TREATMENT AUTHORIZATION REQUEST

Start Date of Request: / End Date of Request:
Patient’s Name:
Social Security#: / DOB:
Current Address:
City/State/Zip:
Medicaid #: -- None / County (Medicaid Eligibility):
Legal Guardian: None Parent DSS Other: / Name:
SERVICE INFORMATION
Level of Care (select only one):
State Services Enhanced Services
High Risk Inpatient Psych Outpatient
PRTF Residential ICF/MR
Innovations/B3 / Type of Review (select only one):
Concurrent Urgent Concurrent Routine Prospective Urgent
Prospective Routine
Retrospective
Type of Care (select only one):
MH SA Voluntary Involuntary
IDD / Retrospective Medicaid Eligibility
Yes
Is this request a revision, additional unit or provider change? No Yes / Urgency of Request: Emergent (Life-Threatening Emergency) Urgent (Non-Life Threatening Emergency)
Routine
Provider of Service: / Attending Provider:
DSMV -DIAGNOSES
DSMV Primary Dx 1:
DSMV Dx 2:
DSM Dx3:
DSM Dx4:
Date of Initial Assessment (and/or subsequent assessments prior to referral)
Unknown
(See attached form for Dimension scoring instructions)
LOCUS / 1 2 3 4 5 / Composite Score / LOC Recommendation
I. Risk of Harm
II. Functional Status
III. Co-Morbidity
IV-a. Recovery Environment (Support)
IV-b. Recovery Environment (Stress)
V. Treatment and Recovery History
VI. Engagement
CALOCUS / 1 2 3 4 5 / Composite Score / LOC Recommendation
I. Risk of Harm
II. Functional Status
III. Co-Morbidity
IV-a. Recovery Environment (Support)
IV-b. Recovery Environment (Stress)
V. Resiliency and Treatment History
VI-a. Acceptance/Engagement (C&Y)
Vi-b. Acceptance/Engagement (Parent/PS)
Comments:
ASAM Patient Placement Criteria Adult/Adolescent
(See ASAM criteria for placement considerations)
I / II.1/5 / III.1 / III.3 / III.5 / III.7 / IV
I. Withdrawal/Intoxication
II. Medical Complication
III. Behavioral/Emotional Cognitive Complication
IV. Readiness for Change
V. Relapse/Continued use or problem potential
VI. Recovery Environment
Placement Recommendation:
ASAM Comments:
CURRENT(C) and PREVIOUS (P) TREATMENT
Service / Current / Previous / Comments
Case Management/Target Case Management / C P
Mental Health Outpatient / C P
Mental Health Inpatient / C P
Substance Abuse Outpatient / C P
Detox / C P
Substance Abuse Inpatient / C P
Other / C P
SUBSTANCE USE
Age of 1st Use / Route of Usage / Frequency / Amount / Date of Last Use
Primary: / 00-None01-Alcohol02-Cocaine/Crack03-Marijuana / Hash04-Heroin05-Non-presc. Methadone06-Other Opiates/Synthetic07-PCP08-Other Hallucinogens09-Methamphetamines10-Other Amphetamines11-Other Stimulants12-Benzodiazapines13-Other Tranquilizers14-Barbiturates15-Other Sed/Hypnotic16-Inhalants17-OTC meds18-Other19-Tobacco99 unknown / Years / 1 - Oral2 - Smoking3 - Inhalation4 - Injection5 - Other99 unknown / 0-Not used past month1-Used 1 to 3x past month2-Used 1 to 2x per week3-Used 3 to 6x per week4-Daily use99 unknown / Per daywkmo.yr.
Secondary: / 00-None01-Alcohol02-Cocaine/Crack03-Marijuana / Hash04-Heroin05-Non-presc. Methadone06-Other Opiates/Synthetic07-PCP08-Other Hallucinogens09-Methamphetamines10-Other Amphetamines11-Other Stimulants12-Benzodiazapines13-Other Tranquilizers14-Barbiturates15-Other Sed/Hypnotic16-Inhalants17-OTC meds18-Other19-Tobacco99 unknown / Years / 1 - Oral2 - Smoking3 - Inhalation4 - Injection5 - Other99 unknown / 0-Not used past month1-Used 1 to 3x past month2-Used 1 to 2x per week3-Used 3 to 6x per week4-Daily use99 unknown / Per daywkmo.yr.
Tertiary: / 00-None01-Alcohol02-Cocaine/Crack03-Marijuana / Hash04-Heroin05-Non-presc. Methadone06-Other Opiates/Synthetic07-PCP08-Other Hallucinogens09-Methamphetamines10-Other Amphetamines11-Other Stimulants12-Benzodiazapines13-Other Tranquilizers14-Barbiturates15-Other Sed/Hypnotic16-Inhalants17-OTC meds18-Other19-Tobacco99 unknown / Years / 1 - Oral2 - Smoking3 - Inhalation4 - Injection5 - Other99 unknown / 0-Not used past month1-Used 1 to 3x past month2-Used 1 to 2x per week3-Used 3 to 6x per week4-Daily use99 unknown / Per daywkmo.yr.
Other: / 00-None01-Alcohol02-Cocaine/Crack03-Marijuana / Hash04-Heroin05-Non-presc. Methadone06-Other Opiates/Synthetic07-PCP08-Other Hallucinogens09-Methamphetamines10-Other Amphetamines11-Other Stimulants12-Benzodiazapines13-Other Tranquilizers14-Barbiturates15-Other Sed/Hypnotic16-Inhalants17-OTC meds18-Other19-Tobacco99 unknown / Years / 1 - Oral2 - Smoking3 - Inhalation4 - Injection5 - Other99 unknown / 0-Not used past month1-Used 1 to 3x past month2-Used 1 to 2x per week3-Used 3 to 6x per week4-Daily use99 unknown / Per daywkmo.yr.
Withdrawal Symptoms: None OR / Nausea Hallucinations Current DT’s Past Seizures Sweating Tremors Past DT’s
Vomiting Agitation Blackouts Current Seizures Cramping
MEDICAL INFORMATION
Current Primary Care Physician Name: / Signed Release to Primary Care Physician? No Yes / Medical Compliancy
Compliant Non-Compliant Unknown / Medical Compliancy Comments:

SERVICES REQUESTED

Service Code / Units Requested / Duration / Frequency (Hours Per Week, Sessions Per Week, Per Month)
Person Filling Out this Form: / Email Address: / Phone Number: / Provider Comments/Notes:
LME Utilization Management Use Only
UM COMMENTS:
Care Manager/Utilization Manager Name:Emily Godfrey 704-743-2102David Hollar 704-743-2117Pamela Caviness Rankin 704-743-2107Tracy Sherrill 704-743-2108Chuck Spears 704-743-2103Jane Austin 704-743-2110Melissa Covert 704-743-2101Janet Garvin 704-743-2109Andria Misenheimer 704-743-2114 Licensure: Credentials: Date/Time (system generated)
**Submission does not automatically constitute payment for services. All treatment is subject to medical necessity determination and based on beneficiary eligibility
MEDICATIONS NONE
Medication Name / Dose / Frequency / # of months (<1 or >1) / Adherent (Yes/No)
prn1x per day1 q.a.m1 q. noon1 q.h.s.1, 2x per day1 b.i.d1 t.i.d.1 q.i.d1 q.a.m. and 2 q.p.m.2 q.a.m. and 1 q.p.m2, 2x per day2 b.i.d2 t.i.d2 q.i.d.i.m. per weeki.m. per 2 weeksi.m. per 3 weeksi.m. per 4 wk / month
prn1x per day1 q.a.m1 q. noon1 q.h.s.1, 2x per day1 b.i.d1 t.i.d.1 q.i.d1 q.a.m. and 2 q.p.m.2 q.a.m. and 1 q.p.m2, 2x per day2 b.i.d2 t.i.d2 q.i.d.i.m. per weeki.m. per 2 weeksi.m. per 3 weeksi.m. per 4 wk / month
prn1x per day1 q.a.m1 q. noon1 q.h.s.1, 2x per day1 b.i.d1 t.i.d.1 q.i.d1 q.a.m. and 2 q.p.m.2 q.a.m. and 1 q.p.m2, 2x per day2 b.i.d2 t.i.d2 q.i.d.i.m. per weeki.m. per 2 weeksi.m. per 3 weeksi.m. per 4 wk / month
prn1x per day1 q.a.m1 q. noon1 q.h.s.1, 2x per day1 b.i.d1 t.i.d.1 q.i.d1 q.a.m. and 2 q.p.m.2 q.a.m. and 1 q.p.m2, 2x per day2 b.i.d2 t.i.d2 q.i.d.i.m. per weeki.m. per 2 weeksi.m. per 3 weeksi.m. per 4 wk / month
Allergies:

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NOTES:

Processing note for development of automated tool:

  • Need to capture date and time submitted to the system
  • Must complete all of LOCUS or all of CALOCUS, not both for each submission
  • If SA selected, required to complete ASAM Substance Use sections in addition to LOCUS or CALOCUS
  • Only allow one service to be entered if MH or SA
  • Need to be able to add requirements when defined for IDD and children under 6 years old

Items needed to be passed back to provider:

  • Authorization Start Date and Authorization Expiration Date
  • Anticipated review date
  • Date/Time CM/UM staff respond to request
  • Total units approved for the authorization
  • Admission into service
  • Total units approved to date

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