APPLICATION FOR AUTHORIZATION FOR
CHILD PNMI
LEVEL CHANGE REQUESTS
LEVEL CHANGE REQUESTS
Use this application to request a level change from MR/MH Level I to Level II, or Level II to Level I. Level increase changes can be made based upon their clinical presentation, an increase in frequency and severity in symptoms or behavior from their initial presentation or admitting behavior. If the member has made significant progress from a Level II to a Level I, a decrease in Level can also be requested by the child PNMI provider.
DEMOGRAPHICS
MaineCare ID #
/ First Name
/ Last Name
/ DOB
CURRENT PNMI SETTING
Agency Name
/ Program/Location
/ Admission Date
/ KEPRO Current Case ID
Name of Staff Requesting:
/ Phone
/ Email
Proposed Start Date (on or after day of submission): Click here to enter a date.
JUSTIFICATION FOR Change in level of Child PNMI
1. Current PNMI authorization is for (please check one):
MR/PDD Level I, OR Mental Health Level I
MR/PDD Level I, OR Mental Health Level II
2. This child must present with (check one or both):
Change in needs that has required a change in the amount of staff support due to a change in treatment or
clinical presentation, OR
Immediate risk of repeated serious physical harm to self or others, or significant self-care deficits, that were
not present or known at the time of admission
Please describe the behaviors and include the frequency, intensity and duration:
Please describe the measures currently implemented to decrease or manage the behaviors, and explain why these are
not deemed to be effective:
IF REQUESTING A DECREASE IN LEVEL (FROM MR/MH LEVEL II TO LEVEL I), PLEASE USE THE SPACE BELOW TO DESCRIBE
THE PROGRESS AND REDUCTION IN SUPPORT THAT WOULD ALLOW FOR LEVEL REDUCTION:
Electronic Requesting Clinical Staff Signature: Date: Click here to enter a date.
In order for KEPRO to approve the change in Level, it may be necessary to submit supporting documentation.
Below is a list of other suggested documentation that may be supportive of the need for the change in level.
SUGGESTED Supporting Documentation:
· Shift notes/milieu logs demonstrating observed behaviors and interventions.
· Incident reports describing behaviors/needs.
· Clinical progress notes and clinical assessments that indicated the need for more intensive services.
· Current behavioral plan.
· Crisis prevention and management plan.
· Documentation indication what has been attempted to meet the child’s needs prior to requesting this service.
Please fax this application and supporting documentation to:
Fax: 866-325-4752
KEPRO
400 Technology Way
Scarborough, ME 04074
For questions, please call KEPRO at 866-521-0027.
KEPRO: Application for Prior Authorization for Temporary High Intensity Service 1