Higher Level of Care Referral Letter (US Specific)
Report Template:
A formal referral, prior authorization, or treatment facility intake clearance request for a client who has reached maximum therapeutic benefit from their current level of care and whose clinical needs now exceed it. Use when writing to insurers (utilization management, medical directors), case managers, referral agencies, or receiving facilities including health professionals, agencies and admissions directors. It establishes medical necessity by documenting: diagnosis, treatment to date, deterioration despite outpatient treatment, symptom exacerbation, functional impairment, risk, assessment results evidencing functional disability, requested level of care and the benefits it provides above the current level of treatment, and the risk of continued deterioration without it.
This template can be used via NovoNote’s “Create Document” tool to integrate psychometric results in NovoPsych, previous sessions in NovoNote, and additional contextual information such as progress notes, intake records and assessment results.
Client’s Full Name
DOB: Client’s Date of Birth
Date
To Whom It May Concern: or the named recipient
Opening Statement:
- Brief statement of the level of care requested, the date treatment commenced, and the primary diagnosis with its ICD-10 code.
Narrative Summary:
- Treatment to date: number of sessions, frequency, therapeutic approach, and medication where documented.
- Engagement and therapeutic alliance, and the documented period of decline despite outpatient treatment.
- What the client now requires, and a statement that the presentation can no longer be safely or effectively managed at the current level of care.
- Symptom exacerbation, with the documented magnitude and period for each symptom that has worsened.
- Functional impairment across the occupational or academic, social or interpersonal, and activities of daily living domains, with the role or task the client is unable to sustain.
- Any risk issues: substance use, self-injury, suicidal or homicidal ideation, or other safety concerns, exactly as documented, or stated as assessed and absent.
- Clinical assessment results: the most recent score on the most relevant measure, its interpretive band, and its link to medical necessity.
- Any standard of care guideline used to determine the level of care (LOCUS, CALOCUS, ASAM, MCG, InterQual, DSM-5, APA, AACAP), including any respect in which the client is atypical against it.
- Course of treatment, the determination of medical necessity, why the current level of care is insufficient, what the requested level of care provides that current treatment cannot, and the consequences of remaining at the current level of care.
Sincerely,
Clinician’s Name, Credentials
Mary Blogs
Date of birth: March 14, 1988
September 3, 2026
To Whom It May Concern:
I am writing to formally request a prior authorization and coverage for admission to a Partial Hospitalization Program for my patient, Mary Blogs. I have been treating Mary Blogs in an outpatient psychotherapy setting since January 12, 2026 for Major Depressive Disorder, Recurrent, Severe (ICD-10 code: F33.2).
Mary has attended twenty-four sessions of weekly individual psychotherapy using Cognitive Behavioral Therapy, alongside pharmacotherapy with sertraline prescribed by her psychiatrist.
Despite consistent engagement in evidence-based outpatient treatment and a strong therapeutic alliance, Mary’s clinical status has deteriorated over the past six weeks. She now requires a structured, higher-intensity treatment environment to ensure her safety and clinical stabilization. Her presentation can no longer be safely or effectively managed on an outpatient basis.
Over this period Mary has developed profound psychomotor retardation and a documented reduction in sleep to approximately three hours per night. Her concentration has declined to the point that she struggles to complete tasks she previously managed without difficulty.
Mary’s psychomotor retardation, exemplified by her taking over four hours to complete a work report that previously took thirty minutes, has left her unable to sustain her required performance at work. Her progressive social withdrawal, exemplified by her declining all contact with her closest support person for the past three weeks, has left her unable to maintain her primary support relationship. Her diminished energy and motivation, exemplified by going four consecutive days without showering, has left her unable to maintain basic personal hygiene.
Mary denied suicidal ideation, intent or plan, and no self-injury or substance use concerns were identified on assessment.
Mary’s most recent WHODAS 2.0 score of 38% placed her in the severe disability range, consistent with significant functional impairment across multiple life domains and supporting the need for a higher level of care.
Mary’s presentation is atypical against LOCUS criteria in that her level of functional impairment now exceeds that anticipated at her current placement, despite the absence of acute suicidal risk.
A Partial Hospitalization Program is determined to be medically necessary. Once-weekly outpatient contact is insufficient to address the acuity of Mary’s current psychomotor and functional decline. A Partial Hospitalization Program provides daily clinical monitoring, a multidisciplinary treatment team, and structured group therapy that outpatient care cannot offer, and will allow closer tracking of her mood and functioning than her current level of care permits.
Without this increase in the intensity of care, Mary is at risk of further functional decline and deterioration to a point requiring emergency or inpatient intervention.
Sincerely,
Sarah Smith
Clinical Psychologist
NovoPsych Practice
- Template Type
- Report
- Letter
Author:
Dr Liz Rojas
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