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.

Intensive In-Home Mental Health and Substance Abuse Treatment Services for Children

All intensive in-home mental health and substance abuse treatment services for children require PA before initiation of services. To request PA for intensive in-home mental health and substance abuse treatment services for children, providers will need to submit the following completed forms and required documentation to ForwardHealth:

• A PA/RF.
• PA/ITA.
• Physician's prescription or order signed and dated not more than one year prior to the requested first DOS.
• Current assessment and treatment plans. Providers may use their own assessment and treatment plan forms as long as all elements are included, or they may use the Prior Authorization Intensive In-Home Mental Health/Substance Abuse Services Assessment and Recovery/Treatment Plan Attachment, which includes the assessment, the multi-agency treatment plan, and the in-home recovery/treatment plan. Both a multi-agency treatment plan and an in-home treatment plan are required. These plans may be combined, making sure all required elements are included.
• The CANS assessment summary, the Achenbach Child Behavior Checklist, or the CAFAS.

Services are authorized based on the clinical documentation supplied by the provider. Services cannot be authorized earlier than the date of the prescription or order.

Information on backdating is available.

Assessment

Additional policy regarding the assessment includes the following:

• The assessment shall be sufficient to identify the member's need for intensive in-home services. A comprehensive assessment shall be valid; accurately reflect the member's current needs, strengths, and functioning as well as historical psychological, social, and physiological data, past treatment and outcome; and include necessary consultation to clarify the diagnosis and treatment.
• A substance abuse assessment must be included if substance abuse-related programming is part of the member's treatment program.
• Initial treatment goals may include assessment of the member and family in the home and these goals may be procedural (for example, complete assessment, complete substance abuse assessment). Where an assessment is part of the initial intervention, be specific and detailed as to the components of the assessment (for example, psychiatrist will complete psychiatric evaluation, substance abuse counselor will complete substance abuse assessment) and when the assessment will be completed. Where appropriate, identify any standardized assessment tools that will be utilized.

In-Home Recovery/Treatment Plan

Additional policy regarding the in-home recovery/treatment plan includes the following:

• The plan must contain measurable goals, specific methods, and an expected time frame for achievement of the goals. The methods must allow for a clear determination that the services provided meet criteria for covered services.
• The plan should clearly identify which team members are providing the services being requested.
• Services provided in the school, or that are primarily social or recreational in nature, are not reimbursable.

Multi-Agency Treatment Plan

Additional policy regarding the multi-agency treatment plan includes the following:

• The individual who is coordinating the multi-agency planning should be clearly identified.
• The multi-agency treatment plan must be developed by representatives from all systems identified on the severe emotional disturbance eligibility checklist.
• The plan should be signed by all participants, but to facilitate submission, the provider may document who was involved.
• Where an agency was not involved in the planning, the provider is required to document the reason and what attempts were made to include them.
• The plan must address the role of each system in the overall treatment and the major goals for each agency involved.

Child and Adolescent Needs and Strengths Assessment Summary, Achenbach Child Behavior Checklist, and the Child and Adolescent Functional Assessment Scale

Providers are required to complete and attach the results of the CANS assessment summary, Achenbach Child Behavior Checklist, or the CAFAS.

Providers are required to be trained to use the CANS assessment tool. For information on how to obtain the CANS assessment tool or training, providers should contact Provider Services.

Information about these screening instruments is available on the internet by searching for "Child and Adolescent Needs and Strengths assessment summary," "Achenbach Behavior Checklist," or "Child and Adolescent Functional Assessment Scale."