Provider Manual


Electro-Convulsive Therapy (ECT)

For inpatient or outpatient ECT services, preauthorization and peer review must be requested by contacting Carelon. Please refer to the procedures for requesting preauthorization and concurrent reviews for inpatient and alternative services in Section III above. The same procedures, required clinical information and Medical Necessity Criteria requirements apply for ECT. Please call our toll-free provider number with any questions you may have or for assistance in requesting service authorizations for ECT.

Psychological and Neuropsychological Testing

All outpatient psychological and neuropsychological testing services require preauthorization and peer review. Providers must complete and submit to the Service Manager a Psychological Evaluation Request (PER) form. This form can be faxed or uploaded via ProviderConnect.

The authorization decision for psychological tests will be provided within two (2) business days of receipt of all clinical information. Authorizations for psychological tests will be in units of 30 minutes. Please contact Carelon for further assistance in completing and submitting these forms. Please note that inpatient psychological testing is included in the inpatient per diem rate, and as such does not require preauthorization.

Methadone Services

All requests for Methadone Services must complete the Methadone Maintenance Report. These services require preauthorization by calling the Engagement Center or via ProviderConnect using the methadone maintenance form.

Note: Forms are available to download for the special procedures above at: