Fillable Consumer Information Utilization Management PO Box 3378 Honolulu, (Hawaii)

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Consumer Information Utilization Management PO Box 3378 Honolulu, (Hawaii)

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Utilization Management
PO Box 3378 Honolulu, Hawaii 96801-3378
Phone: 453-6904, 453-6981 Fax: 453-6995
Updated 10/ 01/15 MT ICM Page | 1/2
Service Authorization Request
Community Based Case Management
All fields are mandatory. UM may send back requests that are inaccurate or missing fields. The provider may not add additional fields, categories or otherwise amend
this form in any way. Requests for authorization must be submitted to UM within thirty (30) days of the provision of service.
Consumer Information
Name (Last Name, First Name, Middle Initial) :
Date of Birth:
SSN:
Phone:
Homeless: Yes No
Veteran: Yes No
Encumbered: Yes No
The following are legal encumbrances recognized by AMHD: Conditional Release (CR), Released on Conditions (ROC), Mental Health Court, and Jail Diversion.
Insurance information
Health Plan:
UNITED
Ohana
Aloha Care
Kaiser
Policy #:
Diagnostic Information
ICD 10 Code:
ICD 10 Code:
ICD 10 Code:
ICD 10 Code:
A minimum of one AMHD eligible ICD-10 code is necessary for authorization.
Case Manager Information
CBCM Agency:
Name of Case Manager:
Case Manager’s Phone:
Case Manager’s Fax:
Provider Information
Agency:
Submitted by:
Phone:
Fax:
Date of Submission:
Attestation I attest that the service requested is clinically necessary for the above named consumer. I have reviewed and approved the information in the
service authorization request.
QMHP Name: (Please Print)
License type:
Date Signed:
Signature:
Authorization Information
Admit
Date: _________
Cont.
Date: _________
Discharge
Date: _________
Utilization Management
PO Box 3378 Honolulu, Hawaii 96801-3378
Phone: 453-6904, 453-6981 Fax: 453-6995
Updated 10/ 01/15 MT ICM Page | 2/2
Service Authorization Request
Community Based Case Management
Authorization Information Continued
Admission Criteria:
(Must Meet one of the following)
Has an AMHD eligible diagnosis that indicates a significant impairment in functioning as evidenced by: inability to adhere
with treatment/recovery, frequent use of crisis services, significant co-morbidity, involvement with the criminal justice
system, troubled significant relationships, and neglect or avoidance on ability to fulfill social or vocational activities.
Consumer is forensically encumbered (Conditional Release, Released on Conditions, Mental Health Court, and Jail
Diversion).
Continuation Criteria:
(Must meet one of the following)
Intensity of service being delivered continues to meet admission criteria
Complications arising from initiation of, or change in, medication or other treatment modalities
Forensically Encumbered (Conditional Release, Released on Conditions, Mental Health Court, and Jail Diversion)
Consumer is experiencing symptoms of such intensity that admission to a higher level of care would likely occur upon
discharge.
Discharge Criteria:
A consumer on Conditional Release (CR) Released on conditions (ROC), Jail Diversion or Mental Health Court may not be discharged without prior permission of the
forensic Coordinator.
Deceased
Unable to locate
Requires Higher LOC
Hospitalization
Clinically Ready For Discharge
Refuses Treatment
Incarceration
Moved from State/County
Linked with CCS
Other Payor
No longer encumbered
Long-term care
Other Discharge Criteria (please specify):
Discharge to:
Consumer Name (Last Name, First Name, Middle Initial) :
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Consumer Information Utilization Management PO Box 3378 Honolulu, (Hawaii)

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Completed 9 November 2020

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