Clinician Exemption Request

Contractor Name:Date of Hire:

Person making request: Date of Request:

Contractor works in(check all that apply): MTD KIS ORMADMIN

Instructions: Only complete fields above the dotted line. The reviewer will check the boxes below the dotted line.

Contractors making this request must demonstrate excellent clinical judgment and fluency with Adapt’s treatment philosophy, as evidenced by the following criteria:

At least 2 years of experience with Adapt

At least 50 clients served

Statistics at or below agency average, especially drop-out rate and >6-month LOS (open & closed)

History of good justification for prior TBOS requests (based on review of TBOS request emails)

No more than 50% of cases with TBOS approved (based on current auth in “What’s Due” report)

No more than 50% (less than 50% for children10 years)of services provided in school (per client) or individually with clients who are “children,” based on review of Billing Logs or client charts

Fluency with Adapt’s treatment approach (based on supervisor assessment & supervision notes)

Absence of ethical concerns (based on Complaint Reports and supervisor assessment)

This “Clinical Exemption” gives the contractor the privilege of making his/her own determination for the situations below:

Extending services >6 months (or beyond last approved extension)

TBOS services for clients with Concordia or Medicaid AHCA, United, or Wellcare

2 sessions per week for non-Medicaid cases (insurance, Healthy Kids, FSPT)

Billing 1 hour of direct clinical services per client within a 2-day period

Billing 2 hours of direct clinical services in the same day in the same home (regardless of number of clients in the home), except when a licensed clinician bills 2 intakes in one home in one day

Location of services other than home or school (or office if client is <14 years old)

Intake conducted at school (or location other than home or office)

Billing any code other than TBOS at school

Multiple clinicians in the same home or with the same client

Other:

CLINICAL DIRECTOR DETERMINATION:

Clinical Exemptionapproved, effective for dates of service after:

Clinical Exemption request denied, based on the following:

Explanation:

Notice sent to Contractor & HR

Reviewed byClinical Director:______Date:______

Exemption entered in DB

Processed by Human Resources: ______Date:______

Cc:Supervisor for distribution to Contractor

Original to Personnel File

07/16