Provider materials and tools

Authorization reminders

Services that require authorization are reviewed for medical necessity and supporting documentation must be included with every authorization request.

Precertification physical health

For additional Information, please refer to the Medicaid fee schedules and Medicaid policies.

Precertification behavioral health

Initial requests:

Attach a summary describing reason(s) for requested service/unit(s) that supports Medical Necessity Criteria, including goals.

  • Substance Use Intensive Outpatient Program (IOP): Assessment, treatment plan, weekly frequency
  • BH Day Services: Assessment, Treatment Plan
  • Psychosocial Rehabilitative Services (PSR): Assessment, Treatment Plan
  • Clubhouse:  Assessment, Treatment Plan
  • TBOS: Assessment
  • TCM/ICM: Goals describing reason(s) for requested unit(s) and any additional available supporting documentation
  • ECT:  Treatment Plan, History of previous treatment (include previous ECT) and response to treatment. Current Medications, and Medical Clearance.
    • Please provide details such as frequency, unilateral vs bilateral, etc.
  • Psychological testing
    • Make sure that your attachment includes information that responds to the questions below:
      • What is the question to be answered by testing that cannot be determined by a diagnostic interview, review of psychological/psychiatric records, or second opinion?  
      • Has the member had a diagnostic interview or Psychiatrist Evaluation? If yes, include the date of the interview
      • Who will administer the test (s)? Include credentials
      • Names and Type(s) of tests and time requested

Continued service request:

If submitting a continued services request(s) please include the supportive documentation listed below and any progress/regression towards goals. 

  • Substance Abuse Intensive Outpatient Program (IOP): Treatment Plan, weekly frequency and progress
  • BH day services: Treatment plan or Treatment plan review. Functional/Behavioral rating scale: List goals including progress/regression or barriers
  • PSR: Assessment, Treatment plan or Treatment plan review. List goals including progress/regression or barriers
  • Clubhouse: Treatment plan or Treatment plan review. List goals including progress/regression or barriers
  • TBOS: Assessment
  • TCM/ICM: Assessment, Treatment plan or Treatment plan review. List goals including progress/regression or barriers
  • ECT Continuation of ECT Maintenance ECT: Treatment plan, Response to current treatment, Current medications. List goals including progress/regression or barriers
    • Please provide details such as frequency, unilateral vs bilateral, etc.

For additional Information, please refer to the Medicaid Fee Schedule and Policies. You can also review our behavioral practice guidelines.

Inpatient concurrent review:

Please include information about member’s current contacts, social environment, and any relevant information to ensure a smooth transition to the member’s next appropriate level of care.

 

 

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