Prior Authorization Form _Target

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Prior Authorization Form _Target Powered By Docstoc
					                                                                           Montana Medicaid Youth
                                                                Unscheduled Revision Request Form
                                                                                               Targeted Case Manage ment (TCM)


Please type or print clearly.
REQUEST ED START DATE FOR T HIS REVISION:

NUMBER OF 15-MINUTE UNITS REQUEST ED:                                  (LESS THAN OR EQUAL TO 120 UNITS)

Youth Information
NAME:                                                                                                              MEDICAID NUMBER:


ADDRESS:                                                       CITY:                                               STATE:           ZIP:


SSN:                                                    DOB:                                                     GENDER:
                                                                                                                        Male   Female

IS THE PATIENT IN STATE CUSTODY?                              CURRENT PLACEMENT:
    Yes         No

Responsible Party who receives determination notifi cation (Li st CPS worker or probation officer when
applicable.)
NAME:


ADDRESS:                                                                            CITY:                          STATE:           ZIP:


RELATIONSHIP TO PATI ENT:           Parent        Go vernment Agency              Other Relative         Other


Responsible party is the person authorized to consent for medical treatment.

Provider Inform ation
PROVIDER NAME:


TCM NAME:


ADDRESS:                                                                            CITY:                          STATE:         ZIP:


PHONE NUMBER:                      FAX NUMBER:                             NPI NUMBER:                             TAXONOMY:



Clinical Information and Admission/Unscheduled Revi sion Criteria 1
Youth must have a serious emotional disturbance to qualify.
*SED must be verified once per state fiscal year
DATE OF MOST RECENT SED CLINICAL ASSESSM ENT:                                            COMPLETED BY:


                                 Note: Processing May Be Delayed if Information Submitted is Illegible or Incomplete.
Rev is ion Date: June 24, 2010                               Magellan Medic aid Administration, Inc.                               Page 1   Page 1
                                                                To transmit request information:
                                                         Fax 1-406-449-6253 Phone 1-866-545-9428
                                                Mail: 314 N. Last Chance Gulch, Suite 200W Helena, MT 59601
                                                                                            Unscheduled Revis ion Request Form: Targeted Case Management



Clinical Information and Admission/Unscheduled Revi sion Criteria 1
Youth must have a serious emotional disturbance to qualify.
*SED must be verified once per state fiscal year
DSM IV-TR DIAGNOSIS:

AXIS I              CODE:                                NARRATIVE:

AXIS II             CODE:                                NARRATIVE:

AXIS III

AXIS IV                             Mild                                                     Moderate                             Severe

AXIS V              NARRATIVE:

Include narrative to justi fy diagnosi s:



Complete thi s Section for Youth 6 through 17 Years Of Age
As a result of the youth's diagnosi s above, and for a period of at least six months, or for a predictable
period over six months the youth consi stently and persi stently demonstrates behavioral abnormality in
two or more spheres, to a signi ficant degree, well outside normative developmental expectations, that
cannot be attributed to intellectual, sensory, or health factors, check those that apply:
      (i) has failed to establish or maintain developmentally and culturally appropria te relationships with adult care givers or
      authority figures;
      (ii) has failed to demonstrate or maintain developmentally and culturally appropriate peer relationships;
      (iii) has failed to demonstrate a developmentally appropriate range and expression of emotion or mood;
      (iv) has displayed disruptive behavior sufficient to lead to isolation in or from school, home, therapeutic, or recreation
      settings;
      (v) has displayed behavior that is seriously detrimental to the youth's growth, development, safety, or welfare, or to the
      safety or welfare of others; or
      (vi) has displayed behavior resulting in substantial documented disruption to the family including, but not limited to,
      adverse impact on the ability of family members to secure or maintain gainful employment.

Describe Youth’ s Behavior that Meets above Criteria:



Complete thi s Section for Youth under 6 Years of Age
For youth under 6 to qualify with a SED, the youth exhibits a severe behavioral abnormality that cannot
be attributed to intellectual, sensory, or health factors and that resul ts in substantial impairment in
functioning for a period of at least six months and obviously predictable to continue for a period of at
least six months, as manifested by one or more of the following check those that apply:
      (i) atypical, disruptive, or dangerous behavior which is aggressive or self-injurious;
      (ii) atypical emotional responses which interfere with the child's functioning, such as an inability to communicate
      emotional needs and to tolerate normal frustrations;
      (iii) atypical thinking patterns which, considering age and developmental expectations, are bizarre, violent, or
      hypersexual;
      (iv) lack of positive interests in adults and peers or a failure to initiate or respond to most social interaction;
      (v) indiscriminate sociability (e.g., e xcessive familiarity with strangers) that results in a risk of personal safety of the child;
      or
      (vi) inappropriate and extreme fearfulness or other distress which do es not respond to comfort by care givers.

                                 Note: Processing May Be Delayed if Information Submitted is Illegible or Incomplete.
Rev is ion Date: June 24, 2010                                 Magellan Medic aid Administration                                      Page 2     Page 2
                                                                To transmit request information:
                                                         Fax 1-406-449-6253 Phone 1-866-545-9428
                                                Mail: 314 N. Last Chance Gulch, Suite 200W Helena, MT 59601
                                                                                            Unscheduled Revis ion Request Form: Targeted Case Management



Describe Youth’ s Behavior that Meets above Criteria :



Unschedul ed Revi sion Criteria (continued)
Unscheduled Revision Criteria includes meeting all of the admission criteria below.
*All authorized units must support activitie s in the four core areas.
Admi ssion Criteria 2: Has an asse ssment of the youth and family’s needs been completed on admission?
Describe the youth and family’s strengths, mental health and substance abuse treatment needs, and
servi ce and resource needs.


Admi ssion Criteria 3: Has a case management plan, with goals in the four core areas of case
management, been developed? Has the plan been updated every 90 days to reflect progre ss or barriers?
List the case management goals, describe the youth and family’s progre ss/barriers, and describe
progre ss towards gaining self-sufficiency.


Admi ssion Criteria 4: Has a cri si s plan for the youth and family been developed, and updated as needed?
Did the youth and family provide input and agree with the plan? Identify problems that may lead to a
mental health crisi s for the youth, the treatment team members and their respective roles and
responsibilities in implementing the plan.


Admi ssion Criteria 5: Has a discharge plan been developed and updated every 90 days a s needed?
Identify the anticipated discharge date from case management and the youth and family’s goals they
must meet for discharge to occur.



Other services youth i s currently recei ving
    Individual Therapy                              Family Therapy                                        Group Therapy
    Therapeutic Family Care                         CBPRS                                                 Respite
    CSCT                                            Day Treatment                                         Therapeutic Foster Care
    Acute Psychiatric Hospitalization               PRTF                                                  Therapeutic Group Home
    Partial Hospitalization                         Medication monitoring/compliance
NUMBER OF PSYCHIATRIC HOSPITALIZATIONS IN PAST 12 MONTHS:

NUMBER OF PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY STAYS IN PAST 12 MONTHS:

Services youth and family needs upon di scharge from case management
    Individual Therapy                              Family Therapy                                        Group Therapy
    Therapeutic Family Care                         CBPRS                                                 Respite
    CSCT                                            Day Treatment                                         Therapeutic Foster Care
    Acute Psychiatric Hospitalization               PRTF                                                  Therapeutic Group Home
    Partial Hospitalization                         Medication monitoring/compliance

UNSCHEDUL ED REVISION COMPLETED BY:
TITLE:                                                                                               DATE:



                                 Note: Processing May Be Delayed if Information Submitted is Illegible or Incomplete.
Rev is ion Date: June 24, 2010                                 Magellan Medic aid Administration                                      Page 3     Page 3
                                                                To transmit request information:
                                                         Fax 1-406-449-6253 Phone 1-866-545-9428
                                                Mail: 314 N. Last Chance Gulch, Suite 200W Helena, MT 59601
                                                                                            Unscheduled Revis ion Request Form: Targeted Case Management



                                        Magellan Medicaid Administration’ s Use Only
APPROVED: FROM:                                                               THROUGH:

DENIED:            FROM:                                                      THROUGH:

REVIEWER SIGNATURE:                                                                                  DATE:




                                 Note: Processing May Be Delayed if Information Submitted is Illegible or Incomplete.
Rev is ion Date: June 24, 2010                                 Magellan Medic aid Administration                                      Page 4     Page 4
                                                                To transmit request information:
                                                         Fax 1-406-449-6253 Phone 1-866-545-9428
                                                Mail: 314 N. Last Chance Gulch, Suite 200W Helena, MT 59601

				
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