Behavioral health records

We have online tools to assist you in providing mental health and chemical dependency services to our members.


Please reference the Pre-authorization section for Mental Health and Chemical Dependency pre-authorization information, including clinical review criteria.


Forms for submitting treatment plans, authorization to disclose protected health information as well as various surveys and tests are available in our forms section.

Treatment record keeping

The provider is responsible for maintaining an adequate clinical record for each patient and providing us with clinical data as requested for utilization review or quality management.

Record details:

  • All appointments, including the patient name and date of contact
  • All entries should be legible, in chronological order and signed in ink with the provider's name and credentials
  • All treatment charts should be readily accessible and stored in a secure environment to protect patient confidentiality

Documentation should include, but is not limited to:

  • Presenting problem
  • Key demographic data
  • ICD-10 diagnosis code(s)
  • Full psychological and medical history
  • Treatment plan with measurable goals
  • Date and length of the therapy sessions
  • Mental status exam and current clinical status
  • All diagnostic and treatment services provided or ordered
  • Summary of the patient's progress or lack of progress toward the treatment goals
  • Prescribing providers should document that noted positive benefits outweigh noted side effects
  • Therapy session content, such as therapeutic interventions used and major themes discussed
  • DSM-5 diagnosis code is acceptable only as supplemental coding to the required ICD-10 diagnosis code
  • Complete developmental history for children and adolescents, including relevant prenatal and perinatal events
  • Current prescription medications, including the name, dosage, instructions for use and any side effects experienced
  • With patient consent, documentation of coordination of care with the primary care physician and other involved health care professionals
  • Substance use evaluation, including past and present use of cigarettes, alcohol, illicit, prescribed and/or over-the-counter drugs
  • Discharge plan for patients being treated in an inpatient setting, residential program, partial hospitalization/day treatment program or intensive outpatient program
  • Number of participants and relationship of the participants to the patient if it is conjoint or family therapy, as well as a summary of how the participants responded to the session

Psychotherapy chart notes and the Health Insurance Portability and Accountability Act (HIPAA) Privacy Regulation

HIPAA regulations significantly direct the way electronic health care information is collected, transmitted and protected:

  • Privacy Regulation pertains to oral and written communication as well as electronic.
    • Providers are required to post detailed privacy policies in a conspicuous place to advise patients of their rights, including the right to request their personal medical record.
  • Psychotherapy notes may be maintained separately from the rest of the patient's chart.
    • Psychotherapy notes may represent personal notes used to record or analyze group, individual or family therapy and unlike the rest of the chart do not have to be disclosed to the patient.
      However, under the HIPAA Privacy Regulations, psychotherapy notes can be secured by a specific authorization, not by a general consent.
  • Non-psychotherapy notes should be maintained in the patient's chart. Non-psychotherapy notes must be disclosed to the health plan and to the patient, with only a general consent. With patient
    • authorization (specific disclosure with expiration and/or revocation rights), psychotherapy notes may also be disclosed to the health plan.
  • Our provider agreements require the creator of the record to release records necessary to facilitate payment and health plan operations.
  • By HIPAA definition, "non-psychotherapy notes" include notes relating to:

    • Diagnosis
    • Prognosis
    • Symptoms
    • Medications
    • Clinical tests
    • Progress notes
    • Treatment plan
    • Functional status
    • Treatment encounters

Behavioral health providers have the option of maintaining notes for the patient and the health plan in one part of the chart, and psychotherapy notes for the professional provider as the "creator" and the health plan in another part of the chart.

Under some circumstances, non-psychotherapy notes may be sufficient to meet the health plan's needs for documentation. However, the quality of record keeping varies widely and access to psychotherapy notes may be necessary to make payment determination on some claims.

Clinical documentation of therapy sessions

Clinical notes for outpatient and inpatient therapy sessions serve as documentation to:

  • Ensure that quality of care is adequate
  • Record the patient's clinical status and progress
  • Offer documentation so that payment is made for services provided

Clinical notes do not need to be lengthy and should include:

  • Date and length of the therapy sessions
  • Treatment plan for the immediate future
  • Summary of the session's therapeutic intervention
  • Content of the therapy session (e.g., note of the major themes discussed)
  • Patient's current clinical status as it relates to diagnosis and as evidenced by the mental status observations
  • Summary of the provider's assessment of the patient's progress or lack of progress toward the treatment goals
  • Medications being prescribed by the provider, such as the name, dosage, instructions and any side effects that have occurred.

    • The record should document that noted positive benefits outweigh noted side effects.

Group, Conjoint and Family Therapy

Clinical notes are required for each group, conjoint or family therapy session and should include:

  • Number of participants
  • Date and length of the therapy session
  • Content of the therapy session (e.g., major themes discussed)
  • Relationship of the participants to the patient, if it is conjoint or family therapy
  • Nature and degree of the patient's participation and response to the therapy session
  • Statement summarizing the therapeutic intervention attempted during the therapy session
  • Statement summarizing how the session has influenced the patient (or relevant significant others) as compared with the treatment goals

The record should also include documentation that each therapy session was an active, directed process and that the therapist regularly took stock of specific important treatment issues.

Inpatient Psychotherapy

Clinical notes for inpatient psychotherapy should contain all elements noted previously to adequately document that individual therapy was provided.

Therapeutic progress notes should occasionally include reference to progress regarding the therapeutic plan and the discharge plan, both of which should have been established and documented during the early part of the hospitalization.

These documentation requirements should serve to assist in the maintenance of an adequate level of quality of care as well as to help ensure that payment is made only for services rendered.