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Psychological Evaluation Agreement

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Psychological Evaluation Agreement Powered By Docstoc
					Behavioral Health Department
                                             Psychological Evaluation Request (PER) Form

 Receipt of this report and subsequent BMC HealthNet Plan (“Plan”) authorization must occur prior to testing.
 Authorization determinations are made within the Plan’s utilization management timelines for review decisions.
 1. Recipient’s Information:
 Last name                                                  First name

 RID #:                                                                Date of Birth

 Address                                                                                 Zip
 DSM-IV Diagnosis:
 Axis I

 Axis II

 Axis III

 Axis IV

 Axis V current GAF                                         Highest GAF in past year



 2. Testing Referral Source:
         Recipient to be tested by primary outpatient provider
         Referral from other primary outpatient provider: Provider Name
         Referral from other agency (e.g. DSS, DMH, DMR, etc) Agency
         Referral from facility (e.g. residential, group home, etc) Facility
         School Referral for Chapter 766 testing:
              Initial chapter 766 evaluation
              Three Year Re-evaluation: Date of last Ch. 766 testing              /      /
              Attach a copy of a referral request from the special education department. This letter must
              specify “initial” or “three year” testing and the date of the last Ch. 766 testing, if the latter.

 3. Prior to testing history:
         None (May also send a release to inquire about past treatment covered by BMC HealthNet Plan to
         inquire about past testing)
         Date(s) of previous testing(s)                                Have you reviewed the report?
           Type of testing

 4. What is the clinical necessity for psychological/neuropsychological testing?




 5. What has prevented the determination of a diagnosis or effective treatment plan prior to this request?




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                       Psychological Evaluation Request (PER) Form (cont.)

Receipt of this report and subsequent Plan authorization must occur prior to testing. Authorization determinations are
made within the Plan’s utilization management timelines for review decisions.

6. Specific test(s) proposed:                  Units requested (one unit = one hour):

1.
2.
3.
4.
5.
6.
7.
8.
9.

                                                                               Total units requested:

7. The PER Form is necessary but not always sufficient for pre-authorization. To expedite an authorization
determination, attach a diagnostic evaluation summary or current treatment plan. In some instances, a prior
testing report may be require before a determination can be made. Again, pre-authorization review will be
expedited if this is forwarded at time of initial PER Form submission.


8. Provider Signature:                                                                            Date

Provider Name

Provider #                                                           FAX #

Address for return correspondence
Street
City/State                                                                           Zip Code




The number you will receive from the Behavioral Health Department for pre-authorization is a reference number. It is not a
guarantee of payment. Actual payment is based upon verification of medical necessity, verification that the service is a covered
benefit, and eligibility of the member on the date of service. Submitting cost and pricing information on an authorization request
does not guarantee payment at those rates. The Plan reimburses providers based on MassHealth rates unless otherwise specified in
their agreement with the Plan.

                                      BMC HealthNet Plan - Behavioral Health Department
                                     Two Copley Place, Suite 600, Boston, MA 02116-6597
                                       Behavioral Health Service Line: 1-866-444-5155
                      Electronic Fax Number: 617-897-0810, Traditional Fax Number: 617-748-6181


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