Outpatient Treatment Review Outlines

To expedite the review process, be sure to have access to the patient’s chart so you are able to not only provide complete clinical, but the Evernorth staff will ask for the customer ID and the date of birth. To prepare for the review, be sure to review our medical necessity criteria expectations for admission.

Medical necessity criteria

Below is a general outline that our care managers will follow when reviewing; however depending on the specifics, the care manager may ask for additional information.

DSM Diagnosis Information

  • Include any Clinical Disorders, Personality Disorders, Intellectual Disability, or General Medical Conditions

Risk History

  • Identify suicidality or homicidality concerns
  • Identify relevant family history

Current Medication(s)

  • Medications: Name, dosage, frequency, start date & end date as well as who prescribed.
  • Identify any other concerns about medication use (e.g., side effects or allergies).
  • Identify the Primary Care Physician and care coordination between practitioners.
  • Was a medication evaluation given?

Substance Use Treatment Issues

  • Identify any substance use issues

Mental Status

  • Mental status issues such as: Orientation, psychosis, or insight/judgment issues.
  • Should Psychological Testing be offered?

Mental Health Symptom Identification

Which of the following apply?

  • Anxiousness
  • Hopelessness
  • Problems with ADLs
  • Concentration problems
  • Concomitant Medical Condition
  • Depressed Mood
  • Decreased Energy
  • Delusions
  • Disruption of Thought Process
  • Dissociative States
  • Grief
  • Guilt
  • Hallucinations
  • Impulsivity
  • Irritability
  • Hyperactivity
  • Mania
  • Memory Problems
  • Mood Lability
  • Obsessions/Compulsions
  • Oppositional
  • Panic Attacks
  • Paranoia
  • Sleep Function
  • Somatic Complaints
  • Tearfulness
  • Weight Change (significant)
  • Worthlessness
  • Other

Does the symptom(s) support the diagnosis?

Treatment History, Goals and Progress

  • Provide treatment history
  • Identify treatment goals, interventions, measurable outcomes
  • Outline progress and identify plan to overcome barriers
  • Current Symptom impact on the participant’s ability to function

Discharge Planning

  • Frequency of sessions and estimates of length of care
  • Identify any barriers to discharge