Clinical Update Request - Blue Cross Blue Shield Of Montana Page 2
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1
2Functioning Levels: How has the member been doing over the last 3-4 weeks?
Very Poor
Poor
Fair
Good
Very Good
Please put an ‘
’ in one of the five spaces to the right of each area below.
✓
Interpersonal Skills, Social Relationships
Coping with Life Stressors
Functioning in Occupational or School Settings
Strength of Support System
Resolution of Problems/Symptoms
What progress has the member achieved since the last review?
Current Treatment Goal #1:
Intervention for Goal #1:
Current Treatment Goal #2:
Intervention for Goal #2:
What social supports and community resources (ex: support groups, church/synagogue/mosque, etc.) has the member accessed (currently or in the past)?
Request for Service Coverage, this review:
Service Code Requests WITHOUT Add on Codes. (Examples: 90832, 90834, 90837, 90845, 90846, 90847, 90849, 90853, E & M codes)
CPT Code: _______________________ Frequency: _______________________ Start Date: __________________________
CPT Code: _______________________ Frequency: _______________________ Start Date: __________________________
CPT Code: _______________________ Frequency: _______________________ Start Date: __________________________
E&M or other Code: __________________ Frequency: _______________________ Start Date: __________________________
Service Code Requests WITH Add On Codes. (Indicate primary CPT code, and then add on code(s). Add on Code Examples: 90785, 90833, 90836, 90838,90840, 90863)
(1)CPT Code#: _____________________ Frequency: _______________________ Start Date: ___________________________
Add On Code #: ___________ Frequency: _______________ Add On Code #: _____________ Frequency: __________
(2)CPT Code#: _____________________ Frequency: _______________________ Start Date: ___________________________
Add On Code #: ___________ Frequency: _______________ Add On Code #: _____________ Frequency: __________
(3)CPT Code#: _____________________ Frequency: _______________________ Start Date: ___________________________
Add On Code #: ___________ Frequency: _______________ Add On Code #: _____________ Frequency: __________
Anticipated Treatment Completion date:
Additional comments:
My signature confirms that I am providing the requested services:
Signature ___________________________________________________________ Date _________________
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
350188.0915
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