• MBHP rTMS Authorization Request Form
• Beacon Health Options (Commercial Contracts) rTMS Authorization Request Form

Psychological Evaluation Forms

• Psychological/Neuropsychological Evaluation Request
• 2019 Psychology and Neuropsychology Testing and Evaluation Service Codes Frequently Asked Questions (FAQ)
• Psychological/Neuropsychological Testing Update
• List of Psychological Tests

Treatment Coordination Forms

• Coordination of Care Authorization
• Member Coordination of Care Tip Sheet

Reporting a Potential Quality of Care Concern to Beacon

Beacon is committed to ensuring that Beacon members receive safe, high quality care. Beacon tracks, investigates, and works to proactively address Potential Quality of Care Concerns.

If you become aware of a Potential Quality of Care (PQOC) Concern, please report the PQOC Beacon immediately, and no longer than 1 business day.

The following form is applicable to all business except health plans based in AR, CO, CT, HI, GA, KS, MA (Medicaid), NH, PA, or WA. For those exceptions, please follow the local notification processes.

• Reporting a Potential Quality of Care Concern: Provider Form (PDF version)
• Reporting a Potential Quality of Care Concern: Provider Form (Word version)

Treatment Record Review Forms

• Standard Treatment Record Review
• Michigan Engagement Center Treatment Record Review

Guides and Resource Documents

• Impairment Scale and Risk Rating Guide

Applied Behavioral Analysis (ABA) Treatment Forms

• ABA Treatment Report Guidelines
• ABA Authorization Request Form – 2019 CPT Codes