Spravato Provider and Staff Guide – Patient Workflow (Internal)

Use this internal guide to follow the Spravato patient journey from first inquiry through induction, maintenance, and discontinuation. This is for Nebraska Peace of Mind staff and providers only.

Always follow REMS requirements, payer policies, and our internal safety and documentation standards when scheduling and treating Spravato patients.

Spravato Patient Workflow

Follow these steps for all patients being considered for Spravato. Update as our process evolves.

1Initial Inquiry and Triage

Patient calls, messages, or submits interest online. If a patient is interested in Spravato:

  • Message Diana (Spravato Coordinator) in RingCentral to reach out to the patient
  • Or direct the patient to our website to schedule a free consultation: they can visit the Spravato page under Services and book a free consultation call with our Spravato Coordinator

If there is any urgent suicide risk, follow the emergency protocol immediately (911, 988, or nearest ER as appropriate) and notify the provider.

2Insurance and Eligibility Check

Spravato Coordinator responsibilities:

  • Confirm the patient’s plan type and whether it is one of our accepted Spravato plans
  • Verify Spravato coverage, benefit type (medical vs pharmacy), and prior authorization requirements
  • Document plan details, coverage notes, and any PA requirements clearly in the chart

Once basic eligibility and interest are confirmed, the Spravato Coordinator will:

  • Schedule the first Spravato intake/assessment labeled “Spravato Initial Assessment” in Tebra with the referring Spravato provider
3Spravato Initial Assessment

During the Spravato Initial Assessment, the provider will:

  • Complete a full psychiatric evaluation and confirm diagnosis (TRD or MDD indication)
  • Document prior antidepressant trials (medication, dose, duration, response/adverse effects)
  • Obtain baseline depression rating scale (e.g., PHQ-9, MADRS, BDI, HAMD, or QIDS)
  • Determine whether the patient is an appropriate candidate to proceed with Spravato pending PA approval
4Prior Authorization (PA) Process

After the Spravato Initial Assessment:

  • Spravato Coordinator prepares and submits the prior authorization according to payer policy
  • Coordinator works with Ashley to obtain PA approval and confirm final authorization details
  • All PA notes and documentation must be uploaded to the chart

Treatment cannot be scheduled until PA approval is received.

5Spravato Consult Scheduling (Post-PA Approval)

Once PA is approved, the Spravato Coordinator will:

  • Contact the patient to schedule a Spravato Consult with the treating provider (this visit occurs after the initial assessment and before starting Spravato treatment)

During the Spravato Consult, the provider will:

  • Review the PA approval and confirm clinical readiness to start Spravato
  • Complete all Spravato consent paperwork and clinic treatment agreements
  • Complete REMS enrollment with the patient and confirm registration is active
  • Review dissociation/sedation risks and clinic monitoring requirements
  • Reinforce transportation requirements (must have a ride; no driving rest of day)
  • Ensure all consents and documents are signed and uploaded to the chart

After the consult is completed and all documentation is finalized, the Spravato Coordinator will schedule the induction series (twice weekly for 4 weeks).

6Induction Visits and Monitoring

Administer Spravato under REMS requirements:

  • Confirm patient identity, dose, and transportation plan each visit
  • Monitor the patient for at least 2 hours after each dose
  • Complete rating scales as scheduled (e.g., PHQ-9, MADRS)
  • Document vitals, side effects, and patient response for every visit
7Week 4 Response Check

At the end of the induction phase (around week 4):

  • Re-assess rating scales and overall functioning
  • Document response, partial response, or non-response to treatment
  • Decide whether to continue to maintenance phase, adjust dosing frequency, or discontinue Spravato
8Maintenance and Reauthorization

For patients continuing treatment:

  • Continue weekly or every-2-week dosing as clinically indicated
  • Track rating scales and functional outcomes at regular intervals
  • Gather documentation needed for payer reauthorization (often every 6–12 months), including baseline vs current scores and a clinical narrative of benefit
9Discontinuation and Follow-Up

If stopping Spravato:

  • Clearly document the reason for discontinuation in the chart
  • Ensure a plan for ongoing medication management and therapy is in place
  • Discuss relapse prevention, safety planning, and follow-up visits

Spravato Provider and Staff Guide

Internal reference for Nebraska Peace of Mind staff and providers only. Use this page for quick clinical criteria, dosing, payer policies, and workflow steps for Spravato.

Always confirm coverage and follow REMS requirements and payer policies before scheduling an induction visit.

Treatment-Resistant Depression (TRD)
MDD with acute suicidal ideation or behavior
Spravato REMS certified clinic
Measurement-based care required

1. Clinical Criteria Cheat Sheet (High-Level)

TRD – Initial Therapy (general framework)

Treatment-Resistant Depression (TRD)

  • Diagnosis of major depressive disorder (recurrent or single episode) with treatment resistance.
  • Failure to respond to at least two adequate antidepressant trials or regimens (usually ≥8 weeks each at therapeutic dose).
  • Trials may include:
    • SSRIs, SNRIs, bupropion, TCAs, mirtazapine, MAOIs
    • Serotonin modulators (e.g., trazodone, nefazodone)
    • Augmentation with antipsychotics, lithium, or thyroid hormone (depending on payer policy)
  • Baseline depression rating documented before starting Spravato using at least one scale:
    • PHQ-9, BDI, HAMD, MADRS, or QIDS
Document each failed trial clearly in the note: medication, dose range, dates, duration (at least 6–8 weeks), and response or adverse effects. This is often required for prior authorization.
MDD + acute suicidal ideation/behavior

MDD with Acute Suicidal Ideation or Behavior

  • Diagnosis of major depressive disorder (per DSM-5-TR) with current acute suicidal ideation or behavior.
  • Spravato is used in conjunction with a newly initiated or optimized oral antidepressant.
  • Standard of care must include close monitoring and safety planning (often higher level of care or intensive follow-up).
For both TRD and MDD with suicidality, Spravato must be administered under direct supervision in our REMS-certified setting, with at least 2 hours of post-dose monitoring and safe transportation home.

2. Spravato Dosing Schedule (Adults – TRD)

Follow FDA label and payer policy

For adults with treatment-resistant depression (TRD), Spravato may be used as monotherapy or in conjunction with an oral antidepressant. Always confirm dose, frequency, and indication against the latest FDA label and payer policies.

Phase Timing Dosing Key Points
Induction Phase Weeks 1–4 56 mg or 84 mg twice per week Evaluate evidence of therapeutic benefit at end of week 4 to determine need for ongoing treatment.
Maintenance Phase 1 Weeks 5–8 56 mg or 84 mg once weekly Continue to monitor depression scores (PHQ-9, MADRS, etc.) and functional improvement.
Maintenance Phase 2 Week 9 and after 56 mg or 84 mg every 2 weeks or once weekly Individualize to the least frequent dosing that maintains remission/response. Adjust interval based on clinical response.
Recommended documentation at every visit: rating scale score (e.g., PHQ-9 or MADRS), suicidality assessment, vital signs, side effects, and functional status (work, school, family).

3. Spravato Patient Workflow (Internal) Page 1

This is a simplified workflow for new Spravato patients. Always follow internal SOPs and update this flow as we refine the process.

4. Accepted Insurance Plans for Spravato (Current)

The list below applies to Spravato only and may be different from general medication management coverage. Always verify benefits and confirm Spravato is covered for the specific plan.

Currently accepted for Spravato
  • UnitedHealthcare – Commercial Choice Plus plans
  • Cigna – Commercial plans
  • Blue Cross and Blue Shield of Nebraska – Nebraska Blue plans
  • Oscar Health Insurance – eligible plans per Oscar policy
Spravato only
Verify benefits every time
Check if PA is required
Not currently accepted for Spravato: Medicare, Medicaid, and exchange marketplace plans, unless specifically confirmed and documented as covered for Spravato at our clinic.
How to recognize eligible cards

Actual eligibility must always be verified through the payer.

UnitedHealthcare – Choice Plus (Commercial)
Look for:
  • UnitedHealthcare logo
  • "Choice Plus" wording on front of card
Reminder: confirm Spravato coverage and whether it is billed under the medical benefit and requires prior authorization.
Cigna – Commercial
Look for:
  • Cigna logo
  • Commercial wording (avoid Medicaid or Medicare products)
Avoid cards labeled Medicaid, HealthSpring, or Medicare unless specifically cleared. Always verify Spravato coverage.
BCBS Nebraska Blue
Look for:
  • Blue Cross and Blue Shield of Nebraska logo
  • "Nebraska Blue" or similar branding
Verify Spravato coverage and PA requirements; note any carve-outs or third-party behavioral vendors.
Oscar Health Insurance
Look for:
  • Oscar logo
  • Plan name and network details
Confirm that the plan and network allow Spravato at our location and whether a PA is required.

5. Payer Policy Links for Esketamine / Spravato

Use these links as references when reviewing coverage criteria. Policies update over time, so always confirm you are looking at the most recent version on the payer’s website.

Reference policy links
Reminder: Providers are responsible for documenting that clinical criteria are met and for using the appropriate codes based on the services rendered and payer requirements. When in doubt, consult the payer policy or our billing/RCM team.

6. Measurement-Based Care and Documentation

Many payers, including UHC, specifically require documentation of baseline and follow-up depression scores to show response or remission on Spravato. Recommended tools:

  • PHQ-9 – quick, patient-friendly, and easy to track over time.
  • MADRS, BDI, HAMD, or QIDS – can also be used depending on provider preference and payer requirements.
At minimum, record a baseline score before starting Spravato and repeat at regular intervals (for example: end of week 2, end of week 4, and prior to reauthorization requests). Clearly document changes from baseline, clinical response, and any functional improvement in work, school, and relationships.

7 Clinical Inclusion and Exclusion Criteria Spravato Eligibility

Use this section to quickly confirm whether an adult patient is appropriate for Spravato based on REMS, FDA labeling, and payer requirements.

Inclusion criteria
Eligible when all met
  • Age 18 or older
  • Diagnosis of Treatment-Resistant Depression (TRD)
  • Documented failure of at least two adequate antidepressant trials
  • Patient is taking or has been prescribed an oral antidepressant unless payer allows monotherapy
  • Can remain in clinic for at least 2 hours after dosing
  • Reliable transportation home with no driving the same day
  • Signed Spravato consent
  • Blood pressure within a safe range before dosing unless cleared by the provider
Exclusion criteria
Do not treat
  • Aneurysmal vascular disease or arteriovenous malformation
  • History of intracerebral hemorrhage
  • Uncontrolled hypertension
  • Active substance use disorder that increases risk of misuse or diversion
  • Current pregnancy or breastfeeding without documented risk-benefit discussion
  • Active psychosis or severe dissociative disorder unless cleared by psychiatrist
  • No driver or safe transport home
  • Inability to comply with REMS requirements or 2-hour observation
Requires provider review before proceeding
Escalate to provider
  • Recent medication changes or new serious medical diagnosis
  • Suicidal ideation with intent or plan
  • Elevated blood pressure or vitals concerns
  • Recent severe illness, hospitalization, or neurological symptoms
  • Concerns about oral antidepressant compliance
  • Any situation staff are unsure about — when in doubt, pause and ask
Front desk and nursing: If anything feels unsafe or unclear, do not administer Spravato until the provider evaluates the patient.

8 In-Clinic Protocol and Observation Requirements Visit Workflow

Every Spravato visit follows the same structure: arrival and screening, dosing, observation, and safe discharge.

Arrival & check-in
Dosing
2-hour observation
Safe discharge
Arrival
1
  • Patient checks in 10–15 minutes early
  • Verify ID, insurance card, consent, and driver
  • Confirm no food for 2 hours and no liquids for 30 minutes before
  • Complete PHQ-9 or other required scale
  • Obtain and record baseline vitals
Dosing
2
  • Provider confirms dose (56 mg or 84 mg)
  • Nurse or trained staff prepares device
  • Observe administration and coach proper technique
  • Document dose, lot number, and time given
Observation
3
  • Patient remains in clinic for at least 2 hours
  • Vitals every 40 minutes or more often if abnormal
  • Monitor for dissociation, nausea, dizziness, BP changes
  • Document mental status and side effects
Discharge
4
  • Confirm vitals are stable and within safe parameters
  • Patient is oriented, steady, and able to ambulate
  • Verify driver or safe transportation
  • Review any side effects and next appointment
  • Document discharge status and instructions
Staff must never release a Spravato patient to drive themselves home or leave alone. A safe ride is required every visit.

9 Emergency and Adverse Event Protocol Safety First

If you are worried about a patient’s safety at any point, stop and escalate to the provider. When in doubt, treat it as an emergency.

! Situations that require immediate escalation
Call 911 if there is chest pain, loss of consciousness, or imminent risk.
Hypertensive crisis
  • Systolic blood pressure over 180 or diastolic over 110
  • Stop treatment if not already done
  • Re-check BP every 5–10 minutes
  • Notify provider immediately and follow their instructions
  • Provider decides whether EMS or ED transfer is needed
Severe dissociation or psychotic symptoms
  • Notify provider immediately
  • Reduce stimulation: quiet room, calm voice, low lights
  • Stay with the patient and provide reassurance
  • Document course and provider interventions
Medical emergencies
  • Chest pain or shortness of breath
  • Loss of consciousness
  • Seizure activity
  • Any acute medical crisis
  • Call 911 and follow internal emergency procedures
Suicidal ideation with intent or plan
  • Provider performs risk assessment
  • Determine if ED transfer or crisis intervention is needed
  • Do not discharge if patient is unsafe
  • Document in detail: risk factors, protective factors, plan
Never leave a high-risk patient alone When in doubt, call the provider Document clearly and objectively

10 Documentation Requirements for Every Spravato Visit What Must Be in the Note

Documentation should support patient safety, clinical decision-making, and payer requirements for TRD.

Induction visits (Weeks 1–4)
  • Depression rating scale (PHQ-9, MADRS, or other approved tool)
  • Baseline and follow-up vitals during the visit
  • Dose, lot number, route, and time of Spravato
  • Observation notes at required intervals
  • Side effects, adverse events, and patient response
  • Provider note including symptoms, assessment, and plan
  • Confirmation of safe discharge and transportation home
  • Next scheduled treatment date and any changes in frequency
Maintenance visits (Week 5 and beyond)
  • Brief update on current depressive symptoms
  • Repeat PHQ-9 or other scale at least monthly
  • Dose used and adherence to oral antidepressant (if applicable)
  • Vitals, side effects, and any functional changes
  • Provider rationale for continuing, spacing out, or adjusting treatment
  • Any change in safety status (SI, HI, psychosis, substance use)
  • Longitudinal response (remission, response, partial response, non-response)
Provider consultation note should include
  • Symptom update and patient-reported outcome scores
  • Medication review and adherence
  • Safety assessment (suicidality, psychosis, severe anxiety, substance use)
  • Medical decision-making and risk/benefit discussion
  • Plan for dose, frequency, and follow-up
Good documentation protects patients, providers, and the clinic. If it is not documented, it did not happen.

11 Billing and Coding Reference for Providers E/M and Time-Based Coding

Providers must always code based on what is documented and follow each payer’s rules. This is a quick reference, not legal or billing advice.

Common E/M codes – new and established patients
Code Description (summary) Approximate time (when using time)
99204 New patient, moderate medical decision-making 45 minutes total time
99205 New patient, high medical decision-making 60 minutes total time
99214 Established patient, moderate medical decision-making 30 minutes total time
99215 Established patient, high medical decision-making 40 minutes total time
Prolonged services
Code When used Notes
99417 Prolonged outpatient E/M time beyond the primary code (commercial plans) Each additional 15 minutes beyond 99205 or 99215 when payer accepts 99417
G2212 Medicare / Medicare Advantage prolonged time Use instead of 99417 when required by payer rules
99415 / 99416 Prolonged clinical staff time with physician supervision First hour (99415) and each additional 30 minutes (99416)
Providers may bill either 99417 or G2212, but never both together. Always check payer-specific rules and confirm which codes are allowed on Spravato days.
Payer policy links – for reference and acknowledgment

Providers should review these policies and acknowledge they understand payer-specific criteria for TRD and Spravato coverage.

Current in-network Spravato plans at Nebraska Peace of Mind (for patient scheduling and eligibility):

  • UnitedHealthcare Commercial – Choice Plus
  • Cigna Commercial
  • BCBS Nebraska Blue
  • Oscar Health Insurance (commercial)
Updated 12/10/2025 SH