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INITIAL Service Authorization Request Form

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THE DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
MENTAL HEALTH INTENSIVE OUTPATIENT (MH-IOP: S9480) and
MENTAL HEALTH
PARTIAL HOSPITALIZATION PROGRAM (MH-IOP: H0035)
INITIAL Service Authorization Request Form
Please be mindful of notes throughout this form providing reference to where documentation obtained during the Comprehensive Needs
Assessment (CNA) is relevant and can be used for efficiency. There will also be sections in this form prompting creation of initial Individual Service Plan
(ISP) goals, which providers must be complete prior to the start of services. Character limits have been established in most sections, please use the notes
section to add additional information.
MEMBER INFORMATION
PROVIDER INFORMATION
Member First Name:
Organization Name:
Member Last Name:
Group NPI #:
Medicaid #:
Provider Tax ID #:
Member Date of Birth:
Provider Phone:
Gender:
Provider E-Mail:
Member Plan ID #:
Provider Address:
Member Street Address:
City, State, ZIP:
City, State, ZIP:
Provider Fax:
Clinical Contact
Name and
Credentials*:
Phone #
* The individual to whom the MCO can reach out to in
order to gather additional necessary clinical information.
Type of Service Request Authorization
Mental Health Intensive Outpatient {S9480}
Mental Health Intensive Outpatient with Occupational Therapy {S9480, GO}. Please place evidence of the need for OT Services in the Notes Section of this form.
Mental Health Partial Ho
spitalization Program {H0035}
R
equest for Approval of Services:
Retro Review Request?
Y e s No
If the member i
s currently receiving MH-IOP/MH-PHP service, start date of service: ______
Proposed/Requested Service Information:
From (date), To (date), for a total of _______ units of service.
Plan to provide _________ hours of service per week.
Primary ICD-10 Diagnosis
Secondary Diagnosis(es)
CLEAR FORM
Member Full Name: Medicaid #:
July 2021 Mental Health IOP_PHP: Initial Serv Auth
2
Other medical/behavioral health concerns (including substance use issues, personality disorders, dementia,
cognitive impairments) that could impact services? Yes No (If yes, explain below.)
SECTION I: ADMISSION CRITERIA & PRELIMINARY TREATMENT GOALS
Individuals must meet ALL of the criteria #1-8.
I
f individual is seeking admission to MH-PHP for Eating Disorder treatment, they must also meet criteria #9 and
#10. Please develop 3 preliminary treatment goals based on the criteria cited below. A treatment goal section is provided below
each criteria. Providers may decide with the individual which goals are most relevant at this time. The goal sections are marked
with “Suggested and Optional” for this initial plan to provide general guidance on what goals are most informative for initial
authorization decisions.
individual’s current symptoms as well as their frequency, intensity and duration.
The initial service and treatment plan proposed here should be reasonable to address these symptoms/diagnosis(es).
Corresponding CNA Elements: 1, 12
Member Full Name: Medicaid #:
July 2021 Mental Health IOP_PHP: Initial Serv Auth
3
the following based on the level of care being requested for authorization:
a. FOR MH-PHP: Describe symptoms specific to the last 14 days and how their level of acuity has maintained
or intensified for this individual. Describe any recent incidents that potentially triggered these symptoms.
What has been the impact on their functioning at home, school, work or in their community? What negative
consequences has this person experienced in their social relationships due to these issues? Be specific about
the frequency, intensity and duration of these symptoms over the last 14-day period and connect these to the
impact on functioning and relationships. The initial service and treatment plan proposed here should be reasonable to
address these symptoms/diagnosis(es). Corresponding CNA Elements: 1, 6, 7, 13
b. FOR MH-IOP: Describe symptoms specific to the last 30 days and how their level of acuity has maintained
or intensified for this individual. What has been the impact on their functioning at home, school, work or in
their community? What negative consequences has this person experienced in their social relationships due
to these issues? Be specific about the frequency, intensity and duration of these symptoms over the last 30-
day period and connect these to the impact on functioning and relationships. The initial service and treatment
plan proposed here should be reasonable to address these symptoms/diagnosis(es). Corresponding CNA Elements: 1, 6, 7, 13
Suggested Preliminary Treatment Goal #2: Create a goal related to the individual’s functioning and social relationships.
Member Full Name: Medicaid #:
July 2021 Mental Health IOP_PHP: Initial Serv Auth
4
based rehabilitation services and the barriers to success in those efforts. What prevented these efforts in other
services from working for this individual? Explain why these efforts did not work for this person and what has
happened to the person’s symptoms and circumstances due to these challenges with other services. How will this
service be a better fit for the individual’s needs? Corresponding CNA Elements: 2, 3
Identify in the table below any identified past and current service providers and the corresponding information:
Provider & Service
Past or
Current?
Start / End Dates of
Service
Available Info on Outcomes/Current Progress
4. The intention of MH-IOP and MH-PHP is to provide service options for both diversion and step-down from residential or
inpatient hospitalization
levels of care. Corresponding CNA Element: 11
One of the following two criteria must be met:
a. The individual is at risk for admission to inpatient hospitalization, residential treatment or residential crisis stabilization
(or in the case of MH-IOP, risk of admission to MH-PHP) as evidenced by acute intensification of symptoms, but the
individual has not exhibited evidence of immediate danger to self or others and does not require 24-hour treatment or
medical supervision.
OR
b. The individual is stepping down from inpatient hospitalization, residential treatment or residential crisis stabilization (or
in the case of MH-IOP admission, the individual is stepping down from MH-PHP) and is no longer exhibiting evidence of
immediate danger to self or others and does not require 24-hour treatment or medical supervision.
Describe the evidence, including symptoms/behaviors that demonstrate that either of these two scenarios are
relevant for this individual. Corresponding CNA Elements: 1, 11
Member Full Name: Medicaid #:
July 2021 Mental Health IOP_PHP: Initial Serv Auth
5
risk in terms of safety/harm for the individual.
caregivers or self-identified family/friends. Describe the community-based network of natural supports who are
able to ensure the individual’s safety outside the treatment program hours and the established safety plan. For
youth, please specify which caregivers/family members will be actively involved in the treatment plan.
Corresponding CNA Elements: 7, 10
supports for this individual in their path to recovery.
psychiatric interventions for medication management is necessary to address and meet the individual’s treatment
needs. Corresponding CNA Elements: 13, 14
Identify all current/p
ast medications, dosage and frequency:
Corresponding CNA Elements: 4
Name of Medication
Current / Past
Dosage
Frequency
and/or medication management.
Member Full Name: Medicaid #:
July 2021 Mental Health IOP_PHP: Initial Serv Auth
6
7. Describe evidence that the individual is able to reliably attend, and actively participate in, all phases of the
treatment program. Corresponding CNA Element: 10
List any potential barriers to engagement and participation as well as a list of potential solutions discussed with the
individual for these treatment barriers. Corresponding CNA Element: 13
8. Describe evidence that the individual has demonstrated willingness to engage and recover in the structure of this
type of treatment program. Corresponding CNA Element: 10
ADDITIONAL ADMISSION CRITERIA (for Eating Disorder treatment)
If an individual is being admitted to MH-PHP for treatment of an Eating Disorder, the individual must meet two sub-
three following sub-criteria: Corresponding CNA Element: 1
9a. Weight stabilization above 80% IBW (or BMI 15-17)
If Yes, please describe current symptoms, behaviors and other pertinent information,
which provides evidence that the individual needs this treatment intervention.
Yes
N
o
Member Full Name: Medicaid #:
July 2021 Mental Health IOP_PHP: Initial Serv Auth
7
9b. Daily, or near daily supervision and structure that could not be attained in a less intensive setting,
to interrupt compensatory weight management behavior (e.g. caloric restriction, intake refusal,
vomiting/purging, excessive exercise, compulsive eating/binging).
If Yes, please describe current symptoms, behaviors and other pertinent information,
which provides evidence that the individual needs this treatment intervention.
Yes
No
9c. Individual has engaged in misuse of pharmaceuticals with an intent to control weight (e.g. laxatives,
diuretics, stimulants) and cannot be treated at a lower level of care.
If Yes, please describe current symptoms, behaviors and other pertinent information,
which provides evidence that the individual needs this treatment intervention.
Yes
No
Suggested Preliminary Treatment Goal #6: Create a goal related to weight stabilization and/or compensatory
weight management behavior and/or misuse of pharmaceuticals.
10. Are there medical comorbidity or medical complications resulting from the eating disorder that
require monitoring during PHP?
If yes, please identify plan to monitor and coordinate with medical provider and evidence that the
individual does not require 24-hour medical monitoring in a hospital level of care.
Corresponding CNA
Element: 4
Yes
No
Member Full Name: Medicaid #:
July 2021 Mental Health IOP_PHP: Initial Serv Auth
8
Suggested Preliminary Treatment Goal #7: Create a goal related to management of the medical co-morbidities
or complications.
Section V: RECOVERY & DISCHARGE PLANNING
Discharge plans are an important tool to emphasize hope and plans for recovery. Planning for discharge from services
should begin at the first contact with the individual. Recovery planning should include discussion about how the
individual and service providers will know that sufficient progress has been achieved to move to a lower, less intensive
level of care or into full recovery with a maintenance plan.
What would progress/recovery look like for this individual?
What
barriers to progress/recovery can the individual, their natural supports, and/or the service provider identify?
What
types of outreach, additional formal services or natural supports, or resources will be necessary to reach
progress/recovery?
At th
is time, what is the vision for the level of care this individual may need at discharge from this service?
What is the best estimate of the discharge date for this individual?
Member Full Name: Medicaid #:
July 2021 Mental Health IOP_PHP: Initial Serv Auth
9
psychiatric history and completed the appropriate assessment or addendum; and 2) that this assessment indicates
that the individual meets the medical necessity criteria for the identified service. The assessment or applicable
addendum for this service was completed on the following date(s): __________
Signature (actual or electronic) of LMHP (Or R/S/RP):
Printed Name of LMHP (Or R/S/RP): _______________________________
Credentials: ________________
Date:
____________
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INITIAL Service Authorization Request Form

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Completed 29 August 2021

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