Behavioral Health Service Request Form Applied Behavior Analysis(ABA) For Autism Spectrum Disorder

Transcription

1 Behavioral Health Service Request Form Medicaid South Carolina Place of Serv ice 11 Office 12 Home 22 Outpatient Hospital 53 Community Mental Health Center Other (prov ide code) Last Name Phone Third Party Insurance Yes No First Name, Middle Initial MEMBER INFORMATION Date of Birth WellCare ID Gender Male Female If Yes, please attach a copy of the insurance card. If the card is not available, provide the name of the insurer, policy type, and number. Languages Spoken TREATING PROVIDER/PRACTITIONER INFORMATION Last Name First Name NPI WellCare ID Street Address Phone Participating Yes No Discipline/Specialty City, State Fax FACILITY/AGENCY INFORMATION Office Contact Name Facility ID NPI Street Address Phone City, State Fax Office Contact BOARD CERTIFIED BEHAVIOR ANALYST INFORMATION For ABA serv ices: Is provider certified to prov ide ABA consistent services as defined by state s licensing requirements? No Yes N/A per state s licensing requirements ZIP ZIP Hav e ABA serv ices been ordered by a board-certified psychiatrist, psychologist or pediatrician qualified to prov ide ABA oversight? No Yes: include copy of BCBA Order Name of BCBA professional who will superv ise services: BCBA certification #: Degree/License: Service Type Requested Applied Behav ior Analysis REQUESTED SERVICES List CPT Code(s) of Units of Each CPT Code Requested Serv ice Request Start Date:

2 Proudly serving Healthy Connections members. Behavioral Health Service Request Form DIAGNOSIS The follow ing are mandatory fields. ABA service requests w ill not be processed if the diagnostic section is not fully completed. Diagnosis Information Assessment Information When w as the Autism Spectrum diagnosis established? Date: When did the most recent assessment occur? By whom?(include full name and credentials) Current IQ lev el: DSM or ICD Diagnosis With or without accompanying intellectual impairment With or without accompanying language impairment Associated with a known medical or genetic condition or env ironmental factor With catatonia Primary Members who are < 18 years old must hav e a diagnosis of one of the following: (Lev el 1, Lev el 2, or Lev el 3) Social (Pragmatic) Communication Disorder Or, a prev ious DSM IV diagnosis of one of the following: o Asperger s Disorder (Asperger Syndrome) o Perv asive Developmental Disorder,not otherwise specified o Childhood Disintegrativ e Disorder (CDD) o Rett Disorder (Rett Syndrome) Psychosocial Barrier, if applicable: Secondary Co-occurring Diagnosis, if applicable: Medical Summary of function capacities and areas of impairment RATIONALE FOR REQUEST AND TREATMENT HISTORY Assessment and clinical tool(s) used for diagnosis (i.e., BLA, Preference Assessment, FBA, ABLL S-R, VB-MAPP) Biopsychosocial summary including household members, env ironmental factors and medical issues, current educational situation and school serv ices What type of treatment components will be prov ided?

3 Behavioral Health Service Request Form Current Psychotropic Medications (if applicable): Medication Name: Dosage: Please explain the current treatment modalities and serv ices in place: Area of Concern #1 TREATMENT PLAN (attach baseline lev el data for each area of concern) Attainment date

4 Interv entions emphasizing generalization of skills and focus on the dev elopment of spontaneous skills and appropriate behav iors Behavioral Health Service Request Form Area of Concern # 2 (attach baseline level data for each area of concern) Attainment date Interv entions emphasizing generalization of skills and focus on the dev elopment of spontaneous skills and appropriate behav iors Area of Concern # 3 (attach baseline level data for each area of concern)

5 Behavioral Health Service Request Form Attainment date Interv entions emphasizing generalization of skills and focus on the dev elopment of spontaneous skills and appropriate behav iors Is the child: Attach additional pages if necessary to identify other areas of concern TRANSITION PLAN Beginning treatment Transitioning from a home-based intensiv e ABA-based program to a lesser lev el of care Transitioning from a most to least restrictiv e setting Transitioning from a home-based ABA interv ention program to a school-based program Projected transition plan/s: If clinically necessary, what are the prev ention plan and/or resolution of crises? (i.e., behavior, consequences, antecedents, de-escalation procedures, prev ention, baseline) Is there a crisis plan in place? No Yes: What is it? How will member transition into adulthood? Projected criteria for discharge: Expected discharge date: Next lev el of care:

6 Behavioral Health Service Request Form Area of Concern # 2 (attach baseline lev el data for each area of concern) Attainment date Interventions emphasizing generalization of skills and focus on the dev elopment of spontaneous skills and appropriate behaviors Area of Concern # 3 (attach baseline lev el data for each area of concern) Attainment date Interventions emphasizing generalization of skills and focus on the dev elopment of spontaneous skills and appropriate behaviors Is the child: Attach additional pages if necessary to identify other areas of concern TRANSITION PLAN Beginning treatment Transitioning from a home-based intensiv e ABA-based program to a lesser lev el of care Transitioning from a most to least restrictiv e setting Transitioning from a home-based ABA interv ention program to a school-based program Projected transition plan/s: If clinically necessary, w hat are the prev ention plan and/or resolution of crises? (i.e., behavior, consequences, antecedents, de-escalation procedures, prev ention, baseline) Is there a crisis plan in place? No Yes: What is it? How w ill member transition into adulthood? Projected criteria for discharge: Expected discharge date: Next lev el of care: