DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11090A (10/08)
STATE OF WISCONSIN HFS 107.13(4), Wis. Admin. Code
MENTAL HEALTH DAY TREATMENT FUNCTIONAL ASSESSMENT COMPLETION INSTRUCTIONS
ForwardHealth requires certain information to enable the programs to authorize and pay for medical services provided to eligible members. Members of ForwardHealth are required to give providers full, correct, and truthful information for the submission of correct and complete claims for reimbursement. This information should include, but is not limited to, information concerning enrollment status, accurate name, address, and member identification number (HFS 104.02, Wis. Admin. Code). Under s. 49.45(4), Wis. Stats., personally identifiable information about program applicants and members is confidential and is used for purposes directly related to ForwardHealth administration such as determining eligibility of the applicant, processing prior authorization (PA) requests, or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of PA or payment for the services. The Mental Health Day Treatment Functional Assessment form, F-11090, must be completed each time a functional assessment is performed and kept with the member's case records. A mental health day treatment staff member, preferably the member's case manager or the primary staff person responsible for the member's treatment, is required to complete this form before treatment begins. Providers are required to submit a copy of Section I of this form (which includes demographic and member information) to ForwardHealth along with the Prior Authorization Request Form (PA/RF), F-11018, and the Prior Authorization/Adult Mental Health Day Treatment Attachment (PA/AMHDTA), F-11038. Providers should not submit this form with claims for payment. This is a mandatory form. ForwardHealth will not accept other versions of this form. Print or type the information on the form so that it is legible. Providers should make duplicate copies of all paper documents mailed to ForwardHealth. Providers may submit PA requests by fax to ForwardHealth at (608) 221-8616 or by mail to the following address: ForwardHealth Prior Authorization Ste 88 6406 Bridge Rd Madison WI 53784-0088 The provision of services that are greater than or significantly different from those authorized may result in nonpayment of the billing claim(s). SECTION I -- DEMOGRAPHIC AND MEMBER INFORMATION Element 1 -- Name -- Member Enter the member's last name, first name, and middle initial. Use Wisconsin's Enrollment Verification System (EVS) to obtain the correct spelling of the member's name. If the name or spelling of the name on the ForwardHealth identification card and the EVS do not match, use the spelling from the EVS. Also include the member's name at the top of the second and subsequent pages. Element 2 -- Member Identification Number Enter the member ID. Do not enter any other numbers or letters. Element 3 -- Date of Initial Assessment Indicate the date the initial functional assessment was performed. Also include the date of initial assessment at the top of the second and subsequent pages. Element 4 -- Date of Reassessment Indicate the date the functional reassessment was performed, if applicable. Also include the date of reassessment at the top of the second and subsequent pages. Element 5 Complete the statement by indicating the total number of hours of day treatment the member has received since the initial assessment. Element 6 -- Referral Source Check the appropriate type of referral.
MENTAL HEALTH DAY TREATMENT FUNCTIONAL ASSESSMENT COMPLETION INSTRUCTIONS F-11090A (10/08)
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Element 7 -- Name / Agency -- Referral Source Indicate the name of the individual or agency making the referral. Element 8 -- Address -- Referral Source Indicate the address, including the street, city, state, and ZIP code, of the person or agency making the referral. Element 9 Indicate whether or not the member is presently an inpatient in an acute care general hospital or a psychiatric hospital or is a resident of a nursing home. Element 10 -- Name / Address -- Facility If the answer is "yes" to either question in Element 9, indicate the name and/or address, including the street, city, state, and ZIP code, of the facility. Element 11 If the answer is "yes" to either question in Element 9, indicate the date the member became an inpatient or resident of the facility. Also indicate the anticipated discharge date (obtained from the facility). Element 12 -- Usual Living Arrangement Check the appropriate box corresponding to the member's usual living arrangement. Element 13 -- Reason for Referral State briefly the major reason(s) the person was referred to day treatment. Element 14 -- Eligibility Decision Criteria The information requested in this element makes up the summary of data obtained through performing the complete functional assessment (Sections II-IV). Based on the information contained in this element, the member may or may not be eligible for ForwardHealth reimbursement of day treatment services. a. Substance abuse currently: Indicate whether or not the member currently exhibits dependence on or abuse of alcohol or other drugs. b. Mental retardation primary diagnosis: Indicate whether or not the member has a primary diagnosis of mental retardation. Mental retardation is defined as anyone with a diagnosis of 317, 318, or 319, according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). c. ICD-9-CM: Primary diagnosis code/Secondary and other code: List the primary and secondary diagnoses using ICD-9-CM diagnosis codes. d. Scores, level of functioning (LOF): Indicate the three scores from the functional assessment scale in the following order: 1) Task Orientation Scale, 2) Social Functioning Scale, and 3) Emotional Functioning Scale. Then add the scores for the total LOF score. e. Likelihood of Benefit: Indicate the answer from Section V, Likelihood of Benefit from Mental Health Day Treatment. f. Course of Functioning: Indicate the total score from Section V, Course of Functioning During the Past Year. The total score is the sum of the scores for indicators 1-5. g. Risk of Hospitalization: Indicate the answer from Section V, Risk of Hospitalization. Element 15 -- Current Services Being Received (Medical and Nonmedical) Indicate any services the member is receiving in addition to day treatment. For example, is the member receiving psychotherapy or occupational therapy in addition to day treatment from the provider's facility? Does the member attend a sheltered workshop? Does the member receive social work services from the county? Does the member have a guardian or advocate? These are the types of services (both medical and nonmedical) that should be indicated. If this information is not known, check with the referral source or the county/tribal social or human services agency of the member's place of residence. Element 16 -- Signature -- Assessor The person performing the functional assessment (e.g., case manager or primary staff person) is required to sign the form. Element 17 -- Discipline Indicate the discipline of the assessor. Element 18 -- Date Signed Indicate the date the form was signed by the assessor.
MENTAL HEALTH DAY TREATMENT FUNCTIONAL ASSESSMENT COMPLETION INSTRUCTIONS F-11090A (10/08)
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Element 19 -- Signature -- Day Treatment Program Director The day treatment program director is required to sign after reviewing the assessment form. Element 20 -- Date Signed Indicate the date the form was signed by the day treatment program director. SECTIONS II-IV -- LEVEL OF FUNCTIONING ASSESSMENT SCALES In each of these sections, circle the indicators on the assessment scale that best describe the member's level of functioning. To score each scale, choose the number associated with the circled indicators. If the circled indicators are split between two numbers, score the scale using the lowest number in which indicators are circled, plus a decimal amount that indicates the percent of indicators beyond that number. For example, if on the Social Functioning Scale the provider circled indicators 3c, 3d, 4a, and 4b for a member, this scale would have a score of 3.5. At the bottom of each section, indicate the score for that scale. At the bottom of Section IV, enter the total LOF score, which is the sum of the scores for all three scales (Sections II-IV). SECTION V -- SCORING Likelihood of Benefit from Mental Health Day Treatment Circle the appropriate level for the likelihood of benefit and enter the percent score in the scoring box to the right of the scale. Course of Functioning During the Past Year Circle the appropriate levels on each scale and enter the scores in the boxes to the right of the scales. Add the scores from scales 15 and enter the sum in the "Total (1-5)" scoring box. Risk of Hospitalization Circle the appropriate level for the risk of hospitalization and enter the percent score in the scoring box to the right of the scale.