Fillable Plan: Medicaid CHIP Medicare DUALS Marketplace

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Plan: Medicaid CHIP Medicare DUALS Marketplace

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☐ Subacute / Residential Detox
Service is for:
☐ Mental Health OR ☐ Substance Use
☐ Electroconvulsive Therapy (ECT)
☐ Psychological/Neuropsychological
Testing
☐ Inpatient Detox Hospitalization
☐ Involuntary ☐ Voluntary
MHTBHSRForm.03072018
Behavioral Health Service Request Form 2018 – Revised 3/7/18 5945090TX0317
☐ Applied Behavior Analysis
☐ Non-PAR Outpatient Services
☐ Other – Describe below:
Procedure Code(s) and Description Requested. (For OP, PHP, & IOP, please describe frequency of visits)
Service Requested
Member Information
Plan: ☐ Medicaid ☐ CHIP ☐ Medicare ☐ DUALS ☐ Marketplace
Date of Request:______________________ Start Date/First Date of Service: _______________________________
Member Name: DOB:
Member ID#:
_______________________________
___________________________________________ Member Phone: _______________________
Service Is: ☐ Elective/Routine ☐ Expedited/Urgent*
*
Urgent/Expedited services are required to prevent serious deterioration in the member’s health or could jeopardize the
member’s ability to regain maximum function. Requests outside of this definition should be submitted as
elective/
routine.
Provider Information
Treatment Provider/Facility/Clinic Name: __________________________________________________________
Address:________________________________________________________________________________________
Provider NPI: ______________________ Provider Tax ID# (to be submitted with claim): __________________
Attending Psychiatrist Name (if applicable): ______________________________________________________
☐ Inpatient Psychiatric Hospitalization
☐ Involuntary ☐ Voluntary
☐ Residential Treatment
☐ Partial Hospitalization Program
☐ Day Program
Intensive Outpatient Program
☐Yes ☐No ☐In Process Court Date: ___________
UR Contact Name: ____________________________ UR Phone#_________________ Fax#: __________________
Facility Status: ☐PAR ☐Non-PAR Member Court Ordered?
_______________________________ _______________________________
Molina Healthcare of Texas
Behavioral Health Service Request Form
Phone Number: (866) 449-6849
Fax Number: (866) 617-4967
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*Medication Administration Document can be submitted in lieu of completing the below
New from
Admit?
Date Current
Dose Initiated
Compliant? Lab/Plasma
Level?
☐ New ☐ Yes ☐ No
☐ New ☐ Yes ☐ No
☐ New ☐ Yes ☐ No
☐ New ☐ Yes ☐ No
☐ New ☐ Yes ☐ No
Clinical Review - Initial and Concurrent
Please submit current (within the last 48 hours) Medical Progress Notes for Clinical Review (inpatient only)
Medication Name Dosage/
Frequency
Psychosocial Barriers
Functioning: Presenting/Current Symptoms that Necessitate Treatment or Continued Treatment. Include
safety/self-harm precautions, or substance withdrawal symptoms as applicable:
Primary Diagnosis (including
Provisional Diagnosis)
Additional Diagnoses
(including
any known Medical Diagnoses
/Conditions)
MHTBHSRForm.03072018
Behavioral Health Service Request Form 2018 – Revised 3/7/18 5945090TX0317
Molina Healthcare of Texas
Behavioral Health Service Request Form
Phone Number: (866) 449-6849
Fax Number: (866) 617-4967
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NOTE: Level of Care coverage is subject to State Contract Specific Covered Services. Please refer to the State
Specific Provider Handbook for a list of covered levels of care. Authorization of services does not guarantee
payment. Payments for services are pending eligibility at the time of service and benefit coverage.
What discharge planning or case management needs does the member have?
Any other information that would help us in reviewing your request?
Aftercare Plans
* NOTE: First follow-up appt must be scheduled within 7 (seven) days of discharge from inpatient stay.
Is treatment being coordinated with any other behavioral health practitioner?
☐ Yes ☐ No
If Yes, Name of Provider: ___________________________________ Last Contact Date with Provider: ___________
If No, please explain:
MHTBHSRForm.03072018
Behavioral Health Service Request Form 2018 – Revised 3/7/18 5945090TX0317
Molina Healthcare of Texas
Behavioral Health Service Request Form
Phone Number: (866) 449-6849
Fax Number: (866) 617-4967
4 of 4
Electroconvulsive Therapy (ECT):
Acute/Short-Term: *as covered per benefit package
Continuation/Maintenance: *as covered per benefit package
o Information updates as indicated above
o Documentation of positive response to acute/short-term ECT
o Indications for continuation/maintenance
o Rationale for utilizing Out of Network provider
o Known or Provisional Diagnosis
acceptable)
o Medication review
o Known barriers to treatment and other psychosocial needs identified
o Treatment plan including ELOS and discharge plan
o Additional supports needed to implement discharge plan
p
o Rationale for utilizing Out of Network provider
o Personal and family sychiatric medical history (comprehensive assessment/History and Physical are
Ongoing:
o Acute symptoms that warrant ECT (specific symptoms of depression, acute mania, psychosis, etc.)
o ECT indications (acute symptoms refractory to medication or medication contraindication)
o Informed consent from patient/guardian (needed for both Acute and Continuation)
o Personal and family medical history (update needed for Continuation)
o Personal and family psychiatric history (update needed for Continuation)
o Medication review (update needed for Continuation)
o Review of systems and Baseline BP (update needed for Continuation)
o Evaluation by anesthesia provider (update needed for Continuation)
o Evaluation by ECT-privileged psychiatrist (update within last month needed for Continuation)
o Any additional workups completed due to potential medical complications
Please provide the following information with the request for review:
Neuropsychological/Psychological Testing: *as covered per benefit package
o Diagnoses and neurological condition and/or cognitive impairment (suspected or demonstrated)
o Description of symptoms and impairment
o Member and Family psych /medical history
o Documentation that medications/substance use have been ruled out as contributing factor
o Test to be administered and # of hours requested, over how many visits and any past psych testing results
o What question will testing answer and what action will be taken/How will treatment plan be affected by results
Clinical Information
Applied Behavior Analysis: *as covered per benefit package
o Diagnosis (suspected or demonstrated)
o Assessment/Clinical Tool used for diagnosis
o Member presenting symptoms and behaviors
o Parent or Caregiver involvement and training
o Provider Qualifications (experience with Autism Spectrum Disorder)
o Treatment plan including measurable goals and outcomes
Non-PAR Outpatient Services
Initial:
Molina Healthcare of T
exas
Behavioral Health Service Request Form
Phone Number: (866) 449-6849
Fax Number: (866) 617-4967
MHTBHSRForm.03072018
Behavioral Health Service Request Form 2018 – Revised 3/7/18 5945090TX0317
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Plan: Medicaid CHIP Medicare DUALS Marketplace

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Completed 21 February 2021

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