Service Request Application (SRA) for:

EPSDTRESIDENTIALTREATMENTFACILITY (PRTF) AND THERAPUETIC GROUP HOMES (TGH)

CONTINUED STAYREQUEST

ALL ITEMS ARE REQUIRED

After response is entered, use the Tab key to advance to next item.

MEMBER INFORMATION / PROVIDER INFORMATION
Member First Name / Provider Name
Member Last Name / ClinicalContact Name
Medicaid Number / Provider MIS#
Member Date of Birth / Provider Tax ID#
Provider NPI
Sex / Male Female / Provider Phone
Member Phone / Provider Email
Member Address
City, State & Zip Code / Service Address
City, State & Zip Code
CLINICAL INFORMATION
Procedure Code / 99221 Revenue Code 096199231 Revenue Code 0961 H0019
Primary Diagnosis
Secondary Diagnosis
Requested Units
Requested Start Date
Requested End Date
Is CSA paying for any portion of this stay? / Yes No If yes, Locality Code:
Is this an EPSDT funded service or stay? / Yes No Not Applicable

Intake

  1. Admission date to this facility:
  1. Isthisarequest from anout-of-stateprovider? Yes No
  2. If yes, complete the attached “Out-of-State Provider Requirements Form” (page 4 of this form).
  1. Is this a retro review request? Yes No
  2. If yes,then the disposition date of Medicaid activation must be within 30 days of this request.
  1. Have you submitted an SRA for this service and for this individual within the last 30 days which was not approved? Yes No
  1. If yes, describe what changes have occurred to indicate that this service is now necessary?
  1. Are you requesting a 1:1 under EPSDT for this individual with this request? Yes No
  2. If yes, please submit an EPSDT Residential 1:1 Care request on separately from this request.
  1. Is there an Comprehensive Individual Plan of Care (CIPOC) with all the required elements completed, signed, and dated as required (includes individual-specific long- and short-term goals, measurable objectives, interventions with timeframes, and family therapy as applicable)? Yes No
  2. If yes, has the individual and their family been involved in the development of the CIPOC?Yes No
  3. If yes, are individual-specific long- and short-term goals and measurable objectives aligned with CANS assessment and ACES screening? Yes No
  4. PleaseattachacopyoftheCIPOCwiththisSRA; service cannot be authorized without a copy of a current CIPOC.
  1. Is the individual treatment partially funded by CSA?Yes No
  2. What is the start date of the reimbursement?
  3. Rateas listedontheReimbursementRateCertification (for Psychiatric Residential Treatment Facilities):
  4. Please attach the rate sheet for any individual funded by CSA in a EPSDT Residential Treatment Facility; service cannot be authorized without a copy of a signed rate sheet.
  1. Has a physician, nurse practitioner, or physician assistant identified that the individual continues to need behavioral therapy as part of their residential treatment? Yes No
  2. Please attach physician letter or physician signed CIPOC indicating medical necessity.

Clinical

  1. Numberof Therapeutic Day Passessincethelast reviewperiod:
  2. Successful: Unsuccessful:
  3. If None, please describe why no passes occurred:
  4. If there were unsuccessful passes, please describe why they were unsuccessful:
  5. Who were the passes with (i.e. family members, mentor, social worker, etc.)?
  6. Dates of Therapeutic Day Passes since the last review:
  1. Numberof Therapeutic Overnight Passessincethelast reviewperiod:
  2. Successful: Unsuccessful:
  3. If None, please describe why no passes occurred:
  4. If there were unsuccessful passes, please describe why they were unsuccessful:
  5. Who were the passes with (i.e. family members, mentor, social worker, etc.)?
  6. Dates of Therapeutic Overnight Passes since the last review:
  1. Total number of therapeutic passes individual has had since admission:
  1. Are you requesting any therapeutic passes beyond the 24 pass admission limit? Yes No
  2. If yes, please include the clinical rationale for the additional passes and how they relate to treatment goals:
  1. Is individual therapy by an LMHP-Type occurring 3 out of every 7 days for Psychiatric Residential Treatment Facilities and weekly for Therapeutic Group Home? Yes No
  2. If no, please describe barriers:
  1. Are a minimum of 3 interventions for Psychiatric Residential Treatment Facilities or a minimum of 1 daily intervention for Therapeutic Group Homes occurring every 24 hour period including nights and weekends (excluding individual treatment, group therapy, medical appointments, school attendance, and family therapy) Yes No
  2. If no, please describe barriers:
  1. Has afamilyengagement activity occurred at least weekly? Yes No
  2. If yes, Frequency and Type of involvement:
  3. If no, what family engagement activities were offered (include dates they were offered):
  4. If no, what are the barriers or reasons why it is contraindicated:
  5. Describe how any barriers are being addressed:
  1. How many family therapy sessions have occurred since the last review period:
  2. If they have occurred, what is the frequency and type of sessions that have occurred:
  3. What family members have been engaged in family therapy since the last review?
  4. If none, please describe why this has not occurred and the actions being taken to overcome the barriers to family therapy:
  1. Pleasedescribe the individual’s behaviors in the 30 days prior to submission of this request thatwarrant this level of care. Please describe the individual’s currentfunctioning, social functioning, current medicationsorrecent changestomedications,andindividual’s ability to care for self, communicate with peers and caregivers and complete activities of daily living (ADL). Please avoid using vague words such as ‘aggressive’ and include dates behaviors occurred:
  1. Has the individual expressed suicidal ideation during the last authorization period?
  2. If yes, what is the safety plan?
  1. Does therecontinuetobesymptomsor emergenceof newsymptomsthatare amenable totreatment? Yes No
  2. If Yes, please describe how the treatment plan that is attached to this request has been amended:
  1. What resources have been identified in the individual’s community that will support the member after discharge?
  1. Describe how the member’s current functioning cannot be addressed using these resources at this time:
  1. Will the individual be discharged in the next 30 days? Yes No
  2. If yes, are aftercare services being arranged in coordination with the family? Please explain:
  1. Please describe the individual’s currentidentified step down placement and discharge plan. (Please avoid simply stating where individual will live upon discharge.):
  2. What is the estimated discharge date?
  3. What is the expected discharge disposition (for example: home with parent, foster care home, Therapeutic Group Home):
  4. What are the recommended aftercare services for this individual?
  5. List the specific agencies to which the individual will be connected prior to leaving residential care?
  6. What are the individual’s natural support systems and/or community supports that will aid him/her in remaining in the community?
  7. Identify barriers to discharge and how they will be addressed prior to discharge (this may include both environmental and individual risk factors):

Revised 5/10/17 ®Magellan Healthcare, Inc.Page 1 of 5

OUT-OF-STATE PROVIDERREQUIREMENT FORM

1.Pleaseselect oneof thefourquestionswhichbestmeetsthereasonyou arerequestingOut-of-StateProvider Services and specifyhowtherequestmeetstheselectedreason.

Servicesprovidedout-of-statefor circumstancesother thanthesespecifiedreasonsshallnot becovered:

The medicalservicesmustbe neededbecauseof amedicalemergency;

a.Istheredocumentationofapsychiatric/behavioralhealthemergency?

Medicalservice mustbe neededandtheIndividual’shealthwould be endangeredifthey wererequiredtotraveltotheir ownstateof residence;

b.Istheredocumentationthattheindividual’spsychiatric/behavioralhealthconditionwillcontinueto decompensateif requiredto travelbacktoVirginia?

The state determinesonthe basisof medicaladvice,thatthe neededmedicalservices,or necessarysupplementary resources,are morereadilyavailableinthe otherstate;

c.Basedona physician’sadvice,isthePsychiatric Residential Treatment Facility (PRTF)servicemorereadilyavailablein theotherstate?Thatis, what documentationistherethattheseservicesarenotavailablein Virginia?Arethereparticularserviceneedsthatcan onlybeaddressedbythisparticularoutofstateprovider?If so providesupportingdocumentationofallneedsand the servicesto beprovided.

It isthegeneralpracticefromIndividuals ina particularlocalityto usemedicalresourcesinanotherstate

d.Whatlocalityistheindividuala residentof?

e.Isitthegeneralpracticeforindividualsin thislocalityto usepsychiatric/behavioralhealth resourcesoutofstate?

YesNo

f.Ifyes,whichstate?

g.IsthisaDepartment of Medial Assistance Services (DMAS)recognized“borderstate”? YesNoEnrollmentofprovidersforLevelCResidentialPsychiatricTreatment forChildrenandAdolescentsaregenerallylimitedto thoselocatedin Virginiaorwithin50 milesofthe stateline. KY,TN,NC,MD,andWVareallborderstatesofVirginia.

h.Ifthe requestisfora differentstatethannotedin “c”,whythisstate?

Explainselectedresponse:

2.Enrolledas a Provider with Magellan of Virginia? YesNo

Outof state providermay enrollwithMagellanbygoingto:

Atthetop of the page clickonProviderServices andthenProviderEnrollmentinthe dropdownbox.Itmaytake upto10businessdaystobecomea Virginiaparticipatingprovider.

Revised 12/14/16 Page 1 of 5