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Outpatient Treatment Requests (OTR) Done Right

Sunshine Health offers these tips to help you complete your Outpatient Treatment Request (OTR) authorization forms properly, reducing the number of problem letters, denials and feedback forms sent to your practice.

Ask yourself these questions:

  1. Am I using the most current OTR?
    • Please download the most up-to-date OTR form. Sunshine Health updates forms to assess the medical necessity of your request, so it’s important that you use the correct OTR.
  2. Did I complete the entire OTR?
    • Leaving sections blank will result in the OTR being returned. Make sure to check each section and fill out the required information. Common areas left blank include primary diagnosis, frequency of sessions, estimated sessions to complete treatment and dates that goals were initiated.
  3. Have I updated the clinical information on the OTR?
    • Sunshine Health requires updated clinical information be added to each request to justify the continued need for treatment. An OTR that has only had the dates changed will be sent back to be updated.
  4. Are the goals measurable?
    • Short-term, measurable treatment goals work best to assess progress over time. To create a measurable goal, try using the SMART (Specific, Measurable, Achievable, Relevant and Time- Bound) format.
  5. Did I indicate objective and attainable discharge criteria?
    • Discharge criteria that says “When all goals are met” or “Per parent’s report” will likely result in a feedback form and possibly a reduced authorization. It is important to know how the clinician will determine when the member is ready to be discharged and end medical services.
  6. Does the Treatment Plan section of the OTR match the diagnosis?
    • Are you treating the member’s current diagnosis? If the diagnosis and presenting problems, goals, etc., do not match, the OTR may be sent to peer-to-peer review for potential denial.
  7. Did I remember to sign and date the OTR?
    • Many providers miss this last step. Sunshine Health cannot accept an unsigned OTR, so please be sure it is signed and dated prior to submission.
OTR Tips

Service Type

Clinical information to include with OTR

Applied Behavioral Analysis (CMS Title 21 Only)
  • Supervising Board Certified Behavior Analyst (BCBA) provider: Name, credentials, NPI/TIN & affiliated agency NPI/TIN
  • Treatment plan including symptoms/behaviors requiring treatment (as indicated by assessment tool)
  • Identify SMART goals in specific, behavioral and measurable terms and progress made toward treatment goals; if no progress explain reason why and plan to address lack of progress
  • Comprehensive diagnostic report (initial request only)
  • List any other services member is receiving (i.e. PT/OT/ST/school)
  • Sample schedule of treatment: codes, frequency, requested units
  • Documentation of parental involvement, parent goals
Electroconvulsive Therapy (ECT)
  • ECT physician NPI
  • Frequency
  • Date of first ECT and last ECT
  • Number of sessions to complete treatment
  • PCP communication or member refusal
  • Coordination of care with other behavioral health providers
  • Informed consent obtained
  • Date of most recent psychiatric evaluation
  • Date of most recent physical exam and anesthesiology consult
  • Psychiatric medications including failed attempts (at least 2)
  • Present or past medical issues
  • Acute symptoms
  • Reasons for ECT, including failed attempts at lower Level of Care (LOC)
  • Education to responsible party for safe transportation to appointments
  • ECT progress
  • Plans to discontinue ECT, including medications. other therapies

Intensive Outpatient Treatment

  • Current symptoms with severity/risk
  • Treatment history
  • Current psychotropic medications
  • Substance use history
  • Functional impairment
  • Treatment details: Therapeutic approach, family involvement
  • Measurable treatment goals, progress toward goals
  • Discharge criteria
  • Total days requested

Outpatient Treatment/Community Based Services

  • Treatment goals, progress toward treatment, barriers
  • Current symptoms with level of severity
  • Risk assessment
  • Functional impairment related to symptoms
  • Codes, number and frequency of units/visits, start date

Psychological or Neuropsychological Testing

  • Current cognitive/psychiatric symptoms prompting request for testing
  • Questions to be answered by testing that can’t be determined by
  • diagnostic interview
  • Medical/psychiatric history includes test results
  • Psychotropic medications
  • Codes, specific tests planned, time/units per code requested