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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11036 (10/08)

STATE OF WISCONSIN HFS 107.22(1), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION / IN-HOME TREATMENT ATTACHMENT (PA/ITA)
Providers may submit prior authorization (PA) requests to ForwardHealth by fax at (608) 221-8616 or by mail to: ForwardHealth, Prior Authorization, Suite 88, 6406 Bridge Road, Madison, WI 53784-0088. Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/In-Home Treatment Attachment (PA/ITA) Completion Instructions, F-11036A. CHECK ONE Initial PA Request First Reauthorization Subsequent Reauthorization

SECTION I -- MEMBER INFORMATION 1. Name -- Member (Last, First, Middle Initial) 2. Age -- Member

3. Member Identification Number

SECTION II -- PROVIDER INFORMATION 4. Name -- Medicaid-Certified Clinic 5. Clinic's National Provider Identifier (NPI)

6. Name -- Rendering Psychotherapist / Substance Abuse Counselor

7. Rendering Psychotherapist's / Substance Abuse Counselor's NPI

8. Telephone Number -- Psychotherapist / Substance Abuse Counselor

9. Discipline -- Psychotherapist / Substance Abuse Counselor

SECTION III 10. Enter the requested start and end dates for this authorization request. On the initial PA request, if backdating is needed, it must be requested in writing, and the clinical rationale for starting services before authorization is obtained must be documented.

11. Enter the number of hours of treatment to be provided to the family over this PA grant period. Providers should indicate the anticipated pattern of treatment by provider (e.g., a two-hour session once a week by certified therapist, a two-hour session once a week by the second team member with a certified therapist, plus a one-hour session twice a week by the second team member independently).

Continued

PRIOR AUTHORIZATION / IN-HOME TREATMENT ATTACHMENT (PA/ITA) F-11036 (10/08)

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SECTION III (Continued) 12. Indicate the following for the period covered by this request.

ˇ The number of hours the certified psychotherapy / substance abuse counselor will provide treatment ___________________ ˇ The number of hours the second team member will provide treatment ______________________________ ˇ The name and credentials of the second team member. Include his or her degree and the number of hours of supervised
clinical work he or she has done with severe emotional disturbance (SED) children in the space provided (attach résumé, if available).

13. Indicate the travel time for the period covered by this request. Certified Psychotherapist / Substance Abuse Counselor Anticipated Number of Visits Travel Time per Visit = SECTION IV Note: The following additional information must be provided. If attaching copies of existing records to provide the information requested, limit attachments to two pages for the psychiatric evaluation and illness / treatment history. Highlighting relevant information is helpful. Do not attach M-team summaries, additional social service reports, court reports, or other similar documents unless directed to do so following initial review of the documentation. 14. Present a summary of the member's current psychiatric assessment and differential diagnosis. Diagnoses on all five axes of the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), or for children to age four, the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0-3), are required. The summary must present the signs and symptoms present in the member that meet criteria for the given DSM or DC:0-3 diagnosis. The summary does not include the history of the child's illness; this history should be provided in Element 15. A psychiatrist or a Ph.D. psychologist* must review and sign the summary and diagnoses. __________ x_________ Second Team Member Anticipated Number of Visits Travel Time per Visit = __________ x_________

0 __________

0 __________

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PRIOR AUTHORIZATION / IN-HOME TREATMENT ATTACHMENT (PA/ITA) F-11036 (10/08)

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SECTION IV (Continued) 15. Present a summary of the member's illness, treatment, and medication history. Include all significant background information. Describe the potential for change. Indicate if the child is currently in out-of-home placement, and, if so, the timeline for family reunification.

Continued

PRIOR AUTHORIZATION / IN-HOME TREATMENT ATTACHMENT (PA/ITA) F-11036 (10/08)

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SECTION IV (Continued) 16. Complete the checklist to determine whether an individual meets the criteria for SED. Criteria for meeting the functional symptoms and impairments are found in the instructions. The disability must be evidenced by a, b, c, and d listed below. a. A primary psychiatric diagnosis of mental illness or SED. Document diagnosis using the most recent version of the DSM or DC:0-3.

_______________________________________________________________________
Primary Diagnosis b. The individual must meet all three of the following. Be under the age of 21. Have emotional and behavioral problems that are severe in nature. This disability is expected to persist for a year or longer.

c.

Symptoms and functional impairments The individual must have one or two of the following. 1. Symptoms (must have one) 2. Psychotic symptoms. Suicidality. Violence.

Functional impairments (must have two) Functioning in self care. Functioning in the community. Functioning in social relationships. Functioning in the family. Functioning at school / work.

d.

The individual is receiving services from two or more of the following service systems. Mental Health. Juvenile Justice. Social Services. Special Education. Child Protective Services.

Enrollment criteria may be waived under the following circumstances. The member substantially meets the criteria for SED, except the severity of the emotional and behavioral problems have not yet substantially interfered with the individual's functioning, but would likely do so without in-home mental health and substance abuse treatment services. Attach an explanation. The member substantially meets the criteria for SED, except the individual has not yet received services from more than one system and in the judgment of the medical consultant, would be likely to do so if the intensity of treatment requested was not provided. 17. Present an assessment of the family's strengths and weaknesses.

Continued

PRIOR AUTHORIZATION / IN-HOME TREATMENT ATTACHMENT (PA/ITA) F-11036 (10/08)

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SECTION IV (Continued) 18. Indicate the rationale for in-home treatment. Elaborate on this choice where prior outpatient treatment is absent or limited.

19. Indicate the expected date for termination of in-home treatment. Describe anticipated service needs following completion of inhome treatment and transition plans.

SECTION V 20. Attach and label all of the following. a. The Prior Authorization / Request Form (PA/RF), F-11018. b. A copy of a physician's prescription / order for in-home treatment services dated not more than one year prior to the requested first date of service (DOS). c. Documentation that the member had a comprehensive HealthCheck screening performed by a valid HealthCheck screener dated not more than one year prior to the first DOS. A copy of this documentation must be attached to all requests for reauthorizations (a copy of the original documentation may be used). The initial request for these services must be received by ForwardHealth within one year of the date of the HealthCheck screening. d. A multi-agency treatment plan. e. An in-home psychotherapy treatment plan. f. Results of either the Achenbach Child Behavior Checklist or the Child and Adolescent Functional Assessment Scale (CAFAS). g. A substance abuse assessment may be included. A substance abuse assessment must be included if substance abuserelated programming is part of the member's treatment program. I attest to the accuracy of the information on this PA request. I understand that I am responsible for the supervision of the other team member(s) identified on this attachment. I, or someone with comparable qualifications, will be available to the other team member(s) at all times when he or she is in the home alone working with the child / family. 21. SIGNATURE -- Certified Psychotherapist / Substance Abuse Counselor 22. Date Signed

23. SIGNATURE -- Supervising Psychiatrist or Ph.D. Psychologist

24. Date Signed

* One who is licensed in Wisconsin and is listed, or is eligible to be listed, in the national register of health care providers in psychology.

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