Behavioral Health Service Request Form Detox and Substance Abuse Rehab
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1 Please Submit to the Dedicated Fax Line Below Medicaid Call for Pre-Certification of Admissions: New Jersey Medicaid Fax: Lev el of Care: Place of Serv ice: Detox Substance Abuse Rehab 21- Inpatient Hospital 51- Inpatient Psychiatric Hospital Facility 56- Psychiatric Residential Treatment Center 55- Residential Substance Abuse Treatment Last Name Phone Third-Party Insurance Yes No MEMBER INFORMATION First Name, Middle Initial 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 SERVICE TYPE REQUESTED REV/HCPCS Code(s) Serv ice Type: REV/HCPS Code : Detox Rehab Serv ice Request Start Date: Projected Length of Stay: City, State Fax Original Admission Date (if different from Start Date Requested): Office Contact Transition of Care ZIP ZIP Continuation of Care Primary Diagnosis Secondary Diagnosis Medical Diagnosis DIAGNOSIS Code and Description
2 Are serv ices requested ordered by court? If yes, please submit a copy of the court order and all supporting documentation. Current CIWA Score: COW Score: Current ASAM Dimension: Scores Date Problem Began: Presenting problem to be addressed by treatment plan: INITIAL REVIEW REQUESTS (See Continued Stay Review for Concurrent Reviews) PRESENTING PROBLEM Duration: Is member currently intoxicated? Is member currently experiencing withdrawal symptoms? Does the member hav e a history of delirium tremens or withdrawal seizures? If yes, please describe: Is there a trigger ev ent identified? Please describe: Substance Method Amount Frequency First Used Last Used Please check all withdrawal symptoms the member is experiencing: Psychological/Physical Hand Tremors Impaired attention /memory Changes in mood/personality (behav ior) Psychomotor agitation Sweating/Weakness Nausea/Vomiting Anxiety/Irritability Nystagmus Fluctuating v ital signs Muscle/Bone/Joint Aches Insomnia Stomach Cramps Vital Signs: Has member been medically cleared? CURRENT IMPAIRMENTS Scale: 0 = none; 1 = mild; 2 = moderate; 3 = sev ere; N/A = not assessed Check the current lev el of impairment for each category and prov ide a brief description: Symptom Scale Description Symptom Scale Description Depressed Mood Nausea and Vomiting Substance Abuse/ Dependence Agitation
3 Tremor Paroxysmal Sweats Unstable Vital Signs Delusions Tactile Disturbances Auditory Disturbances Socially Withdrawn/Isolating Poor Impulse Control Drug Seeking Behav iors Generalized Anxiety Visual Disturbances Memory Impairment Impaired Judgement Headache, fullness in Head Orientation and Clouding of Sensorium Interpersonal Conflict (hostile, intimidating) Crav ings/preoccupation with Substances Work/School Problems Suicidal/Homicidal: Ideation Plan Means (Include prev ious attempts and dates) Hallucinations: Auditory Visual Command (Include examples and dates) CURRENT/PREVIOUS TREATMENT Indicate if any of the following are inv olv ed in the member s care and list Prov ider? Psychiatrist: Prov ider: PCP: Prov ider: Integrated Health Home: Prov ider: If yes, when was the member last seen and what services are being rendered? Is member currently receiv ing Outpatient services? Any Prev ious Inpatient, Residential/Rehab, PHP, or IOP treatment? Level of Care Name or Provider / Facility Dates Successful Inpatient / Detox: Substance Abuse Rehab: IOP/PHP: Outpatient: If treatment was not successful, please explain: Please explain why the member cannot be managed safely in a less intensiv e level of care:
4 Please list any other treatment receiv ed ov er the past two years: Name of Prov ider/facility Dates Compliant SUPPORT SYSTEMS & PERFORMANCE Relationship/Supports (Identify issues/concerns? Is support av ailable? Is support substance free?) What are the env ironmental/community stressors and/or supports that contribute to the member s clinical status? Describe the member/family engagement in treatment: Is the member at risk of legal interv ention or out-of-home placement? (describe) Role performance school/work: CURRENT MEDICATIONS (Psychotropic and Medical) Medication Dosage Frequency Compliant Are there any medication contraindications? If yes, please describe: Detail the expected discharge plan: ATTACHMENTS
5 Current Treatment Plan Incident Report(s) Psychological Report Psychiatric Report Other: CONTINUED STAY REVIEW For continued stay, prov ide a narrativ e of the current symptoms/behav iors that hav e occurred within the past week that support the need for residential care. Summarize the progress or lack of progress and justification for continued stay. If there is no documented progress, explain how this is being addressed. Continued symptoms/behav iors: Current CIWA Score: COW Score: Current ASAM Dimension Scores : Scale: 0 = none; 1 = mild; 2 = moderate; 3 = sev ere; N/A = not assessed Check the impairment lev el for each category and prov ide a brief description Functioning Symptom Scale Description Symptom Scale Description Complete assignments Crav ings/preoccupation with substances Withdrawal symptoms Ability to follow instructions Perform ADLs Drug-seeking behav iors Types of services offered Total number of sessions attended Total number of sessions missed Is member cooperative w ith treatment? Individual Therapy Please provider an explanation of any no responses Group Therapy Substance Abuse Counseling Family Therapy Psychiatric Interventions CURRENT MEDICATIONS (Psychotropic and Medical) Medication Dosage Frequency Compliant
6 Are there any medication contraindications? If yes, please describe: Detail changes to the discharge plan: ATTACHMENTS Current Treatment Plan Incident Report(s) Psychological Report Psychiatric Report Other:
Behavioral Health Service Request Form Detox and Substance Abuse Rehab
Please Submit to the Dedicated Fax Line Below Medicaid Call for Pre-Certification of Admissions: 888-588-9842 South Carolina Medicaid Fax: 888-339-8293 Lev el of Care: Place of Serv ice: Detox Substance
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Arkansas 855-538-0454 Connecticut 855-538-0454 Florida 855-538-0454 Georgia 800-424-5412 Illinois 800-504-2766 Kentucky 855-620-1861 Louisiana 855-538-0454 Arkansas 855-710-0159 Connecticut 888-365-3233
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