CM-06A instructions
04/18
Case Management REQUEST TO CHANGE
AUTHORIZATION TO ANOTHER CASE MANAGER Form
(REQUIRED FORM)
Instructions for completion
FOR USE BY GROUP PROVIDERS ONLY
CLIENT NAME: enter the client’s first and last name.
MEDICAID NUMBER: enter client’s Medicaid number.
CURRENT AUTHORIZATION INFORMATION
CURRENT PAN: document the current prior authorization number (PAN) assigned by DSHS.
EFFECTIVE DATE OF PAN: document the effective date of the current prior authorization number.
EXPIRATION DATE OF PAN: document the expiration date of the current prior authorization number.
TPION CURRENT PAN: document the TPI on the current prior authorization number
CURRENT INDIVIDUAL NPI: enter the current case manager NPI.
AUTHORIZED SERVICES
# COMPREHENSIVE VISITS: enter “1” if a comprehensive visit is approved on the current prior authorization.
# FACE-TO-FACE FOLLOW-UP VISITS: enter the number of face-to-face follow-up visits approved on the current prior authorization.
# TELEPHONE FOLLOW-UP VISITS: enter the number of telephone follow-up visits approved on the current prior authorization.
REQUESTED CHANGE
REASON FOR CHANGE IN CASE MANAGER: check the appropriate box if the client requested the change in case managers, the previous case manager is leaving the position or if there is another reason mark other and enter the reason.
NEW CASE MANAGER NAME: document the new case manager’s name.
NEW CASE MANAGER TPI: document the new case manager’s TPI.
NEW CASE MANAGER INDIVIDUAL NPI: enter the new case manager NPI number.
EFFECTIVE DATE OF CHANGE: document the effective date of the change in case managers.
REMAINING AUTHORIZED SERVICES (RAS) TO BE AUTHORIZED TO NEW CASE MANAGER TPI
# RAS COMPREHENSIVE VISITS: document “1” if the comprehensive visit was not conducted by the original case manager
# RAS FACE-TO-FACE FOLLOW-UP VISITS: document the number of face-to-face follow-ups remaining (the number of face-to-face follow-ups that were not conducted by the original case manager)
# RAS TELEPHONE FOLLOW-UP VISITS: document the number of telephone follow-ups remaining (the number of telephone follow-ups that were not conducted by the original case manager)
THE CLIENT IS A: mark if the client is a child or a pregnant woman.
CASE MANAGER SIGNATURE/DATE: case manager must sign with appropriate credentials and date.
CASE MANAGEMENT AGENCY: enter name of agency case manager works for.
GROUP TPI NUMBER: enter the group TPI for the provider.
GROUP NPI NUMBER: enter the group NPI number for the agency.
PROVIDER PHONE NUMBER: enter the telephone number to be used to request additional information or clarifications.
PROVIDER FAX NUMBER: enter the fax number that requests are to be returned to.
PROVIDER EMAIL: enter the email address to be used if telephone number is not accessible.
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