Request for Service INPATIENT REQUESTS ONLY

Alliance Behavioral Healthcare Out-of-Network Treatment Authorization Request

(See attached form for Dimension scoring instructions)

LOCUS

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:
Patient’s Name:
Social Security #: / DOB:
Current Address:
City/State/Zip:
Medicaid #: -- None / County (Medicaid Eligibility):
Attending Provider:
Legal Guardian: None Parent DSS Other: / Name:
DIAGNOSES: Indicate Primary Diagnosis with (P).
Axis I:
Axis II:
Axis III: Medical Diagnosis (es):
Axis IV:
GAF:
DATE OF INITIAL ASSESSMENT and/or Subsequent Assessments prior to referral:
MH SA Voluntary Involuntary
Initial Request Reauthorization Discharge ** EXPEDITED**
SUBSTANCE USE
Drug of Choice N/A / 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.
ASAM Patient Placement Criteria Adult/Adolescent
(See ASAM criteria for placement considerations) / CURRENT(C) and PREVIOUS (P) TREATMENT)
Service / Current / Previous / Comments
Enhanced Services / 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
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:
MEDICAL: Current Primary Care Physician Name: Signed Release to Primary Care Physician? Yes No
Medically- Compliant Non-compliant Comments:
CURRENT MEDICATIONS / Current Regimen / # of months / CURRENT MEDICATIONS / Current Regimen / # of months
Adderall / amphetamine +Concerta / methylphenidate+Dexedrine / dextroamphetamineDextrostatDexedrine SpansulesMetadate / methylphenidate+MethadoneMethylinRitalin / methylphenidateRitalin SRStrattera / Atomoxetine 0.10.51251015202530405075100125150200250300350400450500 mg / 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 / <1 >1 / Ambien / zolpidemAtivan / lorazepamBuspar / BuspironeCialisKlonopin / clonazapamLevitraOxycodone / OxycontinPercosetRestoril / Vistaril / Valium / diazepamViagraXanax / alprazolam 0.10.51251015202530405075100125150200250300350400450500 mg / 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 / <1 >1
Anafranil / clomipramineAventyl /Celexa / citalopramDesipramineDesyrel / trazadoneEffexor / venflexamineElavil / amitryptalineLudiomil / maprotilineLuvox / fluvoxamineNardil (MAO inhibitor)Norpramine / desipraminePamelor / tranylcyprominePaxil / paroxetinePaxil SRParnate / tranylcypromine** MAOIProzac / fluoxetineSinequan / sertralineSurmontil / trimipramineVivactil / protriptyleneWellbutrin / bupropionWellbutrin SRZoloft / sertralineZybanTofranil / imipramine 0.10.51251015202530405075100125150200250300350400450500 mg / 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 / <1 >1 / Ambien / zolpidemAtivan / lorazepamBuspar / BuspironeCialisKlonopin / clonazapamLevitraOxycodone / OxycontinPercosetRestoril / Vistaril / Valium / diazepamViagraXanax / alprazolam 0.10.51251015202530405075100125150200250300350400450500 mg / 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 / <1 >1
Ambien / zolpidemAtivan / lorazepamBuspar / BuspironeCialisKlonopin / clonazapamLevitraOxycodone / OxycontinPercosetRestoril / Vistaril / Valium / diazepamViagraXanax / alprazolam 0.10.51251015202530405075100125150200250300350400450500 mg / 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 / <1 >1 / Other: / 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 / <1 >1
Allergies:
For Out of Network Requests Only
Select Reason for Out of Network Request
00 No network facility/practitioner available within 30 miles
01 Clinical Specialty and or Services not available in network facility/practitioners
05 Facility participating but not for specific modality
06 Practitioner is Out-of-Network: In-Network attending practitioner requests an Out of Network covering practitioner
07 Transition Period (Provider is treating enrollee at the time of enrollment and will terminate or transfer within 90 days
08 Network facility/practitioner will not admit; no bed/slot , practice full / 09 Emergency treatment/emergency admission with proper notification/enrollee transfers when or if clinically appropriate
10 History with practitioner/facility that clinically supports continued treatment
11 Alliance Administrative Decision to permit Out-of-Network Treatment (For Alliance BHC use Only)
12 Facility/Provider terminated network status during course of treatment
13 Clinically appropriate Psychiatric Consult/s on medical unit
Reason for Admission, Continued Stay or other comments:

Request for Service – INPATIENT REQUESTS ONLY

Service Description & Code / Funding Source / Frequency / Duration / Start Date / End Date / Provider / UM ACTION / Units Approved
INPATIENT / Approved Pended
Denied-Pt Denied-All
Approved Pended
Denied-Pt Denied-All
Approved Pended
Denied-Pt Denied-All
Clinician Signature: / Requesting Provider: / Date:

ALLIANCE BEHAVIORAL HEALTHCARE Utilization Management Use Only

UM COMMENTS:
Utilization Management Care Coordinator: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 Date:
Alliance Behavioral Healthcare Utilization Management ACCESS#: 1-800-510-9132Fax: (919) 651-8685
**Submission does not automatically constitute authorizations. All treatment is subject to medical necessity determination and based on beneficiary eligibility

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Alliance BHC -11/20/2012 rev. 10/3/2014