Please complete this form, save it to your computer, then email it to: [email protected] (preferred) or fax 860-687-7329. Date span of treatment: to

Effective June 1, 2023, this form replaces all other Transcranial Magnetic Stimulation precertification request documents and forms. Failure to complete this form and submit all of the medical records we are requesting may result in the delay of review. Once completed, this form contains confidential information. Only the individual or entity ...

Plans administered by Optum behavioral do not require prior authorization for routine outpatient services. Optum administers a wide range of benefits.

rTMS REQUEST FORM A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 226920.1118 Provider must call . BCBSIL at 800-851-7498. to check the member’s benefits. Print and fax the completed form to BCBSIL at . 877-361-7656.

For TMS request found to be medically necessary, the following CPT codes and units will include: 90867 – One unit per course of treatment. 90868 – 36 units per course of treatment. 90869 – Approval of one unit will be provided. Medical policy informa on is available at Lucethealth.com under Medical Necessity Criteria.

Instructions: Please complete all sections to assist with timely review. Fax completed form to 844-445-6642 (toll free). Request is for TMS of the brain. Individual is an adult. Individual has a confirmed diagnosis of severe major depressive disorder (MDD) (single or recurrent episode).

Instructions: Please complete all the fields on the treatment request form. Please use the checklist when submitting TRICARE referrals through the self-service portal at HumanaMilitary.com to ensure that all necessary clinical information is included and to expedite

rTMS REQUEST FORM Provider must call Blue Cross Community MMAI at 877-723-7702 to verify benefits. After completing the form, fax it to 312-233-4099. Signature _____ Date _____

Optum: TMS Initial Authorization Request Form (Revised: Sept 2016 2. 5. Has the member been diagnosed with any other neurologic conditions? (Seizures, cerebrovascular disease, dementia, movement disorders, increased intracranial pressure, a history of repetitive or severe head trauma, primary/secondary tumors in the central nervous system) 6.

Transcranial Magnetic Stimulation – TMS (including Repetitive TMS – rTMS) AUTHORIZATION REQUEST . Submission of this form is only a request for services and does not guarantee approval. Incomplete forms may delay processing. All NC Providers must provide their 5-digit Blue Cross Blue Shield of North Carolina (Blue Cross NC) provider ID# below.