Intensive Outpatient Program (IOP)
NPI ____________________________________________________
City ___________________________State________ Zip___________
MD NPI __________________________________________________
City ___________________________State________ Zip___________
Phone ___________________ Ext. __________ Fax ______________
Are the total hours per week between 9-20 hrs? c Yes c No
Start Date of Additional Sessions Requested ____________________
IOP End Date _______________________________
c In-network provider c Out-of-network provider
Check One:
c Initial Request c Concurrent c Discharge
Check One:
c CD c MH c ED
Patient Name__________________________________________________
Subscriber Name______________________________________________
Patient Date of Birth__________________________________________
Subscriber ID____________________ Group____________________
This is a request to review whether treatment meets the medical necessity denition under the members health benet plan.
It does not conrm eligibility of benets. For Initial Services, the Provider must call BCBSIL at 800-851-7498 to check benets.
Instructions: For Initial Services, submit completed form through iExchange
or print and fax completed form to BCBSIL at 877-361-7656.
Medications (Dosages)
1. Previous MH/CD/ED Treatment (Reason for same level of care transfer, if applicable)
Current DX — Please list ICD-10 code, Diagnosis Name, Specier and all Medical Diagnoses
ICD-10 Code __________________ DX Name _______________________________ Specier ___________________________________
ICD-10 Code __________________ DX Name _______________________________ Specier ___________________________________
ICD-10 Code __________________ DX Name _______________________________ Specier ___________________________________
Facility/Provider Name __________________________________________
Address _____________________________________________________
MD/Program Dir. Name _________________________________________
Address ____________________________________________________
UR/Contact Name ____________________________________________
Days Per Week (#) ___________ Hrs Per Day (#) ___________
Sessions Requested (#) ________
Date Mbr Started IOP ______________ Total Days Used (#) _______
Treatment days of the week, please check.
c M c T c W c TH c F c S c S
Intensive Outpatient Program (IOP)
2. Current Treatment Goals
3. Aftercare Plan (Provider names, telephone #, appointment date and time)
Current Clinical Presentation
1. Current Mental Status (Substance DO – date of rst use, pattern of use, last date of use, cravings and severity; Eating DO – include HT, WT, BMI)
2. Current Risk Factors (SI, HI, Psychosis, Medical, ADLs or current functional impairments that can’t be addressed in lower level of care)
Intensive Outpatient Program (IOP)
3. Progress on treatment goals and barriers to progress
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
My signature conrms that I, or the facility I represent, will provide the requested services.
Signature ___________________________________________________________ Date _________________
Please complete form in its entirety. Incomplete forms cannot be processed and will require resubmission.
Do not send medical records.
Additional clinical information can be attached if there is inadequate space on the form.
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