ACOPEC-0318-20 May 2020
Behavioral Health Initial Review Form
for Inpatient and Partial Hospital Programs
Instead of faxing this form, submit your request electronically using our preferred method via the Interactive Care Reviewer (ICR)
tool at https://www.availity.com. If you use this form, fax it to 1-877-434-7578.
Today’s date:
Contact Information
Level of care:
Inpatient psychiatric
Inpatient detox
Inpatient substance use rehab
Psychiatric RTC
PHP mental health
Substance use RTC (ASAM level, if
appropriate: )
IOP mental health
PHP substance use
Member name:
Member ID or reference #:
Member DOB:
Member address:
Member phone:
Hospital account #:
For child/adolescent, name of parent/guardian:
Primary spoken language:
Name of utilization review (UR) contact:
UR contact phone number:
UR contact fax number:
Admit date:
Voluntary
Involuntary (If involuntary, date of commitment: )
Admitting facility name:
Facility provider # or NPI:
Attending physician (first and last name):
Attending physician phone:
Provider # or NPI:
Facility unit:
Facility phone:
Discharge planner name:
Discharge planner phone:
Colorado Community Health Alliance
Health First Colorado (Colorado’s Medicaid Program)
Behavioral Health Initial Review Form for Inpatient and Partial Hospital Programs
Page 2 of 5
Diagnosis (psychiatric, chemical dependency and medical)
Precipitant to Admission (Be specific. Why is the treatment needed now?)
Risk of Harm to Self
If present, describe:
If prior attempt, date and description:
Risk rating (Select all that apply.)
Not present
Means
Prior attempt
Risk of Harm to Others
If present, describe:
If prior attempt, date and description:
Risk rating (Select all that apply.):
Not present
Means
Prior attempt
Psychosis
Risk rating (0 = None, 1 = Mild or mildly incapacitating, 2 = Moderate or moderately incapacitating, 3 = Severe or severely
incapacitating, N/A = Not assessed):
0
3
N/A
If present, describe:
Symptoms (Select all that apply.):
Auditory/visual hallucinations
Paranoia
Delusions
Command hallucinations
Substance Use
Risk rating (0 = None, 1 = Mild or mildly incapacitating, 2 = Moderate or moderately incapacitating, 3 = Severe or severely
incapacitating, N/A = Not assessed):
0
1
3
N/A
Colorado Community Health Alliance
Health First Colorado (Colorado’s Medicaid Program)
Behavioral Health Initial Review Form for Inpatient and Partial Hospital Programs
Page 3 of 5
Substance (Select all that apply.):
Alcohol
Marijuana
Cocaine
PCP
LSD
Methamphetamines
Opioids
Barbiturates
Benzodiazepines
Other (Describe.):
Urine drug screen:
Yes No Unknown
Result (if applicable):
Positive (If selected, list drugs.):
Pending
BAL: Yes No Unknown
Result (if applicable): Value: Pending
Substance use screening (Select if applicable and give score.):
CIWA:
COWS:
For substance use disorders, please complete the following additional information.
Current Assessment of American Society of Addiction Medicine (ASAM) Criteria
Dimension (Describe or give symptoms.)
Risk Rating
Dimension 1 (acute intoxication) and/or withdrawal
potential (such as vitals, withdrawal symptoms)
Minimal/none not under influence; minimal withdrawal
potential
Mild recent use but minimal withdrawal potential
Moderate recent use; needs 24-hour monitoring
Significant potential for or history of severe withdrawal;
history of withdrawal seizures
Severe presents with severe withdrawal, current
withdrawal seizures
Dimension 2 (biomedical conditions and
complications)
Minimal/none none or insignificant medical problems
Mild mild medical problems that do not require special
monitoring
Moderate medical condition requires monitoring but
not intensive treatment
Significant medical condition has a significant impact
on treatment and requires 24-hour monitoring
Severe medical condition requires intensive 24-hour
medical management
Dimension 3 (emotional, behavioral or cognitive
complications)
Minimal/none none or insignificant psychiatric or
behavioral symptoms
Mild psychiatric or behavioral symptoms have minimal
impact on treatment
Moderate impaired mental status; passive
suicidal/homicidal ideations; impaired ability to complete ADLs
Significant suicidal/homicidal ideations, behavioral or
cognitive problems or psychotic symptoms require
24-hour monitoring
Severe active suicidal/homicidal ideations and plans,
acute psychosis, severe emotional lability or delusions;
unable to attend to ADLs; psychiatric and/or behavioral
symptoms require 24-hour medical management
Colorado Community Health Alliance
Health First Colorado (Colorado’s Medicaid Program)
Behavioral Health Initial Review Form for Inpatient and Partial Hospital Programs
Page 4 of 5
Dimension 4 (readiness to change)
Maintenance engaged in treatment
Action committed to treatment and modifying behavior
and surroundings
Preparation planning to take action and is making
adjustments to change behavior; has not resolved
ambivalence
Contemplative ambivalent; acknowledges having a
problem and beginning to think about it; has indefinite
plan to change
Precontemplative in treatment due to external
pressure; resistant to change
Dimension 5 (relapse, continued use or continued
problem potential)
Minimal/none little likelihood of relapse
Mild recognizes triggers; uses coping skills
Moderate aware of potential triggers for MH/SA issues
but requires close monitoring
Significant not aware of potential triggers for MH/SA
issues; continues to use/relapse despite treatment
Severe unable to control use without 24-hour
monitoring; unable to recognize potential triggers for
MH/SA despite consequences
Dimension 6 (recovery living environment)
Minimal/none supportive environment
Mild environmental support adequate but inconsistent
Moderate moderately supportive environment for
MH/SA issues
Significant lack of support in environment or
environment supports substance use
Severe environment does not support recovery or
mental health efforts; resides with an
emotionally/physically abusive individual or active user;
coping skills and recovery require a 24-hour setting
If any ASAM dimensions have moderate or higher risk ratings, how are they being addressed in treatment or discharge planning?
Previous Treatment (Include provider name, facility name, medications, specific treatment/levels of care and adherence.)
Current Treatment Plan
Standing medications:
As-needed medications administered (not ordered):
Colorado Community Health Alliance
Health First Colorado (Colorado’s Medicaid Program)
Behavioral Health Initial Review Form for Inpatient and Partial Hospital Programs
Page 5 of 5
Other treatment and/or interventions planned (including when family therapy is planned):
Support System (Include coordination activities with case managers, family, community agencies and so on. If case is open with
another agency, name the agency, phone number and case number.)
Results of Depression Screening
Readmission within the last 30 days? Yes No
If yes, and readmission was to the discharging facility, what part of the discharge plan did not work and why?
Initial Discharge Plan (List name and number of discharge planner and include whether the member can return to current
residence.)
Planned discharge level of care:
Describe any barriers to discharge:
Expected discharge date:
Submitted by:
Phone:
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