Behavioral Health Initial form 1 - Home - AlohaCare · BEHAVIORAL HEALTH LOB: QUEST ACAP Service...

of 3

BEHAVIORAL HEALTH LOB: QUEST ACAP

Service Type: MH CD Dual DX Auth Request Type: Standard Retro

1. Provider/Facility:______________________________________

Contact Person:________________________________________

Big Island Maui Oahu

Molokai Kauai Lanai

Phone: Fax: Request Date:

2. 2. Member Name:_______________________________________________ Member ID:_______________________ DOB:_____/____/__________ Age:________ __

3. DSM/ICD 10 Diagnostic codes:

Primary:___________________________________________________

Secondary:_________________________________________________

__________________________________________________________

4. Medical Conditions:

______________________________________________________________

5. Z Codes: Please check areas of concern ( if applicable)

Primary Support Group Legal System/Crime Housing Economic Social Environment Occupational Access to Care Educational

Other:_________________________________________________________

7. Requested # of Sessions:_________________________________________

From:_________________ ___________To: ___________________________

8. Required Documentation: Please submit required clinical notes for either 6A or6B as listed below:

A. Outpatient Mental Health: Clinical Summary Behavioral Contract (If applicable)

B. Chemical Dependency/Dual Diagnosis: UA results Behavioral Contract (If applicable); progress notes and relapse prevention plan.

9. If this is a Retro-‐request please explain why: ___________________________

____________________________________________________________________

6. Level of Care Requested:

Social Detox Res PHP IOP LIOP OPS Methadone Maintenance 8. 10. Does member require an Interpreter? Yes No If yes, what language:___________________________________________________

Is Care Coordination requested: Yes No (If yes, please explain):____________________________________________________________________________________

QUEST only: Potential SMI/SPMI/SEBD: Yes No

INITIAL MENTAL HEALTH OUTPATIENT AND/OR CHEMICAL DEPENDENCY PRIOR AUTH REQUEST FORM

Contact Person

April 2016 Page 1 of 6

of 3

CLINICAL INFORMATION: (Please complete the following)

Substance Abuse Treatment History: Yes No (If Yes, please complete the grid below) Treatment #1 Treatment #2 Treatment #3 Treatment #4

Dates of TX: Facility: Level of Care: Substance: Length of TX: TX Outcome:

1. Why is member seeking treatment: ______________________________________________________________________________________________________________2. Any CWS (CPS) involvement? Yes No (If Yes, please provide name and phone # of CWS (CPS) worker):________________________________________________ 3. Any pending legal charges? Yes No (If Yes, please explain):___________________________________________________________________________________ 4. Probation/Parole officer name and # if applicable:_____________________________________________________________________ _____________________________5. Recent incarceration? Yes No (If yes, date of release):_________________________________________________________________________________________

6. Substance Use:Drug(s) of Choice: Age of Onset: Date of Last Use: Amount Used: How Often Used:

7. Psychiatric history? Yes No (If yes, please provide DX):________________________________________________________________________________________ 8. Any current psych. symptoms? Yes No (If yes, please describe):_________________________________________________________________________________

____________________________________________________________________________________________________________________________________________ 9. Potential safety risk? Yes No (If yes, please explain):_________________________________________________________________________________________

10. Current psychiatric medication? Yes No Unknown (If yes, please fill out box below): Medication Dose/Frequency Start Date Prescriber/Specialty

Is member adherent with meds? Yes No


of 3

ASAM DIMENSIONS (please explain all medium and high ratings) 1. Alcohol Intox. And/or Withdrawal Potential

• Any risk of severe withdrawal/seizures?• Any current signs of withdrawal?

LOW MED HIGH EXPLAIN

2. Biomedical Conditions & Complications• Any current physical illness (besides withdrawal) that may

impact course of treatment?• Is member pregnant? Yes No

3. Emotional/ Behavioral or Cognitive Conditions & Complications• Any psych. Illness or psychological, behavioral, or emotional

problems that may impact the course of treatment?4. Readiness to Change (Treatment Acceptance/Resistance)

• Is the member objecting/resistant to treatment?• What is the member’s readiness to change?

5. Relapse (Continued Use Potential)• Is the member in immediate danger of continued severe

distress, and drinking/drug behavior?• Does the member have any understanding of, or skills in

which to cope with his/her addiction problems in order toprevent relapse/continued use?

6. Recovery Environment• Are there family members, significant others, living

situations, or school/work situations that pose a threat to TXengagement and success?

• Does the member have supportive friendships, financial,educational, or vocational resources that will increase thelikelihood of successful TX?

Provider Signature: ______________________________________Date:_______________________

LEVEL OF CARE DETERMINATION: **For AC Use onlyLOC DATE OF

REQUESTSESSIONS START DATE END DATE TX PLAN

DUE DATETCDUE DATE

AUTH # CRITERIA USED

APPROVED: YES NO PARTIAL DATE OF DECISION: Reviewers signature____________________________ MD Signature:__________________________________

1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. BH Phone: 973-‐2475 (Oahu) or 1-‐888-‐875-‐4979 (NI). BH FAX: 973-‐6324 or 1-‐800-‐293-‐4580


1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. To contact the BH Dept., call 973-1650 (Oahu) or 1-800-434-1002 (NI). BH FAX: 973 -6324 or 1-800-293-4580

EXPLAIN

Page 3 of 3

ASAM DIMENSIONS (please explain all medium and high ratings)1. Alcohol Intox. And/or Withdrawal Potential

















DUE DATETCDUE DATE





1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. To contact the BH Dept., call 973-1650 (Oahu) or 1-800-434-1002 (NI). BH FAX: 973 -6324 or 1- 800- 293-4580


• Any current physical illness (besides withdrawal) that may impact course of treatment?• Is member pregnant?

2. Biomedical Conditions & Complications HIGHLOW MED

Yes No


EXPLAIN

1. Alcohol Intox. And/or Withdrawal Potential HIGHLOW MED

of 3


















DUE DATETCDUE DATE





1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. To contact the BH Dept., call 973-1650 (Oahu) or 1-800-434-1002 (NI). BH FAX: 973 -6324 or 1-800-293-4580

EXPLAIN

EXPLAIN

Page 3 of 3


















DUE DATETCDUE DATE






April 2016 of 6


4. Readiness to Change (Treatment Acceptance/Resistance) HIGHLOW MED

• Any psych. Illness or psychological, behavioral, or emotional problems that may impact the course of treatment?3. Emotional/ Behavioral or Cognitive Conditions & Complications HIGHLOW MED

of 3
















LEVEL OF CARE DETERMINATION: **For AC Use only LOC DATE OF

REQUEST SESSIONS START DATE END DATE TX PLAN

DUE DATE TC DUE DATE






EXPLAIN

EXPLAIN

Provider Signature: _____________________________Date:___________________

• Does the member have supportive friendships, financial, educational, or vocational resources that will increase the likelihood of successful TX?

• Are there family members, significant others, living situations, or school/work situations that pose a threat to TX engagement and success?

6. Recovery Environment HIGHLOW MED

• Is the member in immediate danger of continued severe distress, and drinking/drug behavior?

• Does the member have any understanding of, or skills in which to cope with his/her addiction problems in order to prevent relapse/continued use?

5. Relapse (Continued Use Potential) HIGHLOW MED

April 2016

Page 3 of 3
















LEVEL OF CARE DETERMINATION: **For AC Use only LOC DATE OF







1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. To contact the BH Dept., call 973-1650 (Oahu) or 1-800-434-1002 (NI). BH FAX: 973 -6324 or 1- 800- 293-4580 of 6

of 3
























LEVEL OF CARE DETERMINATION: ** FOR AC Use Only

Page 3 of 3


















DUE DATETCDUE DATE






April 2016 of 6

Behavioral Health Initial form 1 - Home - AlohaCare · BEHAVIORAL HEALTH LOB: QUEST ACAP Service...

Documents

Transcript of Behavioral Health Initial form 1 - Home - AlohaCare · BEHAVIORAL HEALTH LOB: QUEST ACAP Service...