[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283867-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-283867-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","repetitive-transcranial-magnetic-stimulation-rtms-authorization-request-form-intake-assessment-checklist","Repetitive Transcranial Magnetic Stimulation (rTMS) Authorization Request Form - Intake Assessment Checklist","","Repetitive Transcranial Magnetic Stimulation (rTMS) authorization request form for submitting intake assessment information to support treatment approval. The form collects member and provider details, network status, request date, diagnosis codes, prior TMS history, and evidence-based psychotherapy trials. It also requests past psychotropic medication use with dosing dates and response outcomes, medication use during the current depressive episode, relevant contraindications, and details about initial pulse-strength/coil placement. 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If not adequate, the form requests the type of psychotherapy, trial dates, and the reason the trial was inadequate.",{"name":70,"@type":61,"acceptedAnswer":71},"What safety or contraindication items does the request checklist cover?",{"text":72,"@type":64},"It includes options to check for implanted stimulators, magnetic-sensitive metals near the TMS coil within 30 cm, acute or chronic psychotic disorder, seizure disorder history, substance abuse at treatment time, severe dementia, and non-adherence with previous depression treatments.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283867,1791559167,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":55,"slug":121},21,"Paper Templates","papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":22},1099525198933,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Repetitive Transcranial Magnetic Stimulation (rTMS) Authorization Request Form  \nSecurely email form to: [outpatient_team@carelon.com](outpatient_team@carelon.com)  \nPlease attach your intake assessment for TMS that documents the items below for: diagnosis (and associated symptoms), past trials of TMS, psychotherapy, psychopharmacology, and psychometric measurement.  \n\n| ☐ In Network |  |  | ☐ Out of Network |  |  |\n| --- | --- | --- | --- | --- | --- |\n| Member Name: |  |  | DOB: |  | Gender: |\n| Health Plan: |  |  | Policy \\#: |  |  |\n| Date and Time of Request: |  |  |  |  |  |\n| Treating Clinician/Facility: |  |  |  |  |  |\n| If the treating clinician is not making this request, has the treating clinician been notified? ☐ Yes ☐ No |  |  |  |  |  |\n| Phone \\#: |  |  | NPI/TIN: |  |  |\n| Servicing Clinician/Facility: |  |  |  |  |  |\n| Phone \\#: |  |  | NPI/TIN: |  |  |\n|  |  |  |  |  |  |\n| 1. Diagnosis code and description: |  |  |  |  |  |\n|  |  |  |  |  |  |\n| 2. Does the Member have a history of TMS attempts in the past? |  |  |  |  |  |\n| ☐ Yes\u003Cbr>☐ No\u003Cbr>If yes, was there a positive outcome?\u003Cbr>☐ Yes\u003Cbr>☐ No |  |  |  |  |  |\n| 3. Has the Member had an adequate trial of evidence-based psychotherapy, without significant improvement within the past 5 years? |  |  |  |  |  |\n| ☐ Yes\u003Cbr>☐ No |  |  |  |  |  |\n| Type of psychotherapy: |  |  |  |  |  |\n| Dates of evidence-based psychotherapy trial: |  |  |  |  |  |\n| If the Member has not had an adequate trial of evidence-based psychotherapy, what is the reason? |  |  |  |  |  |\n| 4. Please fill in the Member’s psychotropic medications taken within the past five years: |  |  |  |  |  |\n| Medication Name | Dose | Dates of Use (Start and End Dates) |  | Response Atypical Agents |  |\n|  |  |  |  | 􀂅 Improved 􀂅 Inadequate Response\u003Cbr>􀂅 Adverse Response 􀂅 Intolerability\u003Cbr>􀂅 Non-adherence 􀂅 Other   |  |\n|  |  |  |  | 􀂅 Improved 􀂅 Inadequate Response\u003Cbr>􀂅 Adverse Response 􀂅 Intolerability\u003Cbr>􀂅 Non-adherence 􀂅 Other   |  |\n|  |  |  |  | 􀂅 Improved 􀂅 Inadequate Response\u003Cbr>􀂅 Adverse Response 􀂅 Intolerability\u003Cbr>􀂅 Non-adherence 􀂅 Other   |  |\n|  |  |  |  | 􀂅 Improved 􀂅 Inadequate Response\u003Cbr>􀂅 Adverse Response 􀂅 Intolerability\u003Cbr>􀂅 Non-adherence 􀂅 Other   |  |\n|  |  |  |  | 􀂅 Improved 􀂅 Inadequate Response\u003Cbr>􀂅 Adverse Response 􀂅 Intolerability\u003Cbr>􀂅 Non-adherence 􀂅 Other   |  |\n\n(continued)  \n| Medication Name | Dose | Dates of Use (Start and End Dates) | Response Atypical Agents |\n| --- | --- | --- | --- |\n|  |  |  | 􀂅 Improved 􀂅 Inadequate Response\u003Cbr>􀂅 Adverse Response 􀂅 Intolerability\u003Cbr>􀂅 Non-adherence 􀂅 Other   |\n| Please list any Augmenting Agents used:   If no medications were used, are they contraindicated?\u003Cbr>☐ Yes\u003Cbr>☐ No |  |  |  |\n| 5. Were any of these meds used during this depressive episode? |  |  |  |\n| ☐ Yes , list medications: \u003Cbr>☐ No\u003Cbr>If yes, was improvement inadequate at adequate dose and duration?\u003Cbr>☐ Yes , list dose and duration: ☐ No\u003Cbr>If yes, was the medication discontinued due to side effects?\u003Cbr>☐ Yes , list side effects: ☐ No |  |  |  |\n| 6. Please check all that apply: |  |  |  |\n| ☐ Vagus Nerve Stimulator leads in the carotid sheath\u003Cbr>☐ Other implanted stimulators controlled by or that use electrical or magnetic signals\u003Cbr>☐ Conducive or ferromagnetic or other magnetic-sensitive metals implanted or embedded in head or neck within 11.81 inches (30 cm) of TMS coil\u003Cbr>placement other than dental fillings ☐ Acute or chronic psychotic disorder ☐ Seizure disorder or history of seizure disorder ☐ Substance abuse at time of treatments ☐ Severe dementia\u003Cbr>☐ Non-adherence with previous depression treatments ☐ None of the above |  |  |  |\n| 7. Will the first treatment session include determining correct magnetic pulse strength and placement of the magnetic coil? |  |  |  |\n| ☐ Yes\u003Cbr>☐ No |  |  |  |\n| 8. What is the Member’s most recent score on a validated self-report depression rating scale? |  |  |  |\n| Rating scale used: |  |  |  |\n| Score: |  |  |  |\n| D","cbCaim7Xe8qMur1q","https://ap.wps.com/l/cbCaim7Xe8qMur1q","pdf",766592,"English","# Member and Request Details\n## Network Status and Treating Information\n## Diagnosis and Prior TMS History\n## Psychotherapy Trial and Reason if Inadequate\n## Psychotropic Medications and Treatment Response\n## Depressive Episode Medication Use\n## Contraindications and Safety Checks\n## Initial Treatment Planning\n## Most Recent Depression Rating Scale Score","[{\"question\":\"What information must be included when requesting rTMS authorization?\",\"answer\":\"The form requires member and provider details, diagnosis and symptoms documentation, prior TMS attempts, evidence-based psychotherapy trials, psychotropic medication history over the past five years, depressive episode medication use, and the most recent depression rating scale score.\"},{\"question\":\"How does the form address psychotherapy history?\",\"answer\":\"It asks whether the member had an adequate trial of evidence-based psychotherapy within the past five years. If not adequate, the form requests the type of psychotherapy, trial dates, and the reason the trial was inadequate.\"},{\"question\":\"What safety or contraindication items does the request checklist cover?\",\"answer\":\"It includes options to check for implanted stimulators, magnetic-sensitive metals near the TMS coil within 30 cm, acute or chronic psychotic disorder, seizure disorder history, substance abuse at treatment time, severe dementia, and non-adherence with previous depression treatments.\"}]","Repetitive Transcranial Magnetic Stimulation (rTMS) Authorization Request Form - Intake Assessment Checklist | PDF",1789621091]