Fillable Autism Spectrum Disorder (ASD) Authorization Form (Absolute Total Care)

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Autism Spectrum Disorder (ASD) Authorization Form (Absolute Total Care)

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The Autism Spectrum Disorder (ASD) Authorization Form (Absolute Total Care) form is 2 pages long and contains:

  • 2 signatures
  • 10 check-boxes
  • 53 other fields

Country of origin: US
File type: PDF

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SUBMIT TO
Utilization Management Department
Phone 1-866-534-5976 | Fax 1-866-694-3649
Autism Spectrum Disorder (ASD) Authorization Form
MEMBER INFORMATION
Member Name: ______________________________________________
Date of Birth:
Age:
Medicaid ID #: _____________________________________________________
________________________________________________ Phone #: _________________________________________________________
_______________________________________________________ Gender: Male Female
BILLING PROVIDER
Provider Name: ______________________________________________
Provider NPI:
Contact Name:
Phone #:
Tax ID: ____________________________________________________________
________________________________________________ Provider Address:____________________________________________________
_______________________________________________ __________________________________________________________________
___________________________________________________ Fax #: _____________________________________________________________
SUPERVISING PROVIDER
Provider Name: ______________________________________________ _________________________________________________
Tax ID:
Provider Address:
Group/Facility Name:
_____________________________________________________ Provider NPI: _______________________________________________________
____________________________________________ Phone #: __________________________________________________________
___________________________________________________________ Fax #: _____________________________________________________________
DIAGNOSTIC AND TREATMENT INFORMATION
Primary Diagnosis (Required): __________________________________ ________________________________________________________ Secondary:
Prior Treatment Relative to Diagnosis: _________________________________________________________________________________________________
Standardized Tools Used for Diagnosis: ________________________________________________________________________________________________
Diagnosis Date: ______________________________________________ Is this Member in School? Yes No
Medical Conditions as Reported by Parent or Guardian: ___________________________________________________________________________________
List Prescribed Medications and Dosages: _____________________________________________________________________________________________
Does the Member have an IEP or 504 Plan? Yes No Does the Member Receive Early Intervention Services? Yes No
Please Describe Other Services Received in Addition to the ABA Requested, Including but not Limited to, Physical Therapy, Occupational Therapy and Speech
Therapy, or Mental Health Services: ___________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
Is This an Intitial Request for Authorization? Yes No Date of ASD Treatment: _____________________________________________
Date of Most Recent Reassessment: ______________________________
ABSOLUTE TOTAL CARE | PAGE 1
ATC03202019P1
AUTHORIZATION INFORMATION
Start Date: End Date: _________________________________________
*Please note that prior authorization is required. Retrospective dates will not be processed. Please submit retrospective date requests to: 1866714-7991.
_________________________________
Code Description Time Total Units
Requested
97151
BehaviorIdenticationAssessment Per 15 minutes
97152
BehaviorIdenticationSupportingAssessment–ByTechnician Per 15 minutes
0362T
BehaviorIdenticationSupportingAssessment–
TwoorMoreTechnicians Per 15 minutes
97162
Adaptive Behavior Treatment Protocol Per 15 minutes
0373T
AdaptiveBehaviorTreatmentwithProtocolModication–TwoorMoreTechnicians Per 15 minutes
97155
AdaptiveBehaviorTreatmentwithProtocolModication–B
yTechnician Per 15 minutes
97154
GroupAdaptiveBehaviorTreatment–By Technician Per 15 minutes
97158
GroupAdaptiveBehaviorTreatment–Two or More Technicians Per 15 minutes
97156
FamilyAdaptiveBehaviorTreatmentGuidance–By Technician Per 15 minutes
97157
FamilyAdaptiveBehaviorTreatmentGuidance–Two or More Technicians Per 15 minutes
Please submit the information noted below with all treatment requests. If documentation is not received, the request will be reviewed based on the information
available at the time of review.
For initial assessment, please submit: Comprehensive diagnostic information, including standardized measures and referral from diagnosing provider for
Applied Behavioral Analysis services to include estimated duration of care.
For initial treatment plan please submit:
• Objectivetestingshowingsignicantbehavioraldecit.
•
Description of coordination of services with other providers
(e.g. school, PT, OT, ST).
Proposed treatment schedule including the provider type who will render
services.
•
Proposed functional and measureable treatment goals with expected time
frameswhichtargetidentiedbehaviordecits.
• Proposed plan for parent involvement and training and parent’s goals for
outcomes.
• Any medical conditions that will impact outcomes of treatment.
•
Copy of IEP, 504, or IFSP if applicable.
•
For subsequent treatment requests, please submit:
• Objective measures of current status.
• Objectivemeasuresofclinicallysignicantprogresstowardseachstated
treatment goal.
• Updated plan for treatment including updated goals and timeline for
achievement.
• Any necessary changes to the treatment plan.
• Developmentaltestingwhichshouldhaveoccurredwithinthersttwomonths
of treatment.
Supervising Provider Signature: ______________________________________________________________ Date: _______________________________
By signing above, I attest that I am actively participating in the treatment plan and coordinating services for the member.
Billing Provider Signature: ___________________________________________________________________ Date:
| PAGE 2
_________________________________
By signing above, I attest that all professionals and paraprofessionals rendering service under the proposed treatment plan have the appropriate training and education required to render services.
ABSOLUTE TOTAL CARE
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Autism Spectrum Disorder (ASD) Authorization Form (Absolute Total Care)

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Completed 5 May 2021

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