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Outpatient Service Request Guidelines

The following tips and guidelines will assist providers with submission of accurate and appropriate service requests that will be successfully approved.

In general, we are looking for strength-based, individualized, culturally competent, and medically integrated services that are designed to promote Recovery and Resiliency. Your answers on the form need to demonstrate how you are doing that. For example, under Purpose of Treatment: "John needs individual counseling, skills building and assistance creating and maintaining an active support system to meet his goal of finding a job and moving to his own apartment."

Number of Requested Services

Please ask for only the types and number of services you expect to need for the next three months.

Do Not Leave Blanks on the Form

Blanks are interpreted as an incomplete request, which will delay processing. Please indicate an answer that lets us know you reviewed each field and did not simply skip sections.

Axes I-V

Please complete all Axes. For Axis V, please indicate GAF or CAFAS as used by your state to show the overall functional rating of the member.

Rationale Section of the Form

Treatment Goals

  • Must be individualized and should come directly from your treatment plan.
  • It's always best if your treatment plan includes 'I' statements from the member about what they want to achieve.

Prior Residential/Inpatient Treatment

  • Please indicate previous treatment to indicate the severity of the member's clinical situation. These answers are specifically needed to qualify for some services: i.e., Intensive Family Intervention (IFI) services in Georgia, or Therapeutic Behavioral On-Site (TBOS) services in Florida.

Prior Outpatient Treatment

  • If you have been treating the member continuously, please indicate that and when you started treatment.
  • If the member is new to you but someone else was treating them previously, please tell us who and when to the best of your ability.
  • If the member has tried and failed traditional outpatient services previously, please indicate that. Again, this answer may be needed to qualify for specific levels of outpatient services.


  • Please indicate the reason prescribed, dosage and frequency, and include medication name when possible.

You are always welcome to send additional documents that support your request, however, this is not required unless specifically requested by the UM team.


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Last Updated On: 12/13/2020