Guide to Integrating SPRAVATO® Treatment

Spravato Provider and Staff Guide

Internal reference for Nebraska Peace of Mind staff and providers only. This page includes quick criteria, standardized workflow, documentation tools, onboarding and audit resources for Spravato.

Operational authority: Spravato SOP + Policy Book. Use the checklists and note templates every time.

REMS clinic workflow
Provider on-site required
2-hour monitoring minimum
Measurement-based care
Induction 2x weekly x 4 weeks
Stabilization 1x weekly x 2 weeks
Do not schedule or administer Spravato unless coverage/payment arrangements are confirmed and staffing coverage is confirmed. Provider must remain on-site while Spravato patients are in observation.

0. Program Documents (Internal)

Add your internal links below (OneDrive/SharePoint/Staff Hub)
  • SOP (Spravato Program SOP): Add link
  • Policy Book (Spravato Policies): Add link
  • Training Manual (Role-based): Add link
  • Staff Onboarding Guide (Required Read + Attestation): Add link
  • Audit Readiness Overview (Front door for audits): Add link
  • Deployment & Integration Plan (Phase 4): Add link

Onboarding rule

No Spravato duties until onboarding checklist is completed and signed.

Audit posture

Provide Audit Readiness Overview first. Provide SOP/Policies only if requested.

Chart standard

Initial + treatment note each session + reassessment at required intervals.

1. Clinical Criteria Cheat Sheet (High-Level)

TRD eligibility (operational summary)

Treatment-Resistant Depression (TRD)

  • Age 18+.
  • MDD/TRD diagnosis documented.
  • Inadequate response/intolerance/loss of efficacy to at least 2 antidepressant trials documented (include dose, duration, outcome).
  • Baseline standardized severity documented (MADRS or HAM-D preferred; PHQ-9 may be tracked additionally).
  • Ongoing clinical benefit and medical necessity must be shown to continue (reassessment required).
Minimum documentation for PA: diagnosis, two failed trials with details, baseline score (MADRS or HAM-D), risk assessment, and a clear plan for induction + reassessment.
MDD with acute suicidal ideation/behavior

MDD with Acute Suicidal Ideation or Behavior

  • MDD diagnosis documented with current suicidal ideation/behavior.
  • Used with newly initiated or optimized oral antidepressant.
  • Safety planning, close monitoring, and follow-up plan documented.
Spravato must be administered under direct supervision in the REMS setting with a minimum 2-hour observation and safe transportation home.

2. Program Phases (Scheduling Standard)

Operational standard at NPM

Standard scheduling framework used for program planning. Clinical adjustments are provider-directed and must be documented.

Phase Timing Frequency Documentation requirement
Induction Weeks 1–4 Twice weekly Session note every visit + baseline tool documented before first dose
Stabilization Weeks 5–6 Once weekly Session note every visit + reassessment after induction/early maintenance
Maintenance Ongoing Typically weekly or every other week Session note each visit + reassess at regular intervals for continued medical necessity
Provider must remain on-site while Spravato patients are in observation. Support staff must be present during treatment hours. No provider may be alone in the building with Spravato patients.

3. Spravato Patient Workflow (Internal)

This is the standardized workflow. Use the operational checklists and document each step.

1Intake and screening
Confirm basic eligibility (18+, MDD/TRD), confirm ability to attend in-person and comply with no-driving rule, schedule initial assessment.
2Initial assessment
Provider completes Spravato assessment, baseline MADRS or HAM-D, risk assessment, medical review, informed consent, plan.
3PA + financial review
Coordinator submits PA with required documentation, reviews deductible/OOP/coinsurance, discusses WithMe rebate process if eligible.
4Schedule induction
Schedule only after coverage/payment arrangements and staffing coverage are confirmed. Ensure transportation plan for every visit.
5Day-of-treatment
Check-in, vitals, provider pre-dose check-in, administer per REMS, monitor minimum 2 hours, document session note, discharge with ride.
6Reassessment + continuation
Reassess after induction and at regular intervals. Document objective scores, response, tolerability, and ongoing medical necessity.
7Maintenance planning
Adjust frequency per response to least frequent interval that maintains benefit, with ongoing documentation and periodic reassessment.
8Quality + audit readiness
Use checklist compliance, chart spot-checks, and keep onboarding attestations. Provide Audit Overview first if requested externally.
Coverage and staffing rule
Provider must be on-site during all Spravato treatment sessions and may not leave the facility while Spravato patients are in observation. Support staff must be present. No provider alone in the building with Spravato patients.

4. Operational Checklists (Use Every Time)

These are the required checklist categories from the SOP appendices. Link your internal versions above or paste them into your staff hub.

Intake and eligibility checklist
  • 18+ and MDD/TRD documented
  • Two failed trials documented (medication, dose, duration, outcome)
  • Contraindications reviewed (BP, CV history, neuro history, etc.)
  • Transportation plan confirmed (no driving)
  • Patient understands in-person time commitment
PA and insurance checklist
  • Initial assessment signed
  • Medication history clearly documented
  • Baseline MADRS or HAM-D documented
  • Risk assessment documented
  • PA submitted and tracked to decision
  • Financial responsibility reviewed and documented
  • WithMe rebate discussed if eligible
Day-of-treatment checklist
  • ID verified, transportation confirmed
  • Payment collected if applicable
  • Pre-dose vitals documented
  • Provider check-in completed and approved to proceed
  • Administer per REMS protocol
  • Observe minimum 2 hours; monitor vitals/mental status
  • Document adverse effects, interventions, discharge criteria
  • Next visit scheduled
Reassessment timing checklist
  • Baseline score documented prior to first dose
  • Reassess after induction (Weeks 4–6)
  • Continue reassessment at regular intervals during maintenance
  • Document response, tolerability, continued medical necessity
Coverage and staffing checklist
  • REMS-certified provider on-site
  • Support staff present during treatment hours
  • No provider alone with Spravato patients
  • Emergency protocols accessible

5. Documentation Standards (Notes and Examples)

Required note types
  • Initial Spravato Assessment (prior to first dose)
  • Treatment / Progress Note (every Spravato session)
  • Reassessment Note (after induction and at regular intervals during maintenance)
Documentation must support medical necessity, include objective measurement (MADRS or HAM-D), include safety/risk assessment, and be completed timely.
Initial Spravato Assessment key elements (quick view)
  • HPI with detailed medication trials and outcomes
  • Medical contraindication review (BP/CV/neuro)
  • Baseline MADRS or HAM-D documented
  • Risk assessment and protective factors
  • Medical necessity statement + plan (induction + reassessment timeline)
  • Informed consent documented
Treatment / Progress Note key elements (every visit)
  • Pre-dose vitals and brief symptom update
  • Provider pre-dose check-in and approval
  • Dose and administration time
  • Monitoring/observation summary (2 hours minimum)
  • Adverse effects and interventions if needed
  • Discharge condition + plan
Reassessment key elements (continuation decision)
  • Treatment course summary (number, dose, frequency)
  • Updated MADRS or HAM-D score and comparison to baseline
  • Functional changes and tolerability
  • Clear continuation/adjustment/discontinuation decision

6. Medical Necessity (Provider Fill-in Template)

Use the concise medical necessity letter for PAs, appeals, and re-authorizations. Copy into the chart or attach per payer requirements.

Template location
Quick medical necessity checklist (what must be present)
  • Diagnosis (MDD/TRD) and severity
  • At least two failed antidepressant trials with details
  • Baseline MADRS or HAM-D score
  • Safety/contraindication review
  • Risk assessment
  • Clear plan (induction + reassessment)

7. Staff Onboarding (Required)

Rule
No Spravato duties until the onboarding checklist is completed and the training acknowledgment is signed. Completed acknowledgments must be retained per NPM recordkeeping policy.
Onboarding guide
Role-specific onboarding summary
  • Front Desk: scripts + scheduling rules + escalation triggers + financial policy basics
  • Coordinator: PA workflow + financial education + documentation of communications
  • Support staff/MA: vitals + monitoring + red flags + discharge process
  • Providers: eligibility + reassessment policy + documentation policy + coverage rules

8. Audit and Compliance Defense

Audit response protocol (internal)
  • Designate leadership contact for all audit communications.
  • Provide the Audit Readiness Overview first.
  • Provide SOP/Policy Book only if requested.
  • Document all audit communications.
Keep an audit packet ready: Audit Readiness Overview + current SOP + Policy Book + training acknowledgments + sample de-identified notes.
Audit documents

9. Accepted Insurance Plans for Spravato (Current)

Always verify benefits and confirm Spravato coverage for the specific plan. Coverage may differ from general medication management.

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.

10. Payer Policy Links for Esketamine / Spravato

Policies update over time. Always confirm the most recent version on the payer’s website.

Reference policy links
Providers must document that criteria are met and must document objective symptom measures and clinical response for continuation. For coding/billing questions, consult billing/RCM.

11. Measurement-Based Care and Reassessment

Objective measurement is required for baseline and continuation decisions. Preferred standardized tools: MADRS or HAM-D. PHQ-9 may be used as an additional tracking tool.

Baseline requirement
Document baseline MADRS or HAM-D before first Spravato dose.
Reassessment timing
Reassess after induction (Weeks 4–6) and at regular intervals during maintenance.
Reassessment note must include: updated score, comparison to baseline, functional response, tolerability, and a clear continuation/adjustment/discontinuation decision.

12. Phase 4 Deployment Notes (Tebra + Enforcement)

Tebra build-out
  • Create templates: Initial Assessment, Treatment/Progress Note, Reassessment Note.
  • Create smart phrases: medical necessity, induction plan, maintenance plan, discharge/transportation acknowledgment.
  • Run periodic chart spot-checks for completeness and reassessment timing.
Phase 4 is complete when templates are live in Tebra, all Spravato staff have signed onboarding acknowledgment, and the audit packet folder is assembled and accessible to leadership.

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