Fillable Behavioral Health Initial Review Form for Inpatient and

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Behavioral Health Initial Review Form for Inpatient and

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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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Completed 2 October 2020

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