Service Request Application (SRA) for:
THERAPEUTIC DAY TREATMENT (TDT)
INITIAL REQUEST
ALL ITEMS ARE REQUIRED
After response is entered, use the Tab key to advance to next item.
MEMBER INFORMATION / PROVIDER INFORMATIONMember First Name / Provider Name
Member Last Name / Clinical Contact Name
Medicaid Number / Provider MIS#
Member Date of Birth / Provider Tax ID#
Gender / Male Female / Provider NPI
Member Phone / Provider Phone / Ext:
Provider Email
Member Address
City, State & Zip Code / TDT Service Location (Name of school/program location)
TDT Service Location Address
City, State & Zip Code
TDT Program Hours of Operation
CLINICAL INFORMATION
Procedure Code / H0035 – HA (school day) H0035 – HA, UG (after-school) / H0035 – HA, U7 (summer)
Primary Diagnosis
Secondary Diagnosis
Requested Units
Requested Start Date / Retro Review Request? Yes No
Requested End Date
Is this an EPSDT request? / Yes No Not Applicable
ADDITIONAL INFORMATION
Has the individual used substances (including alcohol and tobacco) in the past 6 months?
Number of days absent in the school year
Number of days in out-of-school suspension in the past 6 months
Number of days in in-school suspension in the past 6 months
Number of excused absences in the past 6 months
Number of unexcused absences in the past 6 months
Number of classes the individual is taking
Number of classes the individual is satisfactorily passing
Intake:
1. Date of the TDT intake for this individual:
a. Was the intake completed by a LMHP-type? Yes No
2. Has the individual expressed suicidal ideation within the last 30 days? Yes No
a. If yes, what is the safety plan?
3. Does the individual have a crisis plan? Yes No
4. Does the individual have a prior history of psychiatric hospitalization(s)? Yes No
a. If yes, when?
b. If yes to #4, please provide the reason(s) for the hospitalization(s):
5. Have you submitted a SRA for this service and for the individual within the last 30 days which was not approved? Yes No
a. If yes, and the SRA was not approved due to medical necessity, what changes have occurred since the last request to indicate that TDT is now necessary?
Service Coordination:
6. Have Health, Safety and Welfare issues been identified with the individual? Yes No
a. If yes, has a Child Protective Services (CPS) referral been made? Yes No
b. If no, what intervention(s) have been taken to address this concern?
7. Has the local CSB been contacted to determine if Mental Health Case Management services are being provided? Yes No
a. Date of Contact:
b. Name of CSB:
8. Is the individual receiving Mental Health Case Management? Yes No
a. If yes, what is the name of the Mental Health Case Manager?
b. If no, was a referral made to the CSB for Mental Health Case Management with the consent of the parent or guardian? Yes No
i. If yes to question #8b, date of referral:
ii. If no to question #8b, why not?
9. Is the individual receiving any other CMHR services? Yes No
a. If yes, please specify in question #19a.
b. If yes, care coordination is required between different providers and must be documented in the ISP and progress notes. Please specify how care coordination is being provided between the TDT provider and the individual’s other service providers:
10. Does the individual have a primary care physician (PCP)? Yes No – If no, skip to question #10c
a. If yes, has there been communication with the PCP to provide updates regarding treatment and service coordination? Yes No
b. If yes, name of Physician:
c. If no, have there been efforts to connect the individual with a PCP? Yes No
i. If no to question #10c, why not?
d. List physical health conditions which require treatment:
e. List all medications (for physical and behavioral health conditions) that the individual is taking. Also describe the individual’s compliance with these medications:
11. Does the individual have an IEP? Yes No
a. If yes, will TDT duplicate what the school is providing? Yes No
i. If no to question #11a, explain how TDT will not duplicate the services provided through the individual’s IEP:
12. Is the individual currently in a self-contained or resource (ED) classroom? Yes No
a. If yes, will TDT duplicate what the school is providing? Yes No
i. If no to question #12a, explain how TDT will not duplicate the services provided within the self-contained or resource (ED) classroom:
13. Could the individual’s mental health symptoms and/or behaviors be handled in the school setting without TDT? Yes No
a. If no, explain how the school would not be able to manage the individual’s mental health symptoms and/or behaviors:
Clinical:
14. Date the individual was admitted to TDT:
15. If there is a dual diagnosis of mental health and substance use disorders, are services integrated?
Yes No Not Applicable
16. Is the individual diagnosed with an Intellectual Disability (ID) and/or does the individual have severe cognitive and/or developmental delays? Yes No
a. If yes, please explain how the individual has the functional capability to understand and benefit from the required activities and counseling of TDT:
Medical Necessity Criteria:
Diagnostic Criteria
17. Does the individual demonstrate a clinical necessity for this service arising from a condition due to mental, behavioral, or emotional illness that results in significant functional impairments in major life activities?
Yes No
At Risk Criteria
MEET TWO (18-20):
18. Does the individual have difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization* or out-of-home placement* because of conflicts with family or community? Yes No *For the definition of at risk of hospitalization or out-of-home placement, please refer to the Community Mental Health Rehabilitative Services (CMHRS) manual, Chapter 4.
a. If yes, explain using specific behaviors and incidents that have occurred in the last 30 days, including the settings where these behaviors occur, the frequency, intensity, and duration of these behaviors, and avoid using vague words such as ‘aggressive.’ If the individual displays aggressive type behaviors, please clearly define what this means:
19. Does the individual exhibit such inappropriate behavior that documented, repeated interventions by the mental health, social services or judicial system are or have been necessary? Yes No
a. If yes, document the mental health, social services, or judicial system interventions that the individual is currently receiving or has received within the last 30 days:
20. Does the individual exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior? Yes No
a. If yes, explain how and/or why the individual is unable to recognize personal danger or significantly inappropriate social behavior using specific behaviors and incidents that have occurred in the last 30 days, including the settings where these behaviors occur, the frequency, intensity, and duration of these behaviors, and avoid using vague words such as ‘aggressive.’ If the individual displays aggressive type behaviors, please clearly define what this means:
Level of Care Criteria
MEET ONE (21-25):
21. Does the individual require year-round treatment to sustain behavioral or emotional gains? Yes No
a. If yes, describe how the individual would regress without year-round treatment:
b. Will year-round treatment be provided to the individual? Yes No
i. If no to question #21b, why not?
22. Does the individual have problems so severe that they cannot be addressed in self-contained or resource (ED) classrooms without this programming during the school day or as a supplement to the school day?
Yes No
a. If yes, explain why the individual cannot be managed within a self-contained or resource (ED) classroom without TDT:
23. Would the individual otherwise be placed on homebound instruction due to severe emotional or behavioral problems that interfere with learning? Yes No
a. If yes, is the school actively considering homebound instruction for the individual? Yes No
i. If yes to question #23a, explain what interventions the school has implemented to prevent the individual from being placed on homebound instruction:
24. If the individual is placed or pending placement in a preschool enrichment and/or early intervention program, are the individual’s emotional and behavioral problems so severe that it is documented that the individual cannot function or be admitted into these programs without TDT? Yes No Not Applicable
a. If yes, explain the specific severe emotional and behavioral problems that the individual exhibits indicating why the individual cannot function or be admitted into a preschool enrichment and/or early intervention program without TDT:
25. As compared with same age peers, does the individual display any of the following?
a. Deficits in social skills or peer relations or in dealing with authority? Yes No
b. Hyperactivity? Yes No
c. Poor impulse control? Yes No
d. Signs of extreme depression? Yes No
e. Signs of being marginally connected with reality? Yes No
f. If yes to any of the above, explain how these behaviors are more significant than those of same age peers using specific behaviors and incidents that have occurred in the last 30 days, including the settings where these behaviors occur, the frequency, intensity, and duration of these behaviors, and avoid using vague words such as ‘aggressive.’ If the individual displays aggressive type behaviors, please clearly define what this means:
26. List the initial treatment goals identified at intake for the individual related to the mental health symptoms and behaviors listed above. If immediate physical threat to self or others is indicated at the intake, include safety goals included in the ISP. Please do not copy and paste the ISP:
Discharge:
27. Describe the individual’s current discharge plan:
a. What is the estimated discharge date?
b. What are the specific services recommended for aftercare for the individual?
c. List the specific agencies to which the individual will be connected to prior to being discharged from TDT:
d. What are the individual’s support systems and/or community supports that will aid them following discharge from TDT:
e. Identify barriers to discharge and how they will be addressed prior to discharge (this may include environmental and individual risk factors):
28. Could a lower level of care help the individual to achieve stabilization? Yes No
a. If no, explain how a lower level of care would not be able to stabilize the individual:
Revised 10/11/2016 ®Magellan Healthcare, Inc. Page 4 of 5