Recently, updates have been made to the Evernorth Inpatient Prior Authorization Form. This form is for inpatient behavioral and substance use services, including mental health, detox, substance use rehabilitation, dual diagnosis, and eating disorder treatment.

Updates

We have updated the form to support timely and effective review of requests. Recent updates to the form include the following improvements:

• Added a question to capture the MD address in alignment with National Committee for Quality Assurance (NCQA) guidelines
• Prompted types of clinical based on responses to questions 13 and 14
• Removed the signature requirement
• Updated guidance for requesting authorization for other levels of care

Previous versions of the old form will still be accepted, and providers do not need to resubmit requests twice.

Accessing the Form

Visit the Evernorth Behavioral Health provider website at Provider.Evernorth.com and navigate to Form Center > Inpatient Prior Authorization Form.

For questions regarding this form, please contact Allison Meier at Allison.Meier@evernorth.com.