Prior Authorization : Forms and Attachments

Attachments

In addition to the PA/RF, PA/HIAS1, or PA/DRF, a service-specific PA attachment must be submitted with each PA request. The PA attachment allows a provider to document the clinical information used to determine whether or not the standards of medical necessity are met for the requested service(s). Providers should include adequate information for ForwardHealth to make a reasonable judgment about the case.

ForwardHealth will scan each form with a barcode as it is received, which will allow greater efficiencies for processing PA requests.

Outpatient Mental Health Services

To request PA for outpatient mental health services, providers are required to complete and submit the following forms and documentation to ForwardHealth:

• A PA/RF
• A PA/PSYA
• The member's assessment and treatment/recovery plan including all of the elements listed under the "Strength-Based Assessment" and "Treatment/Recovery Plan" sections below

Providers may submit the same information on an optional form, the Outpatient Mental Health Assessment and Treatment/Recovery Plan.

Strength-Based Assessment

The assessment shall include the following:

• The member's presenting problem
• Diagnosis established from the current Diagnostic and Statistical Manual of Mental Disorders including all five axes or, for children up to age 4, the current Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood
• The member's symptoms that support the given diagnosis
• The member's strengths including current and past biopsychosocial data
• The member's unique perspective and own words about how they views their recovery, experience, challenges, strengths, needs, recovery goals, priorities, preferences, values and lifestyle, areas of functional impairment, family and community support, and needs
• Barriers and strengths to the member's progress and independent functioning
• Necessary consultation to clarify the diagnosis and treatment

Documentation

Document the assessment of the member, basing it on the member's strengths. Include current as well as historical biopsychosocial data. Include mental status, developmental, school/vocational, cultural, social, spiritual, medical, past and current traumas, substance use/dependence and outcome of treatment, and past mental health treatment/outcome. Include the member's view of the issues; for a child, give the parent/primary caregiver's view. An assessment dated within three months of the request may be attached.

Treatment/Recovery Plan

The goals of psychotherapy and specific objectives to meet those goals shall be documented in the member's treatment/recovery plan that is based on the strength-based assessment. In the treatment/recovery plan, the signs of improved functioning that will be used to measure progress toward specific objectives at identified intervals, agreed upon by the provider and member shall be documented. A mental health diagnosis and medications for mental health issues used by the member shall be documented in the treatment/recovery plan.

If the PA requests a differential diagnostic evaluation in excess of the PA threshold hours, submit the PA with the PA/EA.

Providers may submit selected medical documentation with a PA request and indicate the intended use in lieu of writing the same requested information on the PA attachment. For example, a copy of a recent assessment may be attached.

Health and Behavior Interventions

To request PA for health and behavior interventions, providers are required to submit the following completed forms and required documentation to ForwardHealth:

• A PA/RF
• A PA/HBA

Providers may submit selected medical documentation with a PA request and indicate the intended use in lieu of writing the same requested information on the PA attachment. For example, a copy of a recent assessment may be attached.