BEHAVIORAL HEALTH INITIAL CLINICAL REVIEW FORM ABA

Transcription

1 BEHAVIORAL HEALTH INITIAL CLINICAL REVIEW FORM ABA STAGE 1 Diagnostic/Risk Evaluation and Integrated Service Plan Development (Address all areas. An incomplete form may result in a delay of your request.) Submit completed form and MCO cover sheet by or fax. Date Form Completed: AGENCY/ PROVIDER INFORMATION Name Agency: National Provider ID (NPI): Address/Service Location: Facility/Program Contact (Name): Phone: Fax: Requested dates of service: Requested Number of Service Units (use table provided): Level of Care Requested STAGE 1 Diagnostic/Risk Evaluation and Integrated Service Plan Development Insert the number of units requested per service and provider. Description CPT Codes 1 st Modifier 2 nd Modifier 3 rd Modifier Units (U) requested Comprehensive Diagnostic Evaluation T1026 TG Comprehensive Diagnostic Evaluation T1026 TG U5 Targeted Diagnostic Evaluation T1026 HK Targeted Diagnostic Evaluation T1026 HK U5 October, 2105 Services are funded in part by the State of New Mexico Page 1 of 7

2 Treatment Plan Development ISP initial (comprehensive or targeted) Treatment Plan Development ISP initial (comprehensive or targeted) T1026 TG HI T1026 TG HI U5 NOTE PA is not required for ISP update without diagnostic evaluation MEMBER INFORMATION *Please complete applicable fields. Member Name (First/Last): Member ID or SSN: Member DOB: Member Age: Name of Legal Guardian: Guardian Address: Guardian Phone: Consumer s currently lives with (homeless, parents/siblings): Guardian Name/Phone: Status of DD Waiver: application/ waitlist/ approved (circle one) Have you had contact with the member s MCO care coordinator? Who is the care coordinator s point of contact at your agency? Provide the agency point of contact s and phone number. October, 2105 Services are funded in part by the State of New Mexico Page 2 of 7

3 SCREENING AND DSM DIAGNOSES Current DSM Diagnosis (Include all diagnoses and DSM codes): For Members With Established ASD or Are > 3 years of Age and Are Suspected of Having ASD: Please choose one of the following (either A or B): A. Member has an existing diagnosis of ASD Date of ASD diagnosis: By whom: B. Suspected of having ASD: Has member been screened for ASD? (yes/no) If yes, result (positive/negative): Date of screening: Performed by: Screening tools utilized (Level 1): Is level 1 screen considered valid? (yes/no): If yes, validity is based on : (e.g. Direct Observation, Member s development) Level 2 screen: Other information: ** (Documentation of Levels 1 and 2 screens, direct observation, history of member s development, and other information obtained must be submitted along with this prior authorization form.) For Members At Risk for Developing ASD: Is there concern by referring party that member (under 3 years of age) is at risk for ASD by virtue of his or her genetic status? (yes/no): Explain: October, 2105 Services are funded in part by the State of New Mexico Page 3 of 7

4 Is there concern that member is demonstrating developmental delay(s) and/or differences(s), including early manifestation of one or more ASD characteristics? (yes/no): Explain: Has a screener been conducted? (yes/no): Explain: Evaluations and other tests to rule out other conditions: List physical health diagnosis and treatment receiving October, 2105 Services are funded in part by the State of New Mexico Page 4 of 7

5 REASON FOR REFERRAL: BY WHOM: Describe member caregiver and natural supports available to assist in ABA services Has parent/guardian agreed to participate in Evaluation, Development of an Integrated Service Plan, and resultant recommended treatment? (Yes/No): Most Recent MH/SA Provider: Is the member active in a CSA? If yes, what CSA, and describe services receiving History of Out-of-Home Placements: Family/Guardian and/or Primary Support in the past year (including participation in lower LOC treatment, if parent/guardian has not been involved please give reason): Family History of Mental Health issues: October, 2105 Services are funded in part by the State of New Mexico Page 5 of 7

6 DESCRIBE CURRENT FUNCTIONING IN OTHER LIFE DOMAINS (Including school program, attendance, participation in outpatient therapy including adherence to medications, leisure activities): Language/Spiritual/Cultural Factors (How will these affect treatment engagement? Be sure to incorporate into treatment plans.): MENTAL STATUS EXAM MSE was completed by (Name): Date Completed: If not completed, why not? Appearance and behavior (posture, gestures, attire, facial expressions and speech): Attention (normal, alter, impaired): Mood (normal, euphoric, agitated, sad, etc.): Affect (appropriate, inappropriate, flat, etc.): Perception (hallucinations, delusions, etc.): Thought Content/Process (logical, de-realizations, SI/HI, etc.): Orientations (time, person, place, circumstances): Insight (good/fair/poor/absent): Activities of Daily Living (i.e. within normal limits, impaired): Sleep (e.g. disturbed, early morning awakening, etc.): October, 2105 Services are funded in part by the State of New Mexico Page 6 of 7

7 CURRENT MEDICATIONS (List all MH/SA and Medical) Name: Dose: Frequency Taken: Date Started: Prescriber: Is member adherent to medication (Yes/No)? If No, why not? Response to medication: October, 2105 Services are funded in part by the State of New Mexico Page 7 of 7