Service Request Application (SRA) for:

INTENSIVECOMMUNITYTREATMENT

INITIALREQUEST

ALL ITEMS ARE REQUIRED

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

MEMBER INFORMATION / PROVIDER INFORMATION
Member First Name / ProviderName
Member Last Name / ClinicalContactName
Medicaid Number / Provider MIS#
Member Date of Birth / Provider Tax ID#
Provider NPI
Sex / Male Female / Provider Phone / Ext:
Member Phone / Provider email
Member Address
City, State & Zip Code / Service Address
City, State & Zip Code
CLINICAL INFORMATION
Procedure Code / H0039
Primary Diagnosis
Secondary Diagnosis
Requested Units
Requested Start Date / Retro Review Request? Yes No
Requested End Date
Place of Service / 11-Office 12-Home 53-Comm MH Ctr
71-Health Clinic 72-Rural Health Ctr 99-Other

Intake:

  1. Have you submitted an SRA for this service and for this individual within the last 30 days which was not approved? Yes No
  2. If yes, describe what changes have occurred to indicate that this service is now necessary?
  1. If thereisadual diagnosisofmental healthandsubstanceusedisorders,areservices integratedandisthetreatmentofanysubstanceusedisorderintendedtopositively impact themental healthcondition? Yes No NotApplicable
  1. Was anintake completed by an LMHP typeprior totheinitiationofservices that documentseligibility and theneedfor thisservice inthe individual’sclinical record? Yes No

Clinical:

  1. Date individual was admitted to Intensive Community Treatment:
  2. Has the member expressed suicidal ideation in the last 30 days?Yes No
  3. If yes, what is the safety plan?

Individual must meet at least oneof thefollowingtwo items (5-6):

  1. Is theIndividual at highriskfor psychiatrichospitalizationorfor becomingor remaining homelessorrequiringinterventionbythementalhealthor criminal justicesystemdueto inappropriatesocial behavior: Yes No
  2. If yes,whatarethefactorsbelowthat apply, be specific including frequency, intensity and avoiding vague words such as ‘aggressive’:
  3. Describe risk:
  4. Describe problemsinabilitytoform relationships:
  5. Describe roleperformanceat work,school andincaring for dependents:
  6. Describe support system or lack thereof:
  7. Describe current residence/livingsituation:
  1. Does theindividual havea3monthor morehistoryofaneedforintensive mental healthtreatmentor treatmentforco-occurringserious mental illnessandsubstanceuse disorderanddemonstratesaresistancetoseekoutandutilize appropriate treatment options: Yes No
  2. If yes, please specifically describe need and resistance including frequency, intensity and avoiding vague words such as ‘aggressive’:
  1. Describe mental healthtreatment goalsfor theindividual as it relates to the requested Intensive Community Treatment:
  2. Ifthis individualis receiving this service (services other than intake have begun at the time of this SRA submission) has an Individual Service Plan been approved by an LMHP type:Yes No

Care Coordination:

  1. Has the local CSB been contacted to determine if Mental Health Case Management services are being provided?Yes No
  2. Date of Contact:
  3. Name of CSB:
  1. Is the individual receiving Mental Health Case Management? Yes No
  2. If yes, what is the name of the Mental Health Case Manager?
  3. If no, was a referral made to the CSB for Mental Health Case Management, with the consent of the parent or guardian if necessary? Yes No –If yes, date of referral: If no, why not?
  1. Does the individual have a primary care physician (PCP)? Yes No
  2. If yes, has there been communication with the PCP to provide updates regarding treatment and service coordination? Yes No
  3. If yes, name of Physician:
  4. If no, have there been efforts to connect the individual with a PCP? Yes No
  1. List anyphysical healthconditionswhich requiretreatment:
  1. Is the individual following healthcare directives in managing health issues? Yes No
  1. List allmedications(forphysical andbehavioral healthconditions) that individualis taking:
  1. Is the individual taking medication as prescribed? Yes No

Revised 4/18/2016 ®Magellan Healthcare, Inc.Page 1 of 3