Magellan Healthcare ABA Treatment Plan/Concurrent Review Member s Name: Member s DOB: Insurance ID#: Guardian Name and phone number: Agency Name and address: Agency Tax ID # and NPI #: Agency contact name and phone number: Date ABA services began: Location of services: Home Office Community School Other: Service Schedule: Other Services: Speech Therapy Occupational Therapy Physical Therapy Diagnosis: Medications: Allergies: Is this member currently enrolled in school with an IEP? Yes No If No please provide rationale why there is no IEP in place. Also, include what the family s plan is to have the member enrolled in school/iep. Background Information (i.e. history of ABA and treatment results, parent(s) knowledge of ABA, prior services received in the home, school, or community and at what rate, etc.): Behavior Reduction Goals (please copy the graph for each of your goals) : Target Maladaptive Behavior Name Definition of behavior Function Proactive Strategies Reactive Strategies Behavior Reduction Goal
Enter Graph: of behavior Adaptive Assessment You may use either the ABAS-3 or the Vineland, but you must use at least one of these evaluations on an ongoing basis and will submit a refresh with each report. ABAS-3 Scoring Information Categories GAC Conceptual Social Practical Percentile Rank Percentile Rank Classification Classification ABAS-3 Skill Areas Classification Classification Communication Community Use Functional Pre- Academics Home Living Health and Safety Leisure Self-Care Self-Direction Social Motor Vineland Adaptive Behavior Scales, 2 nd Edition Scores: Domain Communication Daily Living Skills Receptive Expressive Personal Domestic Community Standard Score Standard Score 95% Confidence Interval Age Equivalent Adaptive Level
Socialization Interpersonal Relationships Play and Leisure Time Coping Skills Motor Skills Fine Motor Gross Motor Adaptive Behavior Composite Maladaptive Behavior Index Internalizing Externalizing Other Standard Score- this score should never change Standard Score-The standard scores reported have an average of 100 and a standard deviation of 15. The confidence intervals are a range of scores that reflect a high probability that an individual s true score falls within that range. Age-equivalents indicate the average age of the individual from the Vineland-II normative sample who obtained the same raw score as the individual currently being assessed. Adaptive bevels are scored on a 5 point scale from Low to High. Skill Acquisition goals (Please copy the chart and enter a new chart for each goal. You are not required to have a goal for every area) Communication Goal(s) Adaptive Living Skills Goal(s)
Socialization Goal(s) Caregiver Training Goals: (Please copy the chart for every caregiver goal. You are required to have and track caregiver goals) Caregiver goal with mastery criteria Caregiver goal with mastery criteria
Discharge Criteria: What is the estimated length of treatment for this member? Based on developmental assessment, baseline, age, and progress towards treatment goals, what is the clinical expectation on level of functioning? Transition Plan: Note: It is imperative that a realistic exit criterion is established. Please factor in baseline, proposed length of treatment, and the age of the member when creating the transition plan/exit criteria. Summary of Member s Progress: Recommended Services: CPT Code Description # hours per week Direct Services Supervision of ABA and Treatment Planning Caregiver Training Social Skills Group Location of Service Additional information for consideration: Signature with degree/licensure: