PROVIDER MANUAL - Welcome To The Oklahoma...

PROVIDER MANUAL2004

OUTPATIENT BEHAVIORAL HEALTHREHABILITATIVE SERVICES

Updated 1/2004

Presented byOklahoma Foundation for Medical Quality Medicaid

Pre-Authorization Programand the

Oklahoma Health Care Authority

OHCA and OFMQ recommend that all staff receive a full copy of this new material. Delays in prior authorizations may occur if requests are submitted without these changes incorporated.

Outpatient Behavioral Health Rehabilitative Services Provider Manual

TABLE OF CONTENTS

OFMQ - OVERVIEW & OPERATIONS 1PRIOR AUTHORIZATION OF BEHAVIORAL HEALTH SERVICES & REQUEST PROCESS 2-3FORMS COMPLETION 3PROVIDER ELIGIBILITY 3RECIPIENT ELIGIBILITY 3AUTHORIZATION NUMBERS 3INTERNAL QUALITY CONTROL (IQC) 4INTER-RATER RELIABILITY (IRR) 4EDUCATIONAL OPPORTUNITIES 4

TYPES OF REQUESTSInitial Request for Treatment 4Extension Request 4Modification of Current Authorization Request 5Correction Request 5Provider Change of Demographic Information Request 5Provider Change of Demographic form 6Status Request 7

TYPES OF RESPONSESImportant Notice 7Important Notice Response 7Modification Decision 8Pending Eligibility Decision Notice8Pending Eligibility Decision Response 8Eligibility Decision 8Technical Denial 9

REFERRALS, RECONSIDERATIONS, & APPEALS PROCESSReconsideration Request 9Reconsideration Decision 9Referrals 10Appeals To OHCA 10OHCA LD-2 Provider/Physician Grievance Form 11

CLIENT CHANGES SERVICE PROVIDER FACILITIES 12

COLLABORATIONS BETWEEN PROVIDERS 12Letter of Collaboration Form 13

CLIENT SERVICES REQUIRING NO PRIOR AUTHORIZATION 14

ARRAY OF SERVICES 15

MEDICAL NECESSITY CRITERIAAdult Criteria 16-19

Level I 16Level II 17Level III

18Level IV

19

Child Criteria 20-25Criteria for Children 0-36 Months of Age 20Level I 21Level II 22


Level III23

Level IV24

Criteria for Children in RBMS 25

ICF/MR Criteria 26

Specialized Case Management CriteriaAdult 27

Psychological Evaluation Criteria 28

"Exceptional Case" Criteria 29

CLIENT ASSESSMENT RECORDIntroduction to The CAR 30General Definitions 31-32Level of Functioning Scales 33Domains

1. Feeling/Mood/Affect 34 2. Thinking/Mental Process 35 3. Substance Abuse 36 4. Medical/Physical 37 5. Family 38 6. Interpersonal 39 7. Role Performance 40 8. Socio-Legal 419. Self Care/Basic Needs 42

CAR- Points to Remember43-45

Activities of Daily Living Skills Check List 46Emotional Indicators Behavior Check List 47Criteria Reference Form 48Mental Health Service Plan (MHSP) Definitions 49

SAMPLE MHSP PROB., GOALS, OBJ. & INTER. 50-52SAMPLE MHSP SUMMARY

53 REQUEST CHECKLIST 53-55

HELPFUL REFERENCES 56COMMON ACRONYMS 67INSTRUCTIONS FOR COMPLETING REQUEST FORMS 58-60RELALATIVE VALUE UNIT (RVU) 61

TERMINOLOGY CHANGES 62 STATUS REQUEST FORM 63 OUTPATIENT REQUEST PACKET (Last eleven pages)


Revised - 1/2004 - 1

Outpatient Behavioral Health Rehabilitation Services Pre-Authorization Program

Oklahoma Foundation for Medical Quality

OVERVIEW

In an effort to promote effective and efficient health care for Oklahoma fee-for-service Medicaid recipients receiving behavioral health rehabilitative services, the Oklahoma Health Care Authority (OHCA) has contracted with the Oklahoma Foundation for Medical Quality (OFMQ) to conduct prior authorization (PA) of Outpatient Behavioral Health Rehabilitative Services. This program was implemented on December 2, 1996, for Outpatient Behavioral Health Rehabilitative Services. Medicaid recipients enrolled in the SoonerCare Choice Primary Care Physician Case Manager (PCPCM) program and traditional Fee-for-Service Medicaid must be prior authorized for these services by OFMQ. The PCPCM does not have responsibility for referring, approving or gatekeeping these or any other behavioral health services. This is the seventh edition of the Provider Manual and will be effective on January 1, 2004.

OPERATIONS

PA requests will be electronically reviewed via fax or mail. OFMQ office hours are from 8:00 a.m. to 5:00 p.m. Monday through Friday, except holidays. Requests must be sent in on official OFMQ forms and should be typed or neatly printed. Requests received before 3:00 p.m. will be dated that business day. Requests received after 3:00 p.m.or on a weekend day or holiday, will be dated the next scheduled business day. All new requests that have complete documentation will be reviewed and responded to via fax or mail within 3 business days. Incomplete and/or inappropriate requests will be returned to the provider for the needed corrections. All providers are responsible for keeping records of the dates they successfully fax requests and responses to OFMQ. Providers are encouraged to submit a status request on the third business day after submitting a request or response to OFMQ if OFMQ has not already responded to the fax. All requests may be faxed to OFMQ at (405) 858-9098 or mailed to:

Oklahoma Foundation for Medical Quality, Inc.14000 Quail Springs Parkway, Suite 400Oklahoma City, Oklahoma 73134-2600

http://www.ofmq.com

The OFMQ E-mail address is [email protected]. Please utilize this for inquiries, concerns, or comments only. Do not send requests by E-mail. Please access the OFMQ web page, http://www.ofmq.com, for more information about OFMQ. Providers may also call OFMQ at (405) 858-9090, for assistance in completing the request forms, or any other questions regarding the PA process.

Forms and manuals are available on-line athttp://WWW.OFMQ.COM/html/publications.html


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PRIOR AUTHORIZATION OF BEHAVIORAL HEALTH SERVICES

All recipients are eligible to receive a Mental Health Assessment one time per client per provider when services are first initiated. A Mental Health Service Plan Development of moderate complexity may also be provided without prior authorization. OFMQ will conduct prior authorization of clients to receive Outpatient Behavioral Health Rehabilitative Services beyond this one time Mental Health Assessment when the client is first admitted to a program. The process to continue services beyond this initial assessment is explained in the following detailed methodology for PAs.

All facilities must follow these PA guidelines for assessing Medicaid clients for the appropriate types and frequency of outpatient services. Community Mental Health Centers (CMHCs), as identified by the Oklahoma Department of Mental Health and Substance Abuse Services (DMHSAS), are not required to seek prior authorization from OFMQ, but must carry out an internal process of assessment and assignment of clients to the appropriate level of care as described herein. The CMHCs will be retrospectively reviewed by OFMQ.

OFMQ creates Prior Authorization numbers in the Electronic Data System (EDS). The specific services that are authorized are entered individual. The PA is created using the provider number and the client’s recipient number. During the data entry process services may be broken down into individual months of service or grouped into three-month increments of service. The frequency by which the provider provides these services must not deviate significantly from the treatment plan that was reviewed by OFMQ during the prior authorization process.

OFMQ frequently authorizes multiple treatment services over specific time frames. These services must be identified and described in the provider's treatment plan. An example would be individual psychotherapy, family psychotherapy, and group psychotherapy, one hour per week, over a three-month time frame. It is not acceptable to bunch these services all in one day. While this practice may be convenient for the provider, therapeutic services are designed to be spread over time and should not be overwhelming to the client due to the duration of multiple sessions. Services should always be age and developmentally appropriate. OFMQ does recognize that some programs are designed to offer multiple services in one day; these programs need to identify their intent to provide multiple services in short periods of time on the preauthorization request. OHCA SURS Unit and OFMQ’s Retro-Review Program will review these types of billing practices.

Billing questions (e.g., denied claims) should be directed to OHCA Customer Services at 1-800-522-0310. Prior authorization questions should be directed to OFMQ at 405-858-9090.

It is the intent of OHCA that OFMQ will not retroactively authorize any Outpatient Behavioral Health Rehabilitative Services. Requests older than 30 days will be technically denied. However, providers are not penalized for the number of days it takes OFMQ to work responses; these are added into the authorization.

The requirements for prior authorization of services provided under the Medicaid services entitled “Outpatient Behavioral Health Services" and "Targeted Case Management Services” apply to all Medicaid recipients assessed for these services.

REQUEST PROCESS

Facilities will be required to request prior authorization of extended Outpatient Behavioral Health Rehabilitative Services for clients they determine are in need of such services to maintain or improve their functioning within the community at the level most appropriate for that particular client. "All services are to be for the goal of improvement of functioning, independence, or well being of the client. The client must be able to actively participate in the treatment. Active participation means that the client must have sufficient cognitive abilities, communication skills, and short-term memory to derive a reasonable benefit from the treatment". (Part 21.317:30-5-241)

It is necessary for the facility to request prior authorization no less than five (5) calendar days and no more than fifteen (15) calendar days in advance of the expiration of the current authorization period to alleviate the possibility of days occurring which have not been authorized. If the facility waits until the day before or the last day of the current authorization period, there may be instances when non-covered days occur.


Revised - 1/2004 - 3

FORMS COMPLETION

A member of the treatment team must complete the PA Request Packet. The Responsible MHP is responsible for the accuracy and the appropriateness of the request. The request packet and any necessary supportive documentation may be faxed, mailed, or hand delivered to the OFMQ Pre-Authorization Unit (see pg. 1 for fax number and mailing address). All PA request packet forms must be dated within 30 days of receipt by OFMQ.

Since PA numbers are facility/site specific, all services and the corresponding facility/site must be identified in the request packet. If more than one facility/site is responsible for providing services to a Medicaid recipient, collaboration among facilities is necessary (See collaborations).

OFMQ has made every effort to develop PA request packet forms, including the Addendum, that comply with JCAHO, CARF, AOA, COA, and DMHSAS standards, to assist providers in streamlining their paperwork and avoiding duplication.

PROVIDER ELIGIBILITY

Each site must be clearly affiliated with and under the direct supervision and control of the contracting facility. Each site operated by an outpatient mental health facility must have a separate provider number. Failure to obtain and utilize site-specific provider numbers will result in disallowance of services.

NEWLY CERTIFIED FACILITIES/SITES: Immediately submit information (mailing address, telephone and fax numbers) to the Outpatient Supervisor at OFMQ (See Provider Change of Demographic Information Request). Facilities need to submit requests as soon as possible in order to prevent loss of days. Complete requests will receive a “Pending Eligibility” decision which will suffice until the facility acquires the new provider number. When the new provider number has been acquired, notify OFMQ immediately, by fax or mail, so that the authorization may be completed. OFMQ will then send the facility a PA number.

RECIPIENT ELIGIBILITY

OFMQ will determine recipient eligibility by accessing the EDS eligibility file. If the EDS file shows eligibility for the recipient to be pending, the request will be reviewed based on the information provided in the request packet and a decision for authorizing services will be made. The decision will be pending eligibility. If EDS indicates a recipient has Qualified Medical Benefits (QMB) only, the request will be reviewed based on the information provided in the request packet and a decision “Pending Eligibility” will be issued. A PA number will not be assigned when the recipient's eligibility status is pending. The PA will date back to when the request was received by OFMQ, subject to the eligibility dates contained in the EDS system (e.g., PA request received 02/14/04 and eligibility determined from 03/01/04, no services will be prior authorized before 03/01/04). The facility is responsible for checking the OHCA Recipient Eligibility Verification System (REVS) at 1-800-522-0310, and notifying OFMQ when the recipient becomes eligible. For instructions on using REVS, call 1-800-767-3949.

AUTHORIZATION NUMBERS

OFMQ will assign a recipient and provider site-specific PA number to each approved PA request. This recipient and provider site-specific PA number will be entered in the EDS system via direct on-line entry. Each PA number will be associated with from/through dates by service and month to indicate the length of service being authorized by OFMQ. Once the facility has received an approval notice from OFMQ with the PA number identified, the facility must utilize the EDS MS-MA-5 form when filing a claim for the stated services covered. (Submit the PA number on the HCFA-1500 in Item 23.) Facilities must follow the OHCA Provider Manual for submitting claims requiring PA numbers, as specific procedure codes are to be utilized when filing claims for Outpatient Behavioral Health Rehabilitative Services.


Revised - 1/2004 - 4

INTERNAL QUALITY CONTROL (IQC)

OFMQ has internal quality control measures for both the Review Coordinators and Clinical Consultants. OFMQ will sample a specified number of cases monthly. The PA Program Manager, Supervisor, Quality Improvement Coordinator or Consultant will review each case for the appropriateness of the decision. If inappropriate decisions are found, the Program Manager, Supervisor, Quality Improvement Coordinator or Consultant will educate the RC or Consultant regarding the clinical area of concern. A Corrective Action Plan specific to the identified problem may also be developed.

INTER-RATER RELIABILITY (IRR)

OFMQ has an inter-rater reliability process to develop and maintain consistency among the review coordinators. Cases are randomly selected and reviewed according to OHCA guidelines. All review coordinators participate in the IRR process on a monthly basis. The results are reviewed and analyzed for consistency; and discrepancies are addressed collectively.

OFMQ’s Medicaid Pre-authorization Program staff consists of Master’s level clinicians with Oklahoma licensure (LPC, LMFT, LSW/C, LBP) and/or registered nurses (RN’s) with a minimum of 3 years psychiatric experience.

EDUCATIONAL OPPORTUNITIES

OFMQ offers free monthly meetings at the OFMQ offices on the 2nd Wednesday of each month to educate providers about the PA process. If a facility appears to be having specific problems with the PA process, OFMQ may initiate contact - or the facility may contact OFMQ - and arrange for designated staff to attend an educational session. OHCA will also be available (based on an agreeable date) to attend a requested educational session with OFMQ and a facility. If a large group of providers want to meet with OFMQ and/or OHCA, arrangements may be made to satisfy that request.

TYPES OF REQUESTS

INITIAL REQUEST FOR TREATMENT

An initial request is required when a client has not received outpatient behavioral health services in the fee-for-service system within the last six (6) months. OFMQ processes these requests within 3 business days.

Forms to Submit: The fax cover marked “Initial Request” and the entire request packet.

EXTENSION REQUEST

The client has been receiving outpatient behavioral health services in the fee-for-service system within the last six (6) months, whether your or another facility has been providing the services. If the client changes levels of care to or from a specialized level such as RBMS or ICF-MR during an authorization period, a new extension request and treatment plan must be submitted to begin the new level of care. If the client has an inpatient behavioral health admission during an authorization period, a new extension request is required when the client returns to outpatient services. The treatment history section will need to be updated with the location and the service dates of the inpatient admission. Reason(s) for the hospitalization should also be clearly documented. OFMQ processes these requests within 3 business days.

Extension requests are also needed if a client transfers between agency locations with a different provider number or transfers to another agency with a counselor who changes employment.

Forms to Submit: The fax cover marked “Extension Request” and the entire request packet.


Revised - 1/2004 - 5

MODIFICATION OF CURRENT AUTHORIZATION REQUEST

The client would be better suited with a different array or additional units of services than previously authorized. The Modification Request must be within the current PA period. Any changes that are approved will begin the date a complete modification request is received at OFMQ. Services cannot be modified retroactively. The time period of an authorization will not be modified. The number of Modification Requests submitted within an authorization period should not exceed one per month. If the Modification Request is denied, a Reconsideration Request may be submitted. (See Reconsideration Request)

The start date of the modified authorization will be the date the Modification Request is received by OFMQ. The end date of the Modification Request will remain the same as the current authorization. Exception: Psychological Evaluation requests are dated through December 31, of the current calendar year. OFMQ processes these requests within 3 business days.

A Modification Request is not needed if a facility has decided not to utilize all of the services approved within an authorization period (based upon the client’s need). However, if a separate facility wants to provide other needed Outpatient Behavioral Health Services to the client, then it is expected that the two facilities will collaborate on the use of the available RVU’s.

Forms to Submit: The fax cover marked “Modification Request”, and either an entire new request packet OR the last request packet with updated information (CAR Assessment must be current within the last 30 days), initialed and dated, that provides additional supportive documentation and reasons for the requested modification.

CORRECTION REQUEST

A Correction Request must be submitted when a provider finds any errors on a PA or discrepancies between the OFMQ response and the EDS MS-MA 5 (i.e., typographical error, wrong provider number, wrong procedure code, wrong Recipient ID number, etc.) regardless of who made the error. OFMQ processes these requests within three (3) business days.

Forms to Submit: The fax cover marked “Correction Request”. Complete the entire fax cover including the PA number that needs to be corrected. The Comments section should specify the type of correction being requested. You may attach additional documentation such as the EDS MS-MA-5 or the OFMQ response that needs to be corrected.

PROVIDER CHANGE OF DEMOGRAPHIC INFORMATION REQUEST

If there is a change in provider’s demographic information (e.g., name, address, phone and/or fax numbers, Provider ID number(s), etc) a Provider Change of Demographic Information Request must be submitted.

Forms to Submit: Fax cover marked “Provider Change of Demographic Information”. List all changes on the form provided.


Revised - 1/2004 - 6

CHANGE OF INFORMATIONPlease fill out any of the following information that has changed.

Name of Facility:___________________________

Provider Number:___________________________

Old Address:_______________________________

New Address:_______________________________

Old Fax Number:____________________________

New Fax Number:____________________________

Old Phone Number:___________________________

New Phone Number:__________________________

AdditionalInformation:_______________________________________________________________________________________________________________________________________________________________________________


Revised - 1/2004 - 7

STATUS REQUEST

If a facility has not received a response from OFMQ on an Initial, Extension, or Modification Request, or on an Important Notice Response within three (3) business days, a Status Request should be submitted. A Status Request is the only way the provider can support a statement that the request was faxed to OFMQ three (3) business days earlier, and hold the provider’s start date if the request is not on file at OFMQ.

Response to Status Requests:

1) If a facility receives a response reflecting that the Initial, Extension, or Modification Request, or Important Notice Response was not received by OFMQ, the provider has 2 business days (from the date the Status Request Response was faxed from OFMQ to the provider) to re-fax the request/response. If the Initial, Extension, or Modification Request or Important Notice Response is not re-faxed/re-submitted within 2 business days, the original fax date (as supported by the Status Request) will not be held. If an Initial, Extension, or Modification Request or Important Notice Response is faxed after the 2 business days allowed, the start date of services assigned is the date the fax is received at OFMQ.

2) If a facility receives a response reflecting that the Initial, Extension, or Modification Request has been processed and an Important Notice Decision was issued requesting additional documentation and/or information, the provider has ten (10) calendar days (from the date the Status Request Response was faxed from OFMQ to the provider) to fax/submit the required Important Notice Response. If the Important Notice Response is not faxed within the allowed ten (10) calendar days, a Technical Denial decision will be issued (i.e., due to no response within time frame allowed).

Forms to Submit: The one page Status Request form. (See Request Forms) Complete the entire Status Request form, marking the type of request for which the status is being requested. Fax transmittal forms are no longer necessary, nor will they be accepted in lieu of a Status Request.

TYPES OF RESPONSES

IMPORTANT NOTICE

An OFMQ RC will assess each request for overall completeness of the required elements and all necessary supporting documentation. If the request form and/or the supporting documentation is incomplete, or the RC needs additional information to determine the medical necessity of the requested services, the facility responsible for the request will receive a fax titled “Important Notice” stating what additional information is needed to process the request. The facility has ten (10) calendar days from the date the Important Notice was faxed in which to respond. If there is no response within the required 10 days, the request will be technically denied.

Note: All requests with an Important Notice generated will be dated from the date of receipt of requested information, not the date of the original fax. In addition, please note that all requested information must be addressed to avoid a Technical Denial.

IMPORTANT NOTICE RESPONSE

An Important Notice Response is required from a provider when responding to an OFMQ Important Notice decision.

Forms to Submit: OFMQ’s fax cover marked “Important Notice Response” and ALL requested information that was listed in the Important Notice comments section. Send it “Attention” to the RC who signed those comments.

MODIFICATION DECISIONOutpatient Behavioral Health Rehabilitative Services Provider Manual

Revised - 1/2004 - 8

An OFMQ RC will assess each request for overall completeness and clinical appropriateness. Based on the information provided a reviewer may modify a provider’s request by reducing the total units/RVU’s requested for an authorization period. Modifications are made based on the most appropriate array and frequency of services for each request, utilizing the guidelines established in the Outpatient Manual including the Part 21 Administrative Code. Some of the types of Modifications that a Provider might receive are as follows:

A gradual reduction of a particular service across an authorization period (i.e., approval of the 12 sessions requested for the first month, with a decrease to 10 sessions the second month, and then 8 sessions the third month).

A set reduction of a service for the entire authorization period (i.e., requested 12 sessions, but modified to 8 sessions for each month of the authorization period).

A denial of one requested treatment service, but Approval or Modification of another requested treatment service (i.e., requested 20 sessions of Psychosocial Rehabilitation, & 8 sessions of Individual Psychotherapy- Modified to authorize of 20 sessions of Psychosocial Rehabilitation only; Individual Psychotherapy denied).

PENDING ELIGIBILITY DECISION

An OFMQ RC will determine recipient eligibility by accessing the EDS eligibility file. If the EDS file shows eligibility for the recipient to be pending or having Qualified Medical Benefits (QMB) only, the request will be reviewed based on the information provided in the request packet and a decision of either Pending Eligibility- Approved or Pending Eligibility- Modified will be issued. A PA number will not be assigned when the recipient’s eligibility status is pending. The PA will date back to when the request was received by OFMQ, subject to the eligibility dates contained in the EDS system (e.g., PA request received 02/14/04 and eligibility determined from 03/01/04, no services will be prior authorized before 03/01/04).

A Pending Eligibility Decision will also be used in situations where a provider submits a request for services prior to receiving their Medicaid provider identification number.

PENDING ELIGIBILITY DECISION RESPONSE

A Pending Eligibility Response is required from a provider when responding to an OFMQ Pending Eligibility decision notice.

Forms to Submit: The fax cover marked “Pending Eligibility Response” and requested information regarding client’s eligibility. The Pending Eligibility Response notifies OFMQ that the client is eligible for services, and requests a PA number for the services that have been authorized.

ELIGIBLE DECISION

An Eligible Decision is OFMQ’s notification to the Provider that a client’s eligibility has been verified in EDS and that a PA number has been generated for services that had been approved pending eligibility.


Revised - 1/2004 - 9

TECHNICAL DENIAL DECISION

An RC will issue a Technical Denial decision when a request does not meet the guidelines set forth in this manual, including the Part 21 Administrative Code established by OHCA for outpatient behavioral health services. An RC may also issue a Technical Denial when a provider fails to show that a client meets the Medical Necessity Criteria for the services they are requesting. An RC can issue a Technical Denial in response to Initial, Extension, and Modification Requests, as well as in response to an Important Notice Response.

RECONSIDERATIONS, REFERRALS, AND APPEALS PROCESS

RECONSIDERATION REQUEST

If a request has been denied or if the units of service requested have been modified for any requested outpatient behavioral health service, a PA decision may be appealed by the provider or the client (or parent/guardian) if filed, by fax or mail, within five (5) business days of receipt of the decision. This is considered a reconsideration request. Note: This does not apply when you have received an approval for only part of the requested authorization period. For example, your request for three (3) months was modified to a one (1) month authorization. In those cases, you must resubmit a whole new request packet as instructed by the RC.

An Important Notice decision cannot be appealed for reconsideration. The provider must first submit an Important Notice Response and/or receive a Technical Denial or Modification of services from OFMQ on the request. The provider must show an attempt to respond fully and completely to the RC's request for additional information before a request for reconsideration is made.

A Technical Denial due to not providing requested documentation within the 10 calendar days allowed cannot be reconsidered unless your appeal is based upon a Status Request documenting you have faxed forms that OFMQ states they did not receive. Providers must submit a new request if they failed to submit an Important Notice Response within the 10 calendar days.

A reconsideration decision may be appealed to OHCA through its standard grievance process. Prior to submitting an appeal to OHCA, the provider must first utilize the reconsideration process at OFMQ, which is the first level of the appeal process.

Forms to Submit: Fax cover marked “Reconsideration Request”. Complete response to any requests for information by the previous RC, specific reasons for requesting a reconsideration and any new, additional supporting documentation.

RECONSIDERATION DECISIONS

The start date (when the original request was faxed) will be held only if the decision to overturn a Review Coordinator’s decision is based on information already submitted with the original request. This also includes information submitted with an Important Notice Response.

If the reason to overturn the Review Coordinator’s decision is based on any new information submitted with the Reconsideration Request, the start date for services approved through the reconsideration process will be the date the Reconsideration Request was received.


Revised - 1/2004 - 10

REFERRAL TO A CONSULTANT

If the RC is unable to determine the medical necessity of a request based upon the criteria, the case will be referred to a Clinical Consultant (Board Certified Licensed Psychiatrist, Licensed Clinical Psychologist, or Licensed Psychopharmacologist). OFMQ will provide notification back to the provider within 5 business days of receiving the completed request concerning the outcome of the REFERRAL. The referral decision may be an approval of the original request, a modification of the requested services, or a denial of services. When a consultant requires more information, the RC will fax the consultant’s request for additional information to the provider. The provider has ten (10) calendar days to submit the needed information to OFMQ. The start date for services will be the date the request was submitted to OFMQ or the date the Important Notice Response was received if the RC issued an Important Notice decision prior to sending the request to a consultant.

RECONSIDERATION OF A REFERRAL

If the Clinical Consultant’s decision resulted in a modification or denial of the original requested services/RVU’s, the facility does have the opportunity to request a reconsideration of the initial determination. A referral decision may be appealed by the provider or the client (or parent/guardian) if filed, by fax or mail, within five (5) business days of receipt of the decision. The request for reconsideration must include rationale as to the disagreement with the consultant’s decision or new information that was not included when the initial determination was made by the consultant. A second clinical consultant who was not involved with the original decision will review the information submitted in the initial request along with the information submitted with the reconsideration request. The facility will receive a faxed notification of the reconsideration decision from OFMQ within five (5) business days. A reconsideration decision may then be appealed to OHCA through its standard grievance process.

APPEALS PROCESS

If the facility or the recipient (or parent/guardian of a minor) wishes to appeal the OFMQ determination after a reconsideration review, a hearing with OHCA may be requested. This request must be filed within twenty (20) days of receipt of the reconsideration decision. Contact the Docket Clerk, OHCA,(405) 522-7217. Providers will be further instructed on filing appeals through the Oklahoma Health Care Authority and the appropriate forms necessary for completion. An OHCA LD-2 Form for Provider/Physician Grievances is provided in this manual.


Revised - 1/2004 - 11

OKLAHOMA HEALTH CARE AUTHORITY (OHCA)PROVIDER/PHYSICIAN GRIEVANCE FORM

In order to process your grievance request, all of the requested information must be supplied. Failure to provide all of the information will result in a slower response from the OHCA.

Provider Information:Company Name (if any): Provider ID#: _____________________

Individual Name (if any): Federal Tax ID#: __________________

Mailing Address: Number Street

_________________________________________________________________________________ CityState Zip Code

Phone Number: ( ) _____________________

Date of Adverse Action: ____________________

Authorized Representative Information (if any): ___________________________________________

Name: ____________________________________________________

Mailing Address: __________________________________________________________________Number Street

_________________________________________________________________________________ CityState Zip Code

Phone Number: ( )______________________

Please give a complete narrative explanation of the problem you have encountered. Include the names of OHCA personnel you have dealt with, and the dates that specific events occurred. Use additional paper if necessary. Attach copies of any documents you would like to be considered. If your appeal involves a recipient denial, please include the pertinent case number. _________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________

PLEASE SEND THIS FORM TO: OKLAHOMA HEALTH CARE AUTHORITYGRIEVANCE DOCKET CLERKLEGAL DIVISIONP.O. DRAWER 18497OKLAHOMA CITY, OKLAHOMA

73154-0497OHCA Fax Number: (405) 522-7471OHCA Docket Clerk Telephone Number: (405) 522-7217


Revised - 1/2004 - 12

CLIENT CHANGES SERVICE PROVIDER FACILITIES

There are several instances when a client may change service provider facilities. A client may choose to discontinue receiving behavioral health services from one facility and receive those services from another facility. When this occurs, the latter facility submits a complete PA request and a letter of termination signed and dated by the client and/or legal guardian that indicate his/her desire to change behavioral health service providers. The letter needs to have a requested start date for the new provider; however, services cannot be started prior to receiving the request from the new provider. If a facility submits a PA request for a client who has a current authorization with another facility, an Important Notice will be sent to the facility requesting a termination letter. The current PA will be end-dated and a new PA will be issued.

A client may choose to transfer to another site/location with the same agency, because of a clinician transfer, convenience of location, or some other reason. Each site operated by an outpatient mental health facility must have a site-specific provider identification number. **Authorizations are client and site-specific. Therefore, the site the client transfers to, submits a complete PA request and a termination letter signed and dated by the client and/or legal guardian that indicates his/her desire to change provider sites, including an effective date. Since this is an intra-agency transfer, the Extension Request documentation must reflect the client’s progress and any changes in the client’s treatment plan. The current PA will be end-dated and a new PA will be issued.

From time to time, facilities will close a site and transfer clients to another site or clients may choose to move to another facility with their clinician. Again, authorizations are client and site-specific. Therefore, the site the client transfers to, submits a complete PA request and a letter of termination signed and dated by the client and/or legal guardian that indicates his/her desire to change provider sites, including an effective date. Since this is another form of intra-agency transfer, the Extension Request documentation must be modified to reflect the client’s progress and any changes in the client’s treatment plan. The current PA will be end-dated and a new PA will be issued.

Forms to Submit: The fax cover marked “Extension Request”, the entire request packet, AND the appropriate letter of termination from the client. See the example below.

Letter of Termination

I, ( client’s name), wish to discontinue receiving services with any other provider and begin receiving services from (agency name) as of (MM/DD/YY).

____________________________________ _______________________________________ Client (14 and over must sign) Date Legal Guardian Date

COLLABORATION BETWEEN PROVIDERS ON CLIENT CARE

Many facilities are not able to provide a full array of services to clients in need and/or clients may not choose to receive all of their services from one facility. It is expected that facilities will collaborate on behalf of the client’s best interests and choice of facility.

When there are two agencies (or separate sites for the same agency having different provider identification numbers) providing behavioral health services for a client, a letter of collaboration is required, regardless of the funding source for those services (not just for facilities providing services under Medicaid). The letter of collaboration should be signed and dated by the client and/or legal guardian indicating his/her desire for services to be provided by both facilities. The letter must indicate which types of services and the frequency of the services each facility will provide.

When the two collaborating facilities are both facilities for which prior authorization of Medicaid service is required, ideally, these facilities would send their requests in together so that they can be reviewed simultaneously. In most cases, these requests will be sent/faxed in separately to OFMQ. The second facility to submit a request is responsible for submitting a letter of collaboration.

The collaboration letter is not required when one of the agencies is only providing medication training and support and the other agency is not providing these services.

Forms to Submit: Facilities are asked to utilize the OFMQ Letter of Collaboration Form in order to expedite Outpatient Behavioral Health Rehabilitative Services Provider Manual

Revised - 1/2004 - 13

these requests for collaboration information.


Revised - 1/2004 - 14

Letter of Collaboration Between

and (Facility A) (Facility B)

It is agreed that __________________________________and__________________________________ (Facility A) (Facility B)

will collaborate on services provided to _____________________________________________________ (Client's Name)

Recipient ID # ___ ___ ___ ___ ___ ___ ___ ___ ___ , for the duration of the attached prior authorization request.

This collaboration occurs through two service plans (a Facility A service plan and a Facility B service plan) developed collaboratively by the facilities' treatment teams. Each facility retains clinical control of and responsibility for its portion of the treatment. The progress in treatment will be coordinated through inter-agency staffing and consultations. The signatures of the respective clinicians below constitute agreement to collaborate.

_____________________________________ Facility A Clinician, Credentials Date Facility B Clinician, Credentials Date

As a client, I agree to this treatment approach.

____________________________________________________________________________ Client (14 or older) Date As the parent/guardian of , I agree to this treatment approach.

_________________________________________________________________________ Parent/Guardian (and Relationship to Client) Date The anticipated/estimated division of services is as follows:

Facility A Facility B

Type of Service Hours per week Hours per week

Individual Psychotherapy __________ __________

Family Psychotherapy __________ __________Group Psychotherapy __________ __________

Individual Psychosocial Rehab __________ __________Group Psychosocial Rehab ___ __________

Case Management ___ __________

________________ _________ _________Other (specify)

This is an estimate subject to negotiated change and is included here for reference purposes.


Revised - 1/2004 - 15

CLIENT SERVICES REQUIRING NO PRIOR AUTHORIZATIONALLOTTED PER CALENDAR YEAR

The following Basic Array and Additional/Optional Services for each Medicaid fee-for-service client require no preauthorization. The annual (calendar year) maximum allotted is identified.

Crisis Intervention Services8 units per month and 40 units per year

Mental Health Assessment 1 per client, per provider

Mental Health Service Plan Development

1 per year

The client will receive a PA number on the MS-MA-5 form from EDS for Treatment Plan Review, and for services exceeding the initial basic array for Individual and Family Counseling.

Medication Training and Support. This service now requires prior authorization. In the past (prior to 2004) this service could be done once each month without prior authorization. The current revision of this manual was initially published incorrectly with Medication Training and Support not needing prior authorization if the service did not exceed once per month. Currently providers must document medical necessity criteria to receive a PA number for Medication Training and Support.

Non-compensable Client Services for ICF/MR + Medication Training and Support+ Mental Health Service Plan Development+ Case Management Services+ Psychosocial Rehabilitation (Individual and Group)

Non-compensable Services for Residential Behavioral Management Services(Therapeutic Foster Care or Group Home)

+ Mental Health Service Plan Development+ Case Management Services+ Psychosocial Rehabilitation (Individual and Group)


OFMQ, 01/03/-1,

Revised - 1/2004 - 16

ARRAY OF SERVICES

The following array of services is available for both adults and children, levels I through IV. For the ICF/MR, RBMS and 0-36months levels of care, some of these services are excluded. Exclusions are specifically noted under the level of care criteria listed on the following pages.

Psychotherapy Services:Individual 20-30 minute session 1 unit = 0.92 RVU’s

45-50 minute session 1 unit = 1.76 RVU’s75-80 minute session 1 unit = 2.86 RVU’s

Interactive 20-30 minute session 1 unit = 0.96 RVU’s45-50 minute session 1 unit = 1.85 RVU’s75-80 minute session 1 unit = 3.00 RVU’s

Family 60 minute session 1 unit = 2.30 RVU’sGroup 60 minute session 1 unit = 1.10 RVU’s

Psychosocial Rehabilitation Services:Children/Group 15 minute session 1 unit = 0.17 RVU’sAdult/Group 15 minute session 1 unit = 0.13 RVU’sIndividual 15 minute session 1 unit = 0.45 RVU’s

Case Management 15 minute session 1 unit = 0.49 RVU’s

Mental Health Service Plan Low Complexity 1 per authorization 1 unit = 2.50 RVU’s

Psychological Testing 60 minute units 1 unit = 2.17 RVU’s

Medication Training and Support 1 unit = 0.70 RVU’s

ADULT (21 years or older): LEVEL I CRITERIAOutpatient Behavioral Health Rehabilitative Services Provider Manual

OFMQ, 01/03/-1,

Revised - 1/2004 - 17

General RequirementsA. Treatment

1. Appropriate (Must meet ALL of the following conditions)a) Experiencing slight to moderate functional impairment; ANDb) Able to actively participate in and derive a reasonable benefit from treatment as evidenced by sufficient affective, adaptive and cognitive abilities, communication skills and short-term memory

2. Inappropriatea) Imminent danger to self and/or others (medically unstable)

B. Assessment Results (Must meet ONE condition in BOTH 1 AND 2)1. DSM-IV or DSM-IV-TR Diagnosis (a OR BOTH a AND b)

a) Axis I primary diagnosis (INCLUDING V and 900 codes, EXCLUDING Deferred Diagnosis, 799.9, & Provisional Diagnosis)b) Axis II personality disorders

2. CAR Scores (A minimum of ONE of the following)a) 20 - 29 in 4 or more domains (domains 1 - 9); ORb) 30 - 39 in 2 domains (domains 1 - 9); ORc) 20 - 29 in 3 domains AND 30 - 39 in 1 domain or more (domains 1 - 9)

RegimenA. Amount/Array of Services

1. 1 - 12 RVU’s per month, allotted based upon documentation and determined need

B. Length of Services1. Initial = 6 month authorization

2. Extensions (based on continued need & improvement) = 1 - 6 month authorization


Revised - 1/2004 - 18

ADULT (21 years or older): LEVEL II CRITERIA


1. Appropriate (Must meet ALL of the following conditions)a) Experiencing moderate impairments in functioning; ANDb) Able to actively participate in and derive a reasonable benefit from treatment as evidenced bysufficient affective, adaptive and cognitive abilities, communication skills and short-term memory



a) Axis I primary diagnosis (EXCLUDING V and 900 codes, Deferred Diagnosis, 799.9, & Provisional Diagnosis)b) Axis II personality disorders

2. CAR Scores (A minimum of ONE of the following)a) 30 - 39 in 3 domains (domains 1 - 9); ORb) 40 - 49 in 1 domain (domains 1 - 9)


1. 1 - 20 RVU’s per month, allotted based upon documentation and determined need B. Length of Services

1. Initial = 1 - 6 month authorization



Revised - 1/2004 - 19

ADULT (21 years or older): LEVEL III CRITERIA


1. Appropriate (Must meet ALL of the following condition) Currently experiencing moderate to severe functional impairment; AND

a)With therapy, significant functional improvement is possible; ANDb)Able to actively participate in and derive a reasonable benefit from treatment as evidenced by sufficient affective, adaptive, and cognitive abilities, communication skills, and short-term memory



a) Axis I primary diagnosis (EXCLUDING V and 900 codes, Deferred Diagnosis, 799.9, & Provisional Diagnosis)b) Axis II personality disorders

2. CAR Scores (A minimum of ONE of the following)a) 30 - 39 in 4 domains, with 2 domains being in 1, 6, 7, or 9; ORb) 40 in 2 domains, with 1 domain being in 1, 6, 7, or 9; ORc) 30 - 39 in 2 domains AND 40 in 1 domain, with EITHER the 40 OR 2 of the 30's being in domains 1, 6, 7, or 9



B. Length of Services1. Initial = 1-3 month authorization

2. Extensions (based on continued need & improvement) = 1-3 month authorization

EXTENDED CARE LEVEL (1-6 month authorization)Must meet 1 - 3, documented in the request: 1) Diagnosis of Major Mood Disorder, Schizophrenia/Psychotic Disorder, and/or Personality disorder; AND 2) A minimum of 2 years with significant mental health impairment with current or other related diagnosis; AND3) Appears to be stabilized AND demonstrating progress in treatment.4) OPTIONAL: Possible co-morbid conditions exacerbating mental health diagnosis (i.e., medical conditions, substance abuse, mental retardation, etc.).


Revised - 1/2004 - 20

ADULT (21 years or older): LEVEL IV CRITERIA


1. Appropriate (Must meet ALL of the following conditions)a) Currently experiencing very severe functional impairment; ANDb) Potential risk for hospitalization without intensive outpatient services; ANDc) Able to actively participate in and derive a reasonable benefit from treatment as evidenced by sufficient affective, adaptive and cognitive abilities, communication skills, and short-term memory

2. Inappropriatea) Imminent danger to self and/or others (medically unstable); AND/ORb) Extreme level of functional impairment, meeting medical necessity criteria for inpatient hospitalization.


a) Axis I primary diagnosis (EXCLUDING V and 900 codes, Deferred Diagnosis, 799.9, & Provisional Diagnoses)b) Axis II personality disorders

2. CAR Scoresa) 40 in 4 domains, with 1 domain being in 1, 6, 7, or 9



B. Length of Services1. Initial = 1 - 3 month authorization


EXTENDED CARE LEVEL (1-6 month authorization)Must meet 1 - 3, documented in the request: 1) Diagnosis of Major Mood Disorder, Schizophrenia/Psychotic Disorder, and/or Personality disorder; AND 2) A minimum of 2 years with significant mental health impairment with current or other related diagnosis; AND3) Appears to be stabilized AND demonstrating progress in treatment.4) OPTIONAL: Possible co-morbid conditions exacerbating mental health diagnosis (i.e., medical conditions, substance abuse, mental retardation, etc.).


Revised - 1/2004 - 21

CHILD (0-36 MONTHS OF AGE): CRITERIA

All prior authorization decisions will be based upon the following criteria for children 0-36 months of age:

1. Therapist’s credentials must include degree and licensure: a) Early Childhood Development, diagnosis, and treatment

b) Infant Mental Health, diagnosis, and treatment.c) Clinical experience with this age group.

d) Under supervision with clinician with training/experience with this age group.

2. Treatment plan goals and objectives must be age and developmentally appropriate.

3. Developmental Level of the Client/Child, including a copy of how this was assessed.(Sooner Start Form, statement from pediatrician, County Health Department, Clinical Assessment Summary) The Developmental assessment is not required if the only service requested is family psychotherapy.

4. DSM-IV diagnosis for the Client/Child. Diagnosis is for the child, not the parent.

5. Presenting Problem(s) listed.

6. Individual Counseling is considered appropriate when:a) The above conditions (#1-5) are met b) For short-term assessment sessionsc) Clear evidence that the child can engage in symbolic play

7. CAR domains 1 - 9 must be completed and Caregiver Resources as noted on the Addendum page as part of the client record

REGIMENA. Amount/array of services: 1 - 27 RVU’s/month

FOR CHILDREN 0-18 MONTHS of Age (IN ADDITION TO #1-6 above):1. Developmentally APPROPRIATE therapeutic modalities, services, and/interventions must have a primary focus on the attachment between the child and parental figure(s):

a) Family Psychotherapy

2. Developmentally INAPPROPRIATE therapeutic services:a) Individual Psychotherapyb) Group Psychotherapyc) Psychosocial Rehabilitation (Individual or Group)

3. Mental Health Service Plan will be authorized one (1) per authorization period (2.50 RVU’s).

FOR CHILDREN 19-36 MONTHS of Age (IN ADDITION TO #1-6 above):1. Developmentally APPROPRIATE therapeutic modalities, services, and/or interventions:

a) Family Psychotherapy

2. The following MAY be deemed developmentally APPROPRIATE in SOME cases:a) Individual Psychotherapy (Limited - primarily used for observation for assessment purposes)b) Psychosocial Rehabilitation (Individual) (FOR PARENTING SKILLS TRAINING ONLY)

3. Mental Health Service Plan will be authorized one (1) per authorization period (2.50 RVU’s).

B. Length of Services1. Initial =1 - 3 month authorization2. Extensions (based on continued need & improvement) =1 - 3 month authorization


Revised - 1/2004 - 22

CHILD (under 21 years): LEVEL I CRITERIAGeneral Requirements

A. Treatment1. Appropriate (Must meet ALL of the following conditions)

a) Experiencing slight to moderate functional impairment; ANDb) Able to actively participate in and derive a reasonable benefit from treatment as evidenced by sufficient affective, adaptive and cognitive abilities, communication skills, and short-term memory



a) Axis I primary diagnosis (INCLUDING V and 900 codes, EXCLUDING Deferred Diagnosis, 799.9, & Provisional Diagnosis)b) Axis II personality disorders, ONLY for 18 - 20 years of age (If younger than 18, must include well documented psychiatric supporting evidence)

2. CAR Scores (A minimum of ONE of the following)(CAR descriptors for domains 1 – 9 and must be appropriately documented. Caregiver Resources

must be documented as noted on the Addendum as part of the client record.)a) 20 - 29 in 4 domains (domains 1 - 9); ORb) 30 - 39 in 2 domains (domains 1 - 9); ORc) 20 - 29 in 3 domains (domains 1 - 9) AND 30 - 39 in 1 domain (domains 1 - 9)

RegimenA. AMOUNT/ARRAY OF SERVICES


B. Length of Services1. Initial = 6 month authorization



Revised - 1/2004 - 23

CHILD (under 21 years): LEVEL II CRITERIA


1. Appropriate (Must meet ALL of the following conditions)a) Experiencing moderate functional impairment; ANDb) Able to actively participate in and derive a reasonable benefit from treatment as evidenced by sufficient affective, adaptive and cognitive abilities, communication skills, and short-term memory



a) Axis I primary diagnosis (EXCLUDING V and 900 codes, Deferred Diagnosis, 799.9, & Provisional Diagnosis)b) Axis II personality disorders, ONLY for 18 - 20 years of age (If younger than 18, must include well documented psychiatric supporting evidence)

2. CAR Scores (A minimum of ONE of the following) (CAR descriptors for domains 1 – 9 and must be appropriately documented. Caregiver Resources must be documented as noted on the Addendum as part of the client record.)

a) 30 - 39 in 3 domains (domains 1 - 9); ORb) 40 in 1 domain (domains 1 - 9)



B. Length of Services1. Initial =1 - 6 month authorization

2. Extensions (based on continued need & improvement) =1 - 3 month authorization


Revised - 1/2004 - 24

CHILD (under 21 years): LEVEL III CRITERIA


1. Appropriate (Must meet ALL of the following conditions)a) Experiencing moderate to severe functional impairment; ANDb) Able to actively participate in and derive a reasonable benefit from treatment as evidencedby sufficient affective, adaptive and cognitive abilities, communication skills, and short-term memory


B. Assessment Results (Must meet ONE condition in BOTH 1 AND 2)1. DSM-IV or DSM –IV-TR Diagnosis (a OR BOTH a AND b)

a) Axis I primary diagnosis (EXCLUDING V and 900 codes, Deferred diagnosis, 799.9, & Provisional Diagnosis)b) Axis II personality disorders, ONLY for 18 - 20 years of age (If younger than 18, must include well documented psychiatric supporting evidence)

2. CAR Scores (A minimum of ONE of the following) (CAR descriptors for domains 1 – 9 must be appropriately documented. Caregiver Resources

must be documented as noted on the Addendum as part of the client record.)

a) 30 - 39 in 4 domains, with 2 domains being in 1, 6, 7, or 9; ORb) 40 in 2 domains, with 1 domain being in 1, 6, 7, or 9; ORc) 30 - 39 in 2 domains AND 40 in 1 domain, with the 40 or 2 -30's being in 1, 6, 7, or 9


1. 1 - 44 RVU’s per month, allotted based upon documentation and determined need period (2.50 RVU’s).




Revised - 1/2004 - 25

CHILD (under 21 years): LEVEL IV CRITERIA


1. Appropriate (Must meet ALL of the following conditions)a) Experiencing severe functional impairment;b) Potential risk for hospitalization without intensive outpatient services; ANDc) Able to actively participate in and derive a reasonable benefit from treatment as evidencedby sufficient affective, adaptive and cognitive abilities, communication skills, and short-term memory

2. Inappropriatea) Imminent danger to self and/or others (medically unstable); AND/ORb) Extreme level of functional impairment, meeting medical necessity criteria for inpatient hospitalization.



2. CAR Scores (CAR descriptors for domains 1 – 9 must be appropriately documented. Caregiver Resources must be documented as noted on the Addendum as part of the client record.)

a) 40 in 3 domains, with 1 domain being in 1, 6, 7, or 9


1 - 62 RVU’s per month, allotted based upon documentation and determined need




Revised - 1/2004 - 26

CRITERIA FOR CHILDREN INRESIDENTIAL BEHAVIOR MANAGEMENT SERVICES (RBMS)

THERAPEUTIC FOSTER CARE (TFC) AND THERAPEUTIC GROUP HOMES (Levels C, D, D+, and E)


1. Appropriate (Must meet ALL of the following conditions)a) Experiencing severe functional impairment, illustrating the need for additional treatment beyond the RBMS's required services; ANDb) Demonstrates the need for specialized treatment to augment the services provided by the RBMS; ANDc) Able to actively participate in and derive a reasonable benefit from treatment as evidenced by sufficient affective, adaptive and cognitive abilities, communication skills, and short-term memory

2) Inappropriatea) Imminent danger to self and/or others (medically unstable); AND/ORb) Extreme level of functional impairment, meeting medical necessity criteria for acute inpatient hospitalization

B. Assessment Results (Must meet ONE condition in BOTH 1 AND 21. DSM-IV or DSM-IV-TR Diagnosis


2. CAR Scores (A minimum of ONE of the following) (CAR descriptors for domains 1 – 9 must be appropriately documented. Caregiver Resources must be documented as noted on the Addendum as part of the client record.)

a) 30 - 39 in 4 domains, with 2 domains being in 1, 6, 7, or 9; ORb) 40 in 2 domains, with 1 domain being in 1, 6, 7, or 9; ORc) 30 - 39 in 2 domains AND 40 in 1 domain, with the 40 or 2 -30's being in 1, 6, 7, or 9

3. Submission of the RBMS individual treatment plan, with each request, reflecting the need for the requested additional service and an explanation of the need for the specialized treatment or therapeutic intervention employed by the therapist.



2. Services NOT allowed for fee-for-service Medicaid clients receiving RBMSa) Case Management b) Psychosocial Rehabilitation (Individual or Group)c) Mental Health Service Plan Development

B. Length of Services1. Initial = 1 - 3 month authorization2. Extensions (based on continued need & improvement) = 1 - 3 month authorization


Revised - 1/2004 - 27

ICF/MR CRITERIA


1. Appropriate (Must meet ALL of the following conditions) a) Functional improvement is a realistic expectation; AND b) Potential risk for hospitalization without intensive outpatient services; ANDc) Able to actively participate in and derive a reasonable benefit from treatment as evidenced by sufficient affective, adaptive and cognitive abilities, communication skills, and short-term memory

2. Inappropriatea) Imminent danger to self and/or others (medically unstable); AND/ORb) Inability to actively participate in treatment

B. Assessment Results (Must meet ALL of the following conditions)1. DSM-IV or DSM-IV-TR Diagnosis (BOTH a AND b)

a) Axis I primary diagnosis (EXCLUDING V and 900 codes, Deferred Diagnosis, 799.9, & Provisional Diagnosis)b) Axis II diagnosis, with documented IQ score

2. Submission of a letter from the ICF/MR facility indicating the DSM-IV or DSM-IV-TR multi-axial diagnoses, specific behavioral concerns, reason for referral, and signed by an ICF/MR representative.

3. Submission of the Individual Habilitation Plan that reflects the client’s need for the requested behavioral health services. The current annual plan is required including signature page and legible date of most recent update/revision. 4. Major discrepancies between information obtained from the ICF-MR and provider’s documentation are to be resolved by the provider. It must be clear the client can benefit from outpatient counseling services. 5. Submission of Psychological Testing documenting IQ Score, Vineland Adaptive Scale, and any additional clinical assessment reports that support the requested services.

6. Communication domain at the end of the CAR must be completed; AND 7. For SEVERE or PROFOUND MR diagnosis, the approach(es) to treatment, such as behavior modification, applied behavior analysis, or another widely accepted theoretical framework for treating clients with this diagnosis, must be noted in the Addendum as part of the client record.Regimen

A. Amount/Array of Services 1. 1 - 24 RVU’s per month, allotted based upon documentation and determined need.

2. Services NOT allowed for fee-for-service Medicaid clients in a 24-hr settinga) Case Management b) Psychosocial Rehabilitation (Individual or Group)c) Medication Training and Support

B. Length of Services1. Initial = 1 - 3 month authorization2. Extensions (based on continued need and improvement) = 1 - 3 month authorization

EXTENDED CARE LEVEL (1-6 month authorization)Must meet 1 - 3, documented in the request: 1) Diagnosis of Major Mood Disorder, Schizophrenia/Psychotic Disorder, and/or Personality disorder; AND 2) A minimum of 2 years with significant mental health impairment with current or other related diagnosis;

AND3) Appears to be stabilized AND demonstrating progress in treatment.4) OPTIONAL: Possible co-morbid conditions exacerbating mental health diagnosis (i.e., medical conditions, substance abuse, etc.).


OFMQ, 01/03/-1,

Since this is ICF-MR level, the client is obviously MR.

Revised - 1/2004 - 28

ADULT (21 years or older): SPECIALIZED CASE MANAGEMENT CRITERIA


1. Appropriate (Must meet a AND c, OR b AND c of the following conditions)a) Client is being discharged from an Inpatient hospital (psychiatric);b) Client meets Levels 1 - 4 criteria;c) Case Management (CM) will be provided to assist a client's gaining access to needed medical, social, educational and other services essential to meeting basic human needs. The CM works with the client in gaining access to appropriate community resources. The CM may provide advocacy, linkage, and/or referral.

2. Inappropriatea) Client is residing in a Nursing Home or ICF/MR; AND/ORb) Physically escorting or transporting a client to scheduled appointment or staying with the client during an appointment, monitoring financial goals, providing specific services (e.g., shopping or paying bills), or delivering bus tickets, food stamps, money, etc. AND/ORc) CM must not be used in lieu of psychotherapy or psychosocial rehabilitation services.

B. Assessment Results (MUST meet conditions in BOTH 1 AND 2)1. DSM-IV or DSM-IV-TR Diagnosis

a) Axis I primary diagnosis (EXCLUDING V and 900 codes, Deferred diagnosis, 799.9, and provisional diagnosis)

2. Submission of a mental health service plan that specifically addresses the goals of advocating, linking, and referring the client in behaviorally measurable terms and time frames.

C. Submission Requirements1. Adult Levels 1 - 4

a) Submitted as part of a complete prior authorization packet for other outpatient behavioral health services.

2. Client discharging from Inpatient a) Inpatient: discharge date, if applicable; AND

b) Mental health service plan signed by the client, parent/guardian, and Case Manager with history of CM involvement supporting the need to follow through; AND when appropriate, discharge goals from the inpatient stay and CM follow through; ANDsubmitted as part of a complete prior authorization packet, either as part of a request for other behavioral health services or as a separate request.

RegimenA. Amount/Array of Services (15 minutes/1 unit/1 RVU)

1. Inpatient dischargea) Total maximum allotment for initial requests = 1 - 24 RVU's per monthb) No extensions

2. Levels 1 - 4 a) Total maximum allotment for initial requests = 1 - 12 RVU's per monthb) Total maximum allotment for extension requests = 1 - 8 RVU's per month

B. Length of Services1. One (1) month authorization for clients who are discharging from Inpatient

a) Dates authorized will be 2 weeks before the discharge date and 2 weeks after.2. 3 month authorization for Levels 1 - 4


Revised - 1/2004 - 29

PSYCHOLOGICAL EVALUATION CRITERIA

General RequirementsA. Evaluation

1. Appropriate (Must meet ALL of the following conditions)a) Client is experiencing difficulty in functioning with origins not clearly determined; ANDb) An evaluation has been recommended and/or requested by a psychiatrist, psychologist,or a licensed mental health professional; ANDc) Results of evaluation will directly impact current treatment strategies.

2. Inappropriatea) Evaluation results will not directly impact current treatment or discharge; AND/ORb) Evaluation results will be utilized for academic placement/purposes only; AND/ORc) Evaluation has been conducted by another provider (including private psychologists) within the current calendar year.

B. Assessment Results1. DSM-IV or DSM-IV-TR Diagnosis

a) Axis I primary diagnosis (INCLUDING V and 900 codes, Deferred, and provisional diagnosis).

C. Submission Requirements (must include ALL of the following information)1. Entire prior authorization form; AND2. Treatment plan must document:

a) What tests will be used?b) How many hours will the testing require?c) Who will be performing the tests, and what are their credentials?d) What is the reason for the testing?e) How will evaluation results specifically affect goals and objectives for the client?


1. The MAXIMUM allotment is 6 hours/13.02 RVU’s per calendar year.

NOTE: A psychological technician is defined by the State Board of Examiners of Psychologists as being "under the direct supervision of a licensed psychologist" (Title 59 O.S. 1991, Section 1353.6) and "the Rules of the Board (Section 575:10-1-7) describe the hiring of a psychological technician, a dependent assistant to the psychologist."


Revised - 1/2004 - 30

EXCEPTIONAL CASE CRITERIA

It is recognized that there may be cases in which the client’s condition is severe enough to require a higher intensity of services than is allowed by the Medical Necessity Criteria in the Level(s) of Care. Providers may request additional services beyond the maximum number of RVU’s allowed in the Level(s) of Care when cases would fit into this category. These cases will be considered “Exceptional” and will not be maintained at this same level of intensity each PA period. Requests for this level of service will be covered for a period of one (1) month. Prior authorization will be required monthly.

This level of care is being allowed for exceptional cases in which the child or adult's condition requires more RVU’s than is offered in the Level(s) of Care, but who are not in need of the level of services provided at the Inpatient level of care.

The provider must submit a request to OFMQ using the standard PA Request Packet and specify that this is a request for services beyond the Level(s) of Care. The services to be rendered must be identified specifically as well as the number of RVU’s being requested. An RC will review the first request. Subsequent, additional requests for exceptional case will be automatically referred to Clinical Consultants to evaluate the appropriateness of the requested services for the clinical manifestations identified. Supporting documentation will be required to substantiate the additional requested services above and beyond the Level(s) of Care.

Appropriate (Any/or all of the following)a) Experiencing extreme functional impairment, but does not meet medical necessity criteria for inpatient hospitalization;b) Medically stable (i.e., not an imminent danger to self and/or others);c) Stepping down from a higher level of care (Acute/RTC/Inpatient.);d) Without intensive services, there is an escalation of symptoms (e.g., an increase in aggressive behavior or a decreased ability to perform ADL’s, but is medically stable).

Inappropriatea) Imminent danger to self and/or others (medically unstable); AND/ORb) Extreme level of functional impairment, meeting medical necessity criteria for inpatient hospitalization.


Revised - 1/2004 - 31

CLIENT ASSESSMENT RECORD (CAR)

The CAR is a useful tool for assessing a client’s current functioning and for tracking progress. General definitions for each domain and level of functioning scales are provided. Based on these definitions, the clinician can acquire a reasonably clear idea of the types and intensity of behaviors required to meet the criteria for each scale in each domain, as well as which behaviors to document in each domain to support the score.

The CAR descriptors should include information obtained in a face-to-face interview/assessment with the client on the date noted at the top of each page. Client specific behavioral examples should be included, as well. Submitting a CAR that is a duplicate of a previous CAR or that is a duplicate of the CAR of another client, could result in a technical denial or audit exceptions.

Note: revisions to the original CAR document have been made to help clarify OFMQ and OHCA’s understanding of the intent of the assessment.

INTRODUCTION TO THE CLIENT ASSESSMENT RECORD (CAR)

This manual was developed to assist the clinician in using the Client Assessment Record (CAR) to evaluate the functioning level of their clients. The nine (9) domains and six (6) levels of functioning contained within the CAR provide the clinician with a comprehensive overview of the client’s capacity to adapt to the environment and survive in the community.

The following conditions are prerequisites for using the scale in the most effective and reliable manner:

The clinician must have knowledge of the client’s behavior and adjustment to his/her community. The knowledge must be gained either through direct contact (face-to-face interview) and experience with the client, or by systematic review of the client’s functioning with individuals who have observed and are acquainted with the client (Utilize the review in lieu of a face-to-face interview only when a face-to-face interview is not possible, i.e., small child. Document that the CAR is not the result of a face-to-face interview, noting the reason)

The clinician should be trained in the administration of the CAR prior to using it as the basis for clinical decisions.

The CAR levels of functioning have been structured within a "normal curve" format, ranging from Above Average Functioning (1-10) to Extreme Psychopathology (50). Pathology begins in the 20-29 range. The CAR format provides a broad spectrum of functioning and permits a range within which clients can be described. Descriptors must be current, client specific, age appropriate, and developmentally appropriate. Only current data can be scored. Historical information is documented in the designated section of the request packet.

The clinician’s description of the client’s behavior in each domain needs to include 1) the frequency of the behavior (How often does the behavior occur?); 2) the intensity of the behavior (How severe is the behavior?); 3) duration of the behavior (How long does the behavior last?); and 4) the impact the symptoms/behaviors have on daily functioning, to establish the severity of the client’s current condition. A clear focus on the behaviors that are relevant to each domain, as described in this manual, will help communicate the clinician’s assessment of the client’s current condition. The documentation should be specific to the particular client rather than a duplication of the general definitions or examples noted in this manual.

If the clinician does not have the immediate experience to rate the client on any of the scales, consultation must be made with the client’s family and/or other staff members to acquire information sufficient to make a reliable estimation. (This fact would be documented in the descriptor, i.e., “According to client’s father,”)


Revised - 1/2004 - 32

GENERAL DEFINITIONS

1. FEELING/MOOD/AFFECT: Measures the extent to which the person’s emotional life is well moderated or out of control. Consider the appropriateness of emotional responses to immediate and long range situational factors compared to others of the same age, gender, culture, and life circumstances and how able the client is to use his/her coping skills and emotional responses to enhance personal and interpersonal satisfaction. Document how well the person responds emotionally, as well as the ability to use his/her coping skills.

2. THINKING/MENTAL PROCESS: Measures the extent to which the person is capable of and actually uses clear, well-oriented thought processes. Adequacy of memory and overall intellectual functioning are also to be considered in this scale. This domain includes consideration of thinking style common for the person’s age, gender, culture, and life circumstances. Document how the person’s judgment, beliefs and logical thought processing is impacted by identified emotional and interpersonal stressors.

3. SUBSTANCE USE: Measures the extent to which a person’s current use of synthetic or natural substances is controlled and adaptive for general well-being and functioning. Although alcohol and illegal drugs are obvious substances of concern, any substance can be subjected to maladaptive use or abuse, especially if compounded by special medical or social situations.

4. MEDICAL/PHYSICAL: Measures the extent to which a person is subject to illness, injury and/or disabling physical conditions, regardless of causation. Demonstrable physical effects of psychological processes are included, but not the effects of prescribed psychotropic medications. Physical problems resulting from assault, rape, or abuse are included. List the medications the client is currently taking, including the name, dosage, frequency and reason for taking the medication. The impact of the client’s medical/physical condition on his/her daily functioning must be described.

5. FAMILY: Measures the adequacy with which the client functions within his/her family and current living situation. Relationship issues with family members are included as well as the adequacy of the family constellation to function as a unit. Document attachment or bonding issues, adequacy of communication and structure within the family system, areas of conflict and the presence of any abuse or violence.

6. INTERPERSONAL: Measures the adequacy with which the person is able to establish and maintain interpersonal relationships. Relationships involving persons other than family members should be compared to similar relationships by others of the same age, gender, culture, and life circumstances. Document the client’s ability to respond to affection and human contact, their capacity for empathy and ability to engage in social interaction.

7. ROLE PERFORMANCE: Measures the effectiveness with which the person manages the role most relevant to his or her contribution to society. The choice of whether job, school, or home management (or some combination) is most relevant for the person rated, depends on that person’s age, gender, culture and life circumstances. If disabled, intellectually, mentally or physically, the client would be scored relative to others with the same disability and in the same situation. Whichever role is chosen as most relevant, the scale is used to indicate the effectiveness of functioning within the role at the present time.

8. SOCIO-LEGAL: Measures the extent and ease with which the person is able to maintain conduct within the limits prescribed by societal rules and social mores. It may be helpful to consider this scale as a continuum extending from pro-social to anti-social functioning . Document lack of consideration for others; intentional destruction of property ; defiance of authority; lying, cheating, and/or stealing; temper tantrums; run away behavior; compliance with one’s personal ethical/moral value system; abusiveness and/or aggressiveness to others and/or self; and inappropriate sexual behavior.

9. SELF CARE/BASIC NEEDS: Measures the adequacy with which the person is able to care for him/herself and provide his/her own needs such as food, clothing, shelter and transportation. Document the person’s ability to make reliable arrangements appropriate to his/her age, gender, culture and life circumstances. If the client lives in a supportive or dependent situation for reasons other than lack of ability (e.g. confined on criminal sentence), estimate the ability to make arrangements independently and freely. Children, the disabled and elderly persons who are cared for by others should also be rated on their own ability to make arrangements compared to others their age. Document whether the person can be left alone for a period of time; makes known medical/dental needs; tend to self-grooming and appropriate dress; and take medication as prescribed.


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COMMUNICATION: Attempts to describe the person’s PRIMARY METHOD of communication and their ability to communicate, both verbally and nonverbally. Document whether the client understands and responds appropriately to verbal and/or written or nonverbal communication; participates in social conversation; primary method of communication; requests assistance as needed; exhibits unusual speech patterns or expresses thoughts that are/are not sensible; and responds to the presence of familiar persons or caretakers. This domain is mandatory for ICF/MR clients. It is optional for all other clients. There is no score given.

The following two domains are not required or scored as part of the CAR assessment for preauthorization. This documentation, however, may be required for audit purposes and may be documented on the Addendum to the request packet.

COMMUNITY INTEGRATION: Attempts to describe the person’s ability to connect/engage within the community. The person’s ability to function within the community appropriately/acceptably as compared to others of the same age, gender, culture and life circumstances. This documentation fulfills CARF and JCAHO assessment standards.

CARE GIVER RESOURCES: Attempts to describe the extent to which the care giver has difficulties in providing for the child’s basic needs (e.g., housing) or developmental needs (e.g., emotional, social, etc.) such that there is a negative impact on the child’s level of functioning. This documentation is mandatory for clients under 21 years of age. It is optional for all other clients.


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LEVEL OF FUNCTIONING SCALESGENERAL ABSTRACT ANCHOR GUIDES

1 - 9 (Above Average)

Functioning in the particular domain is consistently better than that which is typical for age, gender, and subculture, or consistently average with occasional prominent episodes of superior, excellent functioning. Functioning is never below typical expectations for the average person. (Over-conforming)

10 - 19 (Average)

Functioning in the particular domain as well as most people of same age, gender, and subculture. Given the same environmental forces is able to meet usual expectations consistently. Has the ability to manage life circumstances.

20 - 29 (Mild to Moderate)Functioning in the particular domain falls short of average expectation most of the time, but is not usually seen as seriously disrupted. Dysfunction may not be evident in brief or casual observation and usually does not clearly influence other areas of functioning. Problems require assistance and/or interfere with normal functioning.

30 - 39 (Moderate to Severe)

Functioning in the particular domain is clearly marginal or inadequate, not meeting the usual expectations of current life circumstances. The dysfunction is often disruptive and self-defeating with respect to other areas of functioning. Moderate dysfunction may be apparent in brief or casual interview or observation. Serious dysfunction.

40 - 49 (Incapacitating)

Any attempts to function in the particular domain are marked by obvious failures, usually disrupting the efforts of others or of the social context. Severe dysfunction in any area usually involves some impairment of other areas. Hospitalization or other external control may be required to avoid life-threatening consequences of the dysfunction. Out of control all or most of the time.

50 (EXTREME)

The extreme rating for each scale, suggests behavior or situations totally out of control, unacceptable, and potentially life threatening. This score indicates issues that are so severe it would not be generally used with someone seeking outpatient care.


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1. FEELING/MOOD/AFFECT

1 - 9 (ABOVE AVERAGE): Anxiety, depression, or disturbance of mood is absent or rare. The person’s emotional life is characterized by appropriate cheer and optimism given a realistic assessment of his/her situation. Emotional control is flexible, with both positive and negative feelings clearly recognized and viewed as within his/her own control. Reactions to stressful situations are clearly adaptive and time limited.

10 - 19 (AVERAGE): No disruption of daily life due to anxiety, depression or disturbance of mood. Emotional control shows consistency and flexibility. A variety of feelings and moods occur, but generally the person is comfortable, with some degree of pleasant or warm affect. When strong or persistent emotions occur, the object and approximate causes are readily identified.

ADULT: Able to cope, either alone or with the help of others, with stressful situations. Not overwhelmed when circumstances seem to go against him/her. Does dwell on worries; tries to work out problems. Frustration, anger, guilt, loneliness, and boredom are usually transient in nature and resolve quickly. Considers self a worthy person.

CHILD: Not overwhelmed when circumstances seem to go against him/her. Frustration, anger, guilt, loneliness, and boredom are usually transient in nature and resolve quickly. Reactions to stressful events are age appropriate.

20 - 29 (Mild to Moderate): Occasional disruption due to intense feelings. Emotional life is occasionally characterized by volatile moods or persistent intense feelings that tend not to respond to changes in situations. Activity levels may occasionally be inappropriate or there may be disturbance in sleep patterns.

ADULT: Tends to worry or be slightly depressed most of the time. Feels responsible for circumstances but helpless about changing them. Feels guilty, worthless and unloved, causing irritability, frustration and anger.

CHILD: Frustration, anger, loneliness, and boredom persist beyond the precipitating situation. May be slightly depressed and/or anxious MOST OF THE TIME.

30 - 39 (Moderate to Severe)): Occasional major (severe) or frequent moderate disruptions of daily life due to emotional state. Uncontrolled emotions are clearly disruptive, affecting other aspects of the person’s life. Person does not feel capable of exerting consistent and effective control on own emotional life.

ADULT: The level of anxiety and tension (intense feelings) is frequently high. There are marked frequent, volatile changes in mood. Depression is out of proportion to the situation, frequently incapacitating. Feels worthless and rejected most of the time. Becomes easily frustrated and angry.

CHILD: Symptoms of distress are pervasive and do not respond to encouragement or reassurance. May be moderately depressed and/or anxious most of the time or severely anxious/depressed occasionally.

40 - 49 (Incapacitating): Severe disruption or incapacitation by feelings of distress. Unable to control one’s emotions, which affects all of the person’s behavior and communication. Lack of emotional control renders communication difficult even if the person is intellectually intact.

ADULT: Emotional responses are highly inappropriate most of the time. Changes from high to low moods make person incapable of functioning. Constantly feels worthless with extreme guilt and anger. Depression and/or anxiety incapacitate person to a significant degree most of the time.

CHILD: Emotional responses are highly inappropriate most of the time. Reactions display extreme guilt and anger that is incapacitating.

50 (EXTREME): Emotional reactions or their absence appears wholly controlled by forces outside the individual and bears no relationship to the situation.


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2. THINKING/MENTAL PROCESS This domain refers to the person’s intellectual functioning and thought processes only. If there is a lowering of functioning level in either one, please rate the more severe of the two.

1 - 9 (ABOVE AVERAGE): Superior intellectual capacity and functioning. Thinking seems consistently clear, well organized, rational, and realistic. The person may indulge in irrational or unrealistic thinking, or fantasy, but is always able to identify it as such, clearly distinguishing it from more rational realistic thought.

10 - 19 (AVERAGE): No evidence of disruption of daily life due to thought and thinking difficulties. Person has at least average intellectual capacity. Thinking is generally accurate and realistic. Judgment is characteristically adequate. Thinking is rarely distorted by beliefs with no objective basis.

ADULT: Capable of rational thinking and logical thought processes. Oriented in all spheres. No memory loss.

CHILD: Intellectual capacity and logical thinking are developed appropriately for age.

20 - 29 (Mild to Moderate): Occasional disruption of daily life due to impaired thought and thinking processes. Intellectual capacity slightly below average (“Dull Normal” to Borderline) and/or thinking occasionally distorted by defensive, emotional factors and other personal features. Poor judgment may occur often, but is not characteristic of the person. Communications may involve misunderstandings due to mild thought disorders. Includes specific impairments of learning or attention and the ability to generalize from acquired knowledge.

ADULT: Borderline retardation, but can function well in many areas. Peculiar beliefs or perceptions may occasionally impair functioning. Occasionally forgetful, but is able to compensate.

CHILD: Borderline retardation or developmentally delayed, but can function well in many areas. Inability to distinguish between fantasy and reality may, on occasion, impair functioning.

30 - 39 (Moderate to Severe)): Frequent or consistent interference with daily life due to impaired thinking. Mild to moderate mental retardation and/or frequent distortion of thinking due to emotional and/or other personal factors may occur Frequent substitution of fantasy for reality, isolated delusions, or infrequent hallucinations may be present. Poor judgment is characteristic at this level.

ADULT: Mild to moderate retardation, but can function with supervision. Delusions and/or hallucinations interfere with normal daily functioning. Frequently disoriented as to time, place, or person. Person is unable to remember recent or past events.

CHILD: Mild to moderate retardation. May be preoccupied by unusual thoughts or attachments.

40 - 49 (Incapacitating): Incapacitated due to impaired thought and thinking processes. Severe to profound mental retardation and/or extreme disruption or absence of rational thinking may exist. Delusions or frequent hallucination that the person cannot distinguish from reality may occur. Communication is extremely difficult.

ADULT: Unable to function independently. Severely disoriented most of the time. Significant loss of memory.

CHILD: Severely disoriented most of the time. Loss of memory. If speech is present, it may manifest itself in peculiar patterns.

50 (EXTREME): Profound retardation, comatose, or vegetative. No process that would ordinarily be considered “thinking” can be detected, although person may appear to be conscious. Communication is virtually impossible. Extreme catatonia.

Note: A score of 40 or more in this domain must include a statement indicating the client’s ability to participate in treatment planning and benefit from the OP services requested.


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3. SUBSTANCE USE

1 - 9 (ABOVE AVERAGE): All substances are used adaptively with good control. Substances known to be harmful are used sparingly, if at all.

10 - 19 (AVERAGE): No impairment of functioning due to substance use. Substance use is controlled so that it is not apparently detrimental to the person’s over-all functioning or well-being. Substances used and amount of use are within commonly accepted range of the person’s subculture. Infrequent excesses may occur in situations where such indulges have no serious consequences.

ADULT: No functional impairment noted from any substance use. Reports occasional use of alcohol with no adverse effects.

CHILD: No effects from intake of alcohol, drugs, or tobacco other than possibly one occurrence of experimentation.

20 - 29 (Mild to Moderate): Occasional or mild difficulties in functioning due to substance use. Weak control with respect to one or more substances. May depend on maladaptive substance use to escape stress or avoid direct resolution of problems, occasionally resulting in increased impairment and/or financial problems.

ADULT: Occasional apathy and/or hostility due to substance use. Occasional difficulty at work due to

hangover or using on the job.CHILD: Occasional incidence of experimentation with alcohol, drugs or other substance with potential

adverse effects.

30 - 39 (Moderate to Severe)): Frequent difficulties in functioning due to substance use. Has little control over substance use. Lifestyle revolves around acquisition and abuse of one or more substances. Has difficulty covering up the detrimental effects of substance abuse. Shows serious deterioration in function when deprived of substance.

ADULT: Needs alcohol, drugs or other substances to cope much of the time, without them feels upset and irritable. Frequent hangovers/highs or other effects of substance abuse that are causing difficulty on the job, at home and/or in other situations.

CHILD: Repeated use of alcohol, drugs, or other substances causing difficulty at home and/or school.

40 - 49 (Incapacitating): Disabled or incapacitated due to substance use. Substance abuse dominates the person’s life to the almost total exclusion of other aspects. Serious medical and/or social consequences are accepted as necessary inconveniences. Control is absent, except as necessary to avoid detection of an illegal substance.

ADULT: Major focus on obtaining desired substance. Other functions ignored. Unable to hold job due to use of alcohol, drugs or other substances.

CHILD: Unable to function at home or in school due to substance use. Life revolves around obtaining desired substance.

50 (EXTREME): Constantly high or intoxicated with no regard for basic needs or elemental personal safety. May include extreme vegetative existence.

Note: The use of substances by family members is recorded in domain #5 , as it relates to the family’s ability to operate as a functional unit.


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4. MEDICAL/PHYSICAL

1 - 9 (ABOVE AVERAGE): Consistently enjoys excellent health. Infrequent minor ills cause little discomfort, and are marked by rapid recovery. Physical injury is rare and healing is rapid. Not ill or injured at this time of rating and in good physical condition.

10 - 19 (AVERAGE): No physical problems that interfere with daily life. Generally good health without undue distress or disruption due to common ailments and minor injuries. Any chronic medical/physical condition is sufficiently controlled or compensated for as to cause no more discomfort or inconvenience than is typical for the age. No life-threatening conditions are present.

ADULT: Occasional colds, fatigue, headaches, gastrointestinal upsets, and common ailments that are endemic in the community. No sensory aids required. No medications.

CHILD: Occasional common ailments. Rapid recovery with no long-term effects. No sensory aids required. No medications.

20 - 29 (Mild to Moderate): Occasional or mild physical problems that interfere with daily living. Physical condition worse than what is typical of age, sex, and culture and life circumstances; manifested by mild chronic disability, illness or injury, or common illness more frequent than most. Includes most persons without specific disability, but frequent undiagnosed physical complaints. Disorders in this range could become life threatening only with protracted lack of care.

ADULT: Controlled allergies. Needs glasses, hearing aid, or other prostheses, but can function without them. Needs medication on a regular basis to control chronic medical problem.

CHILD: Illnesses more frequent than average. Controlled allergies. Needs glasses, hearing aid, or other prostheses, etc.

30 - 39 (Moderate to Severe): Frequent and/or chronic problems with health. Person suffers from serious injury, illness or other physical condition that definitely limits physical functioning (though it may not impair psychological functioning or productivity in appropriately selected roles). Includes conditions that would be life threatening without appropriate daily care. Cases requiring hospitalization or daily nursing care should be rated 30 or above, but many less critical cases may be in this range also.

ADULT: Diabetes, asthma, moderate over/underweight or other evidence of eating disorder. Cannot function without glasses, hearing aid or other prostheses. Heavy dependence on medications to alleviate symptoms of chronic illness.

CHILD: Diabetes, asthma, moderate over/underweight or other evidence of eating disorder. Cannot function without glasses, hearing aid, or other prostheses. Physical problems secondary to abuse. Heavy dependence on medication.

40 - 49 (Incapacitating): Incapacitated due to medical/physical health. The person is physically incapacitated by injury, illness, or other physical condition. Condition may be temporary, permanent or progressive, but all cases in this range require at least regular nursing-type care.

ADULT: Medical/physical problems are irreversible and incapacitating. Must have special medication in order to survive.

CHILD: Medical/physical problems are irreversible and incapacitating.

50 (EXTREME): Critical medical/physical condition requiring constant professional attention to maintain life. Include all persons in a general hospital intensive care unit.

Note: Include how the medical condition limits the client’s day-to-day function for score of 20 and above.


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5. FAMILY

1 - 9 (ABOVE AVERAGE): Family unit functions cohesively with strong mutual support for its members. Individual differences are valued.

10 - 19 (AVERAGE): Major conflicts are rare or resolved without great difficulty. Relationships with other family members are usually mutually satisfying.

***** DEFAULT TO AVERAGE RATING IF ADULT HAS NO FAMILY OR LACK OF FAMILY CONTACT. Feelings about lack of contact would be noted in domain # 1. *****

ADULT: Primary relationships are good with normal amount of difficulties. Feels good with family relationships and secure in parent role. Destructive behavior among family members is rare.

CHILD: Conflicts with parents or siblings are transient; family is able to resolve most differences promptly. Parenting is supportive and family is stable.

20 - 29 (Mild to Moderate): Relationships within the family are mildly unsatisfactory. May include evidence of occasional violence among family members. Family disruption is evident. Significant friction and turmoil evidenced, on some consistent basis, which is not easily resolved.

ADULT: Family difficulties such that client occasionally thinks of leaving. Some strife with children.CHILD: Problems with parents or other family members are persistent, leading to generally unsatisfactory

family life. Evidence of recurring conflict or even violence among siblings.

30 - 39 (Moderate to Severe): Occasional major or frequent minor disruption of family relationships. Family does not function as a unit. Frequent turbulence and occasional violence involving adults and children.

ADULT: Turbulent primary relationship or especially disturbing break-up. Adult rage and/or violence directed toward each other or children.

CHILD: Family inadequately supportive of child. Constant turmoil and friction. Family unit is disintegrating.

40 - 49 (Incapacitating): Extensive disruption of family unit. Relationships within family are either extremely tenuous or extremely destructive.

ADULT: Not capable of forming primary relationships. Unable to function in parenting role. Abusive or abused.

CHILD: Isolated. Lacking family support. Abused or neglected.

50 (EXTREME): Total breakdown in relationships within family. Relationships that exist are physically dangerous or psychologically devastating.

Note: For adults, note and score current, ACTIVE family problems only.For children report and score the behavior of the current family as it affects the child.


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6. INTERPERSONAL

1 - 9 (ABOVE AVERAGE): Relationships are smooth and mutually satisfying. Conflicts that develop are easily resolved. Person is able to choose among response styles to capably fit into a variety of relationships. Social skills are highly developed.

ADULT: Has wide variety of social relationships and is sought out by others.CHILD: Social skills highly developed for age.

10 - 19 (AVERAGE): Interpersonal relationships are mostly fruitful and mutually satisfying. Major conflicts are rare or resolved without great difficulty. The person appears to be held in esteem within his or her culture.

ADULT: Good relationship with friends. Forms good working relationships with co-workers.CHILD: Client is able to relate well to peers or adults without persistent difficulty.

20 - 29 (Mild to Moderate): Occasional or mild disruption of relationships with others. Relationships are mildly unsatisfactory although generally adequate. May appear lonely or alienated although general functioning mostly appropriate.

ADULT: Some difficulty in developing or keeping friends. Problems with co-workers occasionally interfere with getting work done.

CHILD: Some difficulty in forming or keeping friendships. May seem lonely or shy.

30 - 39 (Moderate to Severe): Occasional major or frequent disruption of interpersonal relationships. May be actively disliked or virtually unknown by many with whom there is daily contact. Relationships are usually fraught with difficulty.

ADULT: Has difficulty making and keeping friends such that he/she has few friends or tenuous, strained relationships. Generally rejects or is rejected by co-workers; tenuous job relationships.

CHILD: Unable to attract friendships. Persistent quarreling or social withdrawal. Has not developed age appropriate social skills.

40 - 49 (Incapacitating): Serious disruption of interpersonal relationships or incapacitation of ability to form relationships. No close relationships; few, if any, casual associations which are satisfying.

ADULT: Socially extremely isolated. Argumentative style or extremely dependent style makes work relationships virtually impossible.

CHILD: Socially extremely isolated. Rejected, unable to attach to peers appropriately.

50 (EXTREME): Relationship formation does not appear possible at the time of the rating.

Note: Relationships with family members are reported in domain # 5.


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7. ROLE PERFORMANCE

1 - 9 (ABOVE AVERAGE): The relevant role is managed in a superior manner. All tasks are done effectively at or before the time expected. The efficiency of function is such that most of the tasks appear easier than for others of the same age, sex, culture, and role choice.

10 - 19 (AVERAGE): Reasonably comfortable and competent in relevant roles. The necessary tasks are accomplished adequately and usually within the expected time. There are occasional problems, but these are resolved and satisfaction is derived from the chosen role.

ADULT: Holds a job for several years, without major difficulty. Student maintains acceptable grades with minimum of difficulty. Shares responsibility in childcare. Home chores accomplished.

CHILD: Maintains acceptable grades and attendance. No evidence of behavior problems.

20 - 29 (Mild to Moderate): Occasional or mild disruption of role performance. Dysfunction may take the form of chronic, mild overall inadequacy or sporadic failures of a more dramatic sort. In any case, performance often falls short of expectation because of lack of ability or appropriate motivation.

ADULT: Unstable work history. Home chores frequently left undone; bills paid late. CHILD: Poor grades in school. Frequent absences. Occasional disruptive behavior at school.

30 - 39 (Moderate to Severe): Occasional major or frequent disruption of role performance. Contribution in the most relevant role is clearly marginal. Client seldom meets usual expectations and there is a high frequency of significant consequences, i.e. firing, suspension.

ADULT: Frequently in trouble at work, or frequently fired. Home chores ignored; some bills defaulted.CHILD: Failure or suspension from school. Persistent behavior problems in school.

40 - 49 (Incapacitating): Severe disruption of role performance due to serious incapacity or absent motivation. Attempts, if any, at productive functioning are ineffective and marked by clear failure.

ADULT: Client not employable. Is unable to comply with rules and regulations or fulfill ANY of the expectations of the client’s current life circumstance.

CHILD: Expelled from school. Constantly disruptive and unable to function in school.

50 (EXTREME): Productive functioning of any kind is not only absent, but also inconceivable at the time of rating.

Note: Identify and assess only the client’s primary role. Family role would be described in domain 5. If residing in an RCF, RCF resident would be considered the primary role. Score functioning relative to others in the same life circumstance.


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8. SOCIO-LEGAL

1 - 9 (ABOVE AVERAGE): Almost always conforms to rules and laws with ease, abiding by the “spirit” as well as the “letter” of the law. Any rare deviations from rules or regulations are for altruistic purposes.

10 - 19 (AVERAGE): No disruption of socio-legal functioning problems. Basically a law-abiding person. Not deliberately dishonest, conforms to most standards of relevant culture. Occasional breaking or bending of rules with no harm to others.

ADULT: No encounters with the law, other than minor traffic violations.CHILD: Generally conforms to rules. Misbehavior is non-repetitive, exploratory or mischievous.

20 - 29 (Mild to Moderate): Occasional or mild disruption of socio-legal functioning. Occasionally bends or violates rules or laws for personal gain, or convenience, when detection is unlikely and personal harm to others is not obvious. Cannot always be relied on; may be in some trouble with the law or other authority more frequently than most peers; has no conscious desire to harm others.

ADULT: Many traffic tickets. Creates hazard to others through disregard of normal safety practices.CHILD: Disregards rules. May cheat or deceive for own gain.

30 - 39 (Moderate to Severe): Occasional major or frequent disruption of socio-legal functioning. Conforms to rules only when more convenient or profitable than violation. Personal gain outweighs concern for others leading to frequent and/or serious violation of laws and other codes. May be seen as dangerous as well as unreliable.

ADULT: Frequent contacts with the law, on probation, or paroled after being incarcerated for a felony. Criminal involvement. Disregard for safety of others.

CHILD: Unable to consider rights of others at age appropriate level. Shows little concern for consequences of actions. Frequent contact with the law.

40 - 49 (Incapacitating): Serious disruption of socio-legal functioning. Actions are out of control without regard for rules and law. Seriously disruptive to society and/or pervasively dangerous to the safety of others.

ADULT: In confinement or imminent risk of confinement due to illegal activities. Imminent danger to others or property.

CHILD: In confinement or imminent risk of confinement due to delinquent acts.

50 (EXTREME): Total uncontrolled or antisocial behavior. Socially destructive and personally dangerous to almost all unguarded persons.

Note: Since danger to others is a clear component of scores of 20 and over, a clear statement as to the client’s danger to others must be included in the request.


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9. SELF CARE/BASIC NEEDS

1 - 9 (ABOVE AVERAGE): Due to the fundamental nature of this realm of behavior, “above average” may be rated only where needs can be adequately and independently obtained in spite of some serious obstacle such as extreme age, serious physical handicap, severe poverty or social ostracism.

10 - 19 (AVERAGE): Client is able to care for self and obtain or arrange for adequate meeting of all basic needs without undue effort.

ADULT: Able to obtain or arrange for adequate housing, food, clothing and money without significant difficulty. Has arranged dependable transportation.

CHILD: Able to care for self as well as most children of same age.

20 - 29 (Mild to Moderate): Occasional or mild disruption of ability to obtain or arrange for adequate basic needs. Disruption is not life threatening, even if continued indefinitely. Needs can be adequately met only with partial dependence on illegitimate means, such as stealing, begging, coercion or fraudulent manipulation.

ADULT: Occasional assistance required in order to obtain housing, food and/or clothing. Frequently has difficulty securing own transportation. Frequently short of funds.

CHILD: More dependent upon family or others for self care than would be developmentally appropriate for age.

30 - 39 (Moderate to Severe): Occasional major or frequent disruption of ability to obtain or arrange for at least some basic needs. Include denial of need for assistance or support, or meeting needs wholly through illegitimate means. Unable to maintain hygiene, diet, clothing and/or prepare food.

ADULT: Considerable assistance required in order to obtain housing, food, and/or clothing. Consistent difficulty in arranging for adequate finances. Usually depends on others for transportation. May need assistance in caring for self.

CHILD: Ability to care for self considerably below age and developmental expectation.

40 - 49 (Incapacitating): Severe disruption of ability to independently meet or arrange for the majority of basic needs by legitimate or illegitimate means. Unable to care for self in a safe and sanitary manner.

ADULT: Housing, food and/or clothing must be provided or arranged for by others. Incapable of obtaining any means of financial support. Totally dependent on others for transportation.

CHILD: Cannot care for self. Extremely dependent for age and developmental level.

50 (EXTREME): Person totally unable to meet or arrange for any basic needs. Would soon die without complete supportive care.

Note: When rating a child in this domain, rate on child’s functioning only, without regard to adequacy of parent’s provisions for basic needs. The developmental level of the child must also be considered.

CLIENT ASSESSMENT RECORD (CAR)Points To Remember

ALL CAR Domains:


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To establish the severity of the client’s current condition, examples of the client’s current behavior/symptoms must include: frequency of behavior/symptoms (how many times hourly, daily, weekly, etc.), intensity of the behavior/symptoms (how severe is the behavior- pouts, yells, breaks things, hits, harms others, etc.), time frame (when and for how long does the behavior occur), and the impact the behavior/symptoms have on client’s daily functioning (no impact, conflict with co-workers, reprimands at work, fired from job, etc.)

For Example: CAR Domain 1: Anxious 3 or 4 times per week lasting up to 3 hours at a time as evidenced by motor tension, autonomic hyperactivity, apprehension, and vigilance. When anxious, client talks non-stop and interrupts others 3 or more times daily. Doesn’t respond to encouragement and/or redirection. Client’s behavior has put him at risk of being dropped from college courses and is causing conflict at work.

Specific examples should be given to support the assessments documented in the descriptors.

Descriptors should be relevant to the domain in which they are documented (i.e., family interactions should be documented in domain 5- the family domain, not in domain 6 which addresses interactions/relationships outside of the family).

Only current information is to be scored, not historical information. Relevant historical information is documented in the Historical Information section of the request.

Descriptors should be scored considering reasonable expectations for the person’s age, gender, culture and life circumstance to differentiate between expected behavior/symptoms and pathological behavior/symptomology.

CAR Domain 1:

Does the depression, worry, anxiety cause “occasional” (20-29) or “occasional major” (30-39) disruption to daily functioning? The key is to determine whether or not the feelings are out of control for the client. A score in the 20-29 range can include descriptors such as “can be persistent and fail to respond to changes in situations, change in activity levels, disturbance of sleep, helplessness, worthlessness, irritability, frustration and anger”. Therefore, a full-blown depressive episode or anxiety disorder could score 20-29. A score in the 30-39 range would have to demonstrate that the client’s lack of emotional control occurs frequently. A score in the 40-49 range must demonstrate that the client’s lack of emotional control is functionally incapacitating.

Common Problems:

Using relative terms like sometimes, occasionally, usually, constantly, always, never etc., instead of including specific frequency statements such as 3 times weekly, 5 times daily, etc.

Not providing adequate descriptors, such as severity and duration of symptoms and the impact they have on client’s daily functioning, to support the degree of the client’s lack of emotional control. Particularly when scoring in 40-49 range, adequate descriptors/specific examples are not provided to support that the client is “unable to control one’s emotions, which affects all of the person’s behavior and communication.

CAR Domain 2: The phrase “poor judgment” is used in both the 20-29 and 30-39 ranges. The 30-39 range indicates that “poor judgment is characteristic”. Therefore, it is necessary to demonstrate that poor judgment occurs more than just “often” which is descriptive of 20-29. In order to score 40-49, descriptors need to clearly demonstrate that the client is “severely disoriented most of the time”. It is questionable that a client who scores 40-49 in this domain could benefit from insight oriented counseling services or would be able to actively participate in


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treatment planning. A score of 40 or more in CAR Domain 2 must include a statement indicating the client’s ability to participate in treatment planning and benefit from the OP services requested.

Common Problems:

Scoring in 40-49 range when descriptors do not support that client is “severely disoriented most of the time”.

CAR Domain 3: Client’s substance use alone does not rate a score of even 20-29, which would require at least a low level of dependence. Descriptors in CAR 3 need to reflect current level of abuse/dependence. In addition to the substance(s) used, amount and frequency of use, duration of use, and how use impacts the client’s daily functioning should also be documented. The substance use of persons other than the client (parents, spouse, etc.) would not be noted or scored in this domain.

Common Problems:

Scoring a child based on parents substance use.

Scoring history of use rather than current use and/or current level of dependence.

CAR Domain 4: The impact of the client’s medical condition on day-to-day life/functioning is key to determining the level of incapacitation. For example, a person with arthritis that causes painful joints would be scored lower than one who is wheel chair bound or bed ridden.

Common Problems:

Behavioral health issues are scored rather than medical/physical issues. .

Impact on daily functioning is omitted, which is necessary to determine level of incapacitation.

CAR Domain 5: A clear picture of the client’s current family situation must be provided to determine the appropriate score. Historical information is valuable, but must not be scored and should be documented in the Historical Information section of the request. Some dysfunction can be normal. For adult’s, what the family actually does would be scored, rather than what they fail to do (i.e., visit/contact client regularly).

Common Problems:

Adult’s that have little or no contact with their family are scored for “missing or grieving” their family in CAR domain 5, instead of in CAR domain 1 (feelings) where it should be documented.

Adults with no family or lack of family contact are scored above the average rating, rather than defaulting to the average rating (10-19) as instructed in the manual.

Recurring conflict or even violence among siblings is scored as supporting 30-39, rather than the 20-29 reflected in the manual.

Client’s previous family system is scored, rather than current family system (i.e., scoring family system child was removed from, rather than current foster family).

CAR Domain 6: Outpatient Behavioral Health Rehabilitative Services Provider Manual

Revised - 1/2004 - 46

Scores the client’s ability to make and keep friends. If a client is geographicallyisolated or isolated due to physical/medical problems (i.e., client is bedridden), this would not be scored as pathological.

Common Problems:

Client’s poor judgment regarding choice of friends is scored in CAR 6, rather than CAR 2 where poor judgment should be documented.

Relationships with family members are scored in CAR 6, rather than CAR 5 where family information should be scored.

CAR Domain 7: The provider must determine the most relevant role and that role should be scored. Senior citizens, the disabled, and children are not generally expected to work and would not be rated for the role of employee. A disabled client that has not worked for years, and there is no expectation of working in the near future, would not be rated as an employee. The primary role for most school age children is student.

Common Problems: Specific role is not identified.

Specific examples of poor role performance are not given.

The role for which descriptors reflect performance is not the primary role of the client indicated (i.e., descriptors reflect performance based on expectations of someone living independently for someone residing in an RCF).

Family role is described in Domain 7 rather than Domain 5, where family information should be scored.

CAR Domain 8: This domain measures pro-social vs. anti-social behavior. Although this domain scores more than just criminal behavior, the examples of criminal behavior can be a good guide as to the severity required to qualify for each level. A child who does not follow rules at home would not equate to a person who disregards the safety of others and has frequent contact with the law.

Common Problems:

DHS involvement with the family, or parent/s going to court for custody or other legal reasons is scored, rather than client’s ability to follow rules/laws, which should be scored. Only the client’s behavior is to be scored in this domain.

CAR Domain 9: The client’s developmental level and functioning compared to others the same age must be considered in scoring the domain. The expectations for a small child and for a person in an RCF are much different than for that of a healthy adult. Receiving TANF, Social Security, Medicaid, Medicare, etc. to provide needed services are legitimate forms of self-care and must not be scored. If a person is in need, but refuses the services they clearly need, this would be described and scored.

Common Problems: A parent’s inability to provide needed resources for a child’s self care are scored (i.e., client

has poor hygiene due to parents not providing shelter with running water), when only the child’s ability to arrange for age appropriate self care should be scored.

Client self care is scored based on unrealistic expectations, (i.e., a minor child is expected to rely on parent/guardian for food and shelter) rather than age appropriate expectations.


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Revised - 1/2004 - 48

EMOTIONAL INDICATORS BEHAVIOR CHECK LIST(Developed by the Oklahoma Private Mental Health Providers Association)

Optional checklist to assist providers in completing the CAR. Numbers in parentheses refer to CAR domains.


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____Exhibits anxiety (1)

____Cries/laughs too easily; emotionally labile (1)

____Appears unhappy; depressed (1)

____Stubborn and/or sullen (1)

____Unduly impulsive (2)

____Has excessive and/or peculiar preoccupations with objects/activities (2)

____Expresses thoughts that are not sensible (2)

____Appears to be attending and/or responding to internal stimuli, e.g., possible hallucinatory activity (2)

____Unaware of happenings in immediateenvironment (2)

____Inability to follow simple instructions (2)

____Unresponsive to redirection by caregiver (2)

____Exhibits facial/body tics (4)

____Grinds teeth (4)

____Exhibits peculiar mannerisms/ habits; stereotypical behavior (4)

____Rocks back and forth when sitting/standing (4)

____Incontinent for urine and/or feces (4, 9)

____Eating difficulties (4, 9)

____Sleep disturbance (4, 9)

____Does not allow anyone to touch; tactile defensiveness (5, 6)

____Unable to recognize the rewarding aspects of human contact (5, 6)

____Withdraws from contact with others; isolates (6)

____Poor eye contact (6)

____Refuses scheduled activities (7)

____Overly active (7)

____Refuses work assignments (7)

____Has temper tantrums (8)

____Negativistic and/or defiant (8)____Teases/bullies others (8)

____Shows a lack of consideration

for others (8)

____Lies, cheats, or steals (8)

____Physically aggressive toward others (8)

____Runs away if not supervised (8)

____Removes clothing in inappropriate places (8)

____Engages in inappropriate sexual behavior (8)

____Displays self abuse and/or self-injurious behavior (8)

____Intentionally destroys property of own/others (8)

____Uses bizarre speech (2, )

____Does not respond to presence of familiarcaretakers; minimal attachment/bonding behavior (5, 6)

____Unresponsive to positive statements/behavior from caretakers with smiles,laughter, etc. (1, 5, )

____Makes no effort to communicate needs (9)


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REVISED CRITERIA REFERENCE FORM

LEVEL OF CARECAR SCORES INITIAL EXTENSION

Child (0-36 mos)1 – 27 RVU’s/mo

Complete all domains (1-11) 1 - 3 months 1 - 3 months

Child Level 11 - 18 RVU’s/mo

20 - 29 in 4 domains (1 - 9); OR30 - 39 in 2 domains (1 - 9); OR

20 - 29 in 3 domains AND30 - 39 in 1 domain (1 - 9)

6 months 1 - 6 months

Child Level 21- 27 RVU’s/mo.

30 - 39 in 3 domains (1 - 9); OR40 - 49 in 1 domain (1 - 9)

1 - 6 months 1 – 3 months


30 – 39 in 4 domains, w/ 2 in 1, 6, 7 or 9; OR40 – 49 in 2 domains, w/ 1in 1, 6, 7 or 9; OR

30 - 39 in 2 domains AND40 - 49 in 1 domain, w/ 1-40 OR 2-30s in 1, 6, 7 or 9

1 – 3 months 1 – 3 months


40 - 49 in 3 domains,with 1 in 1, 6, 7 or 9

1 - 3 months 1 - 3 months

Child RBMS1 - 22 RVU’s/mo.

30 - 39 in 4 domains, w/ 2 in 1, 6, 7 or 9; OR40 - 49 in 2 domains, w/ 1 in 1, 6, 7 or 9; OR

30 - 39 in 2 domains AND40 - 49 in 1 domain,

1-40 or 2-30s in 1, 6, 7 or 9

1 – 3 months 1 – 3 months

Adult Level 11 - 12 RVU’s/mo.

20 - 29 in 4 domains (1 - 9); OR30 - 39 in 2 domains (1 - 9); OR20 - 29 in 3 domains (1 - 9) AND

30 - 39 in 1 domain (1 - 9)

6 months 1 - 6 months

Adult Level 21 - 20 RVU’s/mo

30 - 39 in 3 domains (1 - 9); OR40 - 49 in 1 domain (1 - 9)

1 - 6 months 1 - 3 months


30 – 39 in 4 domains, w/ 2 in 1, 6, 7 or 9; OR40 – 49 in 2 domains, w/ 1in 1, 6, 7 or 9; OR

30 - 39 in 2 domains AND 40 - 49 in 1 domain,w/ EITHER 1-40 OR 2-30s in 1, 6, 7 or 9

1 - 3 months 1 - 3 monthsExtended Care Level:

1 - 6 months


40 - 49 in 4 domains (1 - 9), with 1 in 1, 6, 7 or 9 1 - 3 months 1 - 3 monthsExtended Care Level:

1 - 6 months

ICF/MR1 - 24 RVU’s/mo.

Complete all domains 1 - 3 months 1 - 3 monthsExtended Care Level:

1 - 6 months

Note: In many cases, although symptoms are severe, intense treatment may not be the most prudent or productive treatment strategy, particularly over many months or years of service. For example, a severely depressed or highly anxious person might be overwhelmed with several hours of treatment per week. A chronically mentally ill person may become overly dependent on the support of an agency, decreasing rather than increasing independence.


MENTAL HEALTH SERVICE PLANDEFINITIONS

PROBLEM - The behavior or situation that is problematic to the client. The symptom pattern must be associated with the diagnostic criteria, but the problem should not be a restatement of the diagnosis.

GOAL - General outcome statement of what the client will ultimately attain through treatment that is important to the client; focuses on the positive; is realistic and achievable; and is perceived as worthwhile by the client. A positive statement that is, in effect, the opposite of the problem to which it relates.

CURRENT OBJECTIVE - The primary short-term steps required for the client to attain the long-term treatment goal, which can be realistically achieved within the treatment review period. The objectives are to identify what the client and/or family will do while in session and are to be stated in behaviorally measurable terms. Objectives may be stated using the client’s own words.

TYPE OF SERVICE - The specific type of treatment intervention identified to treat client’s symptoms. Treatment services can include: Individual, family and group psychotherapy, individual and group psychosocial rehabilitation, and case management. A treatment service is to be listed for each service plan objective.

DATE INITIATED – The date the objective was first listed on the mental health service plan. The month and year should be noted. This date remains the same as long as this objective is continued on the service plan.

TARGET DATE – The expected date the objective is to be completed within the current authorization period being requested, typically one to six months. This date is revised if the treatment objective is not met and is continued on the following service plan extension.

PROGRESS ON CURRENT/PREVOUS GOAL SINCE LAST AUTHORIZATION -- Summary of specific progress the client has made toward achieving the stated goal since the previous authorization. This is completed only for Extension Requests.

STATEMENT OF INVOLVEMENT- A statement regarding client’s participation in the service plan development. If client has no comment, the clinician must make a statement regarding client’s involvement. If the client is under the age of 14 or has a legal guardian, the guardian may complete the statement of involvement on behalf of the client.

HISTORICAL INFORMATION – A brief summary of historical data relevant to current diagnosis and treatment. Relevant family history would be included.

INTERPRETIVE SUMMARY/ADDITIONAL INFORMATION -- Initial Requests: An overall summary of client’s current level of functioning, history of previous

treatment, any current stressors not mentioned elsewhere in the request, and prognosis for treatment.

Extension Requests: A summary of client’s overall compliance or noncompliance with treatment, prognosis for continued treatment and any other relevant data not previously documented in the request.

MENTAL HEALTH SERVICE PLAN EXAMPLES

INDIVIDUAL PSYCHOTHERAPY- Individual psychotherapy typically includes exploring/processing client’s thoughts and feelings, and requires client to have insight.

EXAMPLES (ADULT): Diagnosis- Bereavement

Problem- Grief/loss related to death of spouse.Goal- Begin the process of acceptance of the loss.

Objective A- Identify and process 3 ways the loss has affected life. Target Date: 11/04 Objective B- Identify and process 3 memories. Target Date: 11/04

Treatment Service A- Individual PsychotherapyTreatment Service B- Individual Psychotherapy

EXAMPLES (CHILD): Diagnosis- Post Traumatic Stress Disorder

Problem- Recurring, traumatic memoriesGoal- “Be able to go to sleep, stop nightmares”

Objective A- “Talk about one scary thing to help me not be so scared” Target Date: 11/04Objective B- “Play/talk about 2 safe places in the doll house where a kid can go and not be hurt, and find a place like it at my home and school” Target Date: 11/04

Treatment Service A- Individual PsychotherapyTreatment Service B- Interactive Psychotherapy

FAMILY PSYCHOTHERAPY- Family psychotherapy focuses on treatment of the family system. Objectives should reflect family participation and identify the measurable steps that the family needs to accomplish during sessions. Objectives reflecting what the client needs to accomplish, even when family members are present, is considered individual psychotherapy.

EXAMPLES (CHILD-FAMILY): Diagnosis- Adjustment Disorder with Depressed Mood

Problem- Client experiencing depressive symptoms in response to parent’s divorce.Goal- Process acceptance of parent’s divorce and decrease depression

Objective A- Client/Family will identify and process 3 feelings related to change in the family system. Target Date: 11/04 Objective B- Client/Family will identify and process 3 ways to maintain effective communication even though family members do not all live in the same home. Target Date: 11/04

Treatment Service A- Family PsychotherapyTreatment Service B- Family Psychotherapy

GROUP PSYCHOTHERAPY- Group psychotherapy is similar to individual psychotherapy in that it also typically entails exploring/processing thoughts and feelings, and requires client insight. However, group psychotherapy is utilized when it is felt that the client would benefit from processing feelings and thoughts within a group of individuals with similar issues.

EXAMPLES (ADULT): Diagnosis- Schizophrenia, Undifferentiated Type

Problem- Auditory hallucinations interfere with daily livingGoal- Decrease auditory hallucinations

Objective A- Client will identify 3 triggers that make voices worse and will process with the group. Target Date: 11/04 Objective B- Client will problem solve with group 3 ways to avoid or diffuse the triggers identified in objective A. Target Date: 11/04

Treatment Service A- Group PsychotherapyTreatment Service B- Group Psychotherapy

EXAMPLES (CHILD): Diagnosis- Adjustment Disorder with Depressed Mood

Problem- Client experiencing depressive symptoms in response to parent’s divorceGoal- Process acceptance of parents divorce and decrease depression

Objective A- Client will identify and process with group 3 feelings related to parent’s divorce. Target Date: 11/04Objective B- Client will identify and process with group 3 changes in family routine since parent’s divorce. Target Date: 11/04

Treatment Service A- Group PsychotherapyTreatment Service B- Group Psychotherapy

GROUP PSYCHOSOCIAL REHABILITATION- Group Psychosocial Rehab includes learning information/skills and/or practicing skills. Content of education/learning/practicing can include basic living skills, social skills (re)development, independent living skills, interdependent living skills, self-care, lifestyle change and recovery principles and practices. Rehab objectives should not require client insight, or include processing thoughts and feelings, as this is content for therapy.


Problem- Social isolation due to negative symptoms of schizophreniaGoal- Increase social contact

Objective A- Client will learn 3 effective ways to initiate a conversation. Target Date: 11/04 Objective B- Client will initiate 1 conversation each rehab session, utilizing the conversation starters learned in Objective A. Target Date: 11/04

Treatment Service A- Group Psychosocial RehabilitationTreatment Service B- Group Psychosocial Rehabilitation

EXAMPLES (CHILD): Diagnosis- Oppositional Defiant Disorder

Problem- Client argues frequently with adultsGoal- Decrease arguments and increase positive communication

Objective A- Client will learn and practice 3 ways to effectively handle a disagreement. Target Date: 11/04Objective B- Client will learn and practice 3 ways to positively present an idea and/or a request. Target Date: 11/04

Treatment Service A- Group Psychosocial Rehabilitation Treatment Service B- Group Psychosocial Rehabilitation

INDIVIDUAL PSYCHOSOCIAL REHABILITATION- Individual Psychosocial Rehabilitation includes learning information/skills and/or practicing skills. However, individual rehabilitation is utilized when one on one attention is needed. It includes educational and supportive services regarding independent living, self-care, social skills (re)development, lifestyle changes and recovery principles. Rehab objectives should not require client

insight, or include processing thoughts and feelings, as this is content for therapy.


Problem- Poor hygiene due to negative symptoms of SchizophreniaGoal- Improve hygiene

Objective A- Client will learn 3 ways poor hygiene can negatively impact his life. Target Date: 11/04 Objective B- Client will learn 3 ways to improve hygiene. Target Date: 11/04

Treatment Service A- Individual Psychosocial RehabilitationTreatment Service B- Individual Psychosocial Rehabilitation

EXAMPLES (CHILD): Diagnosis- Social Phobia

Problem- Client avoids contact with peers due to fear that she will act “wrong” or say something “wrong”Goal- Decrease anxiety and increase contact with peers

Objective A- Client will learn 3 relaxation skills to use to decrease anxiety in social situations. Target Date: 11/04Objective B- Parents will learn 2 symptoms of social phobia and 3 ways to assist client in managing anxiety in a social setting. . Target Date: 11/04

Treatment Service A- Individual Psychosocial RehabilitationTreatment Service B- Individual Psychosocial Rehabilitation

CASE MANAGEMENT- Case Management includes referral, linkage, and/or advocacy on behalf of the client, to help access appropriate community resources. The psychosocial and environmental problems identified in Axis IV diagnosis should indicate potential need for access to community resources. Case Management objectives must be measurable and time-limited. Case Management does not include: physically escorting, transporting or staying with the client for scheduled appointments; monitoring financial goals; providing specific services such as shopping or paying bills; delivering bus tickets, food stamps, money, etc.; psychotherapy or rehabilitation services; filling out forms, applications, etc., on behalf of the consumer when the consumer is not present; filling out Medicaid forms, applications, etc.; mentoring or tutoring; services being provided or available from DHS/OJA caseworker; services to children receiving residential behavior management services in foster homes or group home settings; or services to consumers residing in ICF/MR facilities.

EXAMPLES (ADULT): Problem- Lacks adequate food supply to meet the nutritional needs of self and familyGoal- Adequately meet the nutritional needs of self and family

Objective A- Apply for food stamps within 1 week. Target Date: 11/04 Objective B- Access local food bank for grocery assistance. Target Date: 11/04

Treatment Service A- Case ManagementTreatment Service B- Case Management

EXAMPLES (CHILD):

Problem- Inadequate clothing and medical careGoal- Obtain clothing and medical care to adequately meet needs of child/family.

Objective A- Refer client/family to 3 resources for new and used clothing.. Target Date: 11/04Objective B- Link client/family to medical clinic and assist in application process for reduced cost medication. Target Date: 11/04

Treatment Service A- Case ManagementTreatment Service B- Case Management

SAMPLE HISTORICAL INFORMATION

The client is the third of three children. The biological mother abandoned the children when the client was 4 years of age, approximately one year ago and has made no attempts to visit or contact the children since then. All three children were placed with the maternal aunt. The child has never had contact with his biological father.

SAMPLE INTERPRETIVE TREATMENT SUMMARY (INITIAL)

He appears to be suffering from an adjustment disorder following abandonment by the mother and placement with the maternal aunt. The biological mother reportedly has substance abuse problems and was extremely neglectful of the children. He will be starting kindergarten. He does not appear to be suffering from any developmental problems or delays. He reportedly functioned within normal limits in preschool this past year. The client’s kindergarten teacher has been contacted and there are plans to collaborate on a monthly basis regarding limit setting and anger management. The client’s Aunt is having difficulty with parenting issues. She describes the client as having angry outbursts 3 or 4 times per week, and they seem to occur at times of limit setting. During the outbursts, he will scream, cry uncontrollably, break objects, and is inconsolable. The severe angry outbursts started after he was abandoned. He is also aggressive with his older siblings. He will hit his siblings for no apparent cause. The aggressive behavior occurs on a daily basis. There is no goal for reunification with the biological mother at this time. The aunt indicates that she is willing to participate in family therapy and is anxious to learn new ways to help the client overcome his behavioral problems. The client appears to have insight and is willing to participate in therapy and attend sessions. Both the aunt and client appear able to meet the treatment objectives. The prognosis is good and measurable improvement in functioning is expected during this initial authorization period. The client will be treated in family and individual therapy. The focus being to help him with the adjustment to living with the aunt, process of dealing with the abandonment issues, and helping the aunt develop effective ways to deal with the client’s behavioral problems. The siblings are not receiving mental health services at this time, but will be participating in family psychotherapy sessions with the client.

SAMPLE INTERPRETIVE TREATMENT SUMMARY (EXTENSION)

Client has attended 15 of 20 scheduled sessions during the past authorization period. Depressive symptoms have decreased, but are still evident. For example, client reports crying for “no reason” 3-4 x per week. She also has problems sleeping 2-3 nights per week. This is an improvement over past daily crying and daily insomnia. She states her appetite is improving, and while she still does not leave the house much, she is thinking of places she would like to go (church). Client reports she is meeting goal of taking medication as prescribed. She lists church, her sister, and a friend as support, but she wasn’t attending church or actually using her sister or friend as support; she is now beginning these interactions. She has begun using relaxation techniques and knitting, which she enjoys and reports an improved ability to regulate her anxiety. Client reports she has not talked to ex-husband in three weeks, but he has written to her. Client says she cannot decide if she wants to stay divorced or try to get back together with ex-husband. One of the client’s 2 children is also receiving services from this agency, which includes family psychotherapy (1 hr per week)

REQUEST CHECKLIST

Are all request pages present, complete, and dated?

Is client name, Recipient ID d #, Social Security #, and birth date documented correctly?

Is Provider ID #, provider name, address and contact person documented correctly?

Is DSM-IV or DSM-IV-TR diagnoses and codes recorded for all 5 Axes codes?

Is the principal Axis I diagnosis, a diagnosis that is allowed for the level of care requested?

If MR is diagnosed on Axis II, is the client’s IQ score documented?

If Dementia is diagnosed on Secondary Axis I, is a rating included?

Is the request documentation less than 30 days old, per the dates on the request?

Is all required additional documentation present?

Some requests require additional documentation to support medical necessity criteria. Examples:

RBMS requests: RBMS plan with each request

ICF/MR requests: Current IHP on file with OFMQ dated within the past year, Psych Testing with initial requests

0-36 months requests: Requests should include the developmental assessment of the child, including a copy of how this was assessed. This can include: Sooner Start Form, Statement from Pediatrician, Information from County Health Department, and/or clinical assessment summary. Therapist’s credentials for working with this age group should also be included.

Adult requests: If diagnoses include any form of dementia or OBS, MMSE required with each request.

Adult/child requests: A score of 40 or higher in CAR domain 2, must include a statement demonstrating the client’s ability to participate in treatment planning and benefit from outpatient services requested.

Danger to Self/Others: If request documentation reflect thoughts/statements of self-harm, or threats of harm to others, additional comments indicating the client is not in imminent danger to self or others needs to be provided. This should include information regarding whether or not client has been assessed for a higher level of care (inpatient, etc.), who made the assessment (psychiatrist, inpatient psychiatric clinical review coordinator, etc.) and the outcome.

Child requests: Family psychotherapy is viewed as CRITICAL in the treatment of minors. If there is no family psychotherapy requested , information should be provided to support that family psychotherapy is either not needed or not possible for child/family.

Letter of Collaboration: A letter of collaboration is required when a client is receiving services from 2 or more facilities, or 2 or more separate sites for the same agency (different Provider ID #)). A letter of collaboration is required, regardless of funding source.

Termination Letter: A letter signed and dated by the client and/or legal guardian that indicates his/her desire to change behavioral health service providers, including an effective date is required for the following:

Client is authorized for services with a specific agency, and chooses to discontinue services with that agency and receive those services from a different agency.

Client chooses to transfer from one agency site to another (same agency, but different Provider ID #s).

Agency closes a site and transfers clients to another site, or clients may choose to move to another facility with their clinician.

Are ALL current CAR scores recorded?

Do CAR scores support the Level requested?

Do CAR descriptors support ALL scores given?

Is it clear that the CAR is an assessment of current information (descriptors reflect new/current information, and scores have been updated)?

Is the CAR documentation congruent with client’s diagnoses?

Do the RVU’s requested on the RVU page fall within the RVU range allowed for the level supported by the CAR?

If the current service plan objectives have been worked on for 6 months or longer, does clinical documentation support the need to continue with the same objectives, rather than revising the

objectives on the service plan?

Are ALL objectives related to their problem/goal?

Are target dates present for each objective?

Are objectives congruent with the type of treatment service(s) requested

Is there a treatment service identified for each objective?

Does the frequency of service noted match the number of sessions requested for each treatment service on the RVU page?

Are ALL objectives behaviorally measurable?

Does the content of the objectives on the Mental Health Service Plan support the frequency of service requested?

Is the Mental Health Service Plan congruent with the client’s diagnosis and CAR assessment?

Is the staff providing services identified for each treatment service?

Is client/guardian statement regarding participation in development of the Mental Health Service Plan present?

Are ALL required signatures, credentials, and dates present on the Mental Health Service Plan signature page?

Is the information provided in the Interpretive Treatment Summary congruent with the information provided in the rest of the request?

If request documentation reflects client neglect and/or abuse, does documentation reflect whether or not it has been reported, and/or DHS involvement?

If client was hospitalized for psychiatric reasons during the previous authorization period, is this information, (including actual dates of hospitalization, included in the request?

HELPFUL REFERENCES

NOTE: The following references are not endorsed by OFMQ, nor does use of these references guarantee authorization. These are merely resources that OFMQ staff are aware of as available tools in treatment plan development. This is not an exhaustive list.

Birren and Schaie, Handbook of the Psychology of Aging, 5th edition (2001). NY: Academic Press.

DeGood, Douglas E., Crawford, Angela L., & Jongsma, Arthur E. The Behavioral Medicine Treatment Planner (1999). NY: Wiley & Sons.

Diagnostic and Statistical Manual of Mental Disorders, 4th edition Text Revision (2000). Washington, DC: American Psychiatric Association.

Evosevich, J. M. & Michael Avriette. The Gay and Lesbian Psychotherapy Treatment Planner (1999). NY: Wiley & Sons.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO). A Practical Guide to Clinical Documentation in Behavioral Health Care. Oakbrook Terrace, IL: JCAHO.

Jongsma, Arthur E., Jr. and L. Mark Peterson. The Complete Adult Psychotherapy Treatment Planner, 2nd edition (1999). NY: Wiley & Sons.

Johnson, Sharon L. Therapist’s Guide to Clinical Intervention: The 1-2-3s of Treatment Planning (1997). San Diego, CA: Academic Press.

Jongsma, Arthur E., Jr., L. Mark Peterson, & William P. McInnis. The Adolescent Psychotherapy Treatment Planner, 2nd Ed. (1999). NY: Wiley & Sons.

Jongsma, Arthur E., Jr., L. Mark Peterson, & William P. McInnis. The Child Psychotherapy Treatment Planner, 2nd Ed. (1999). NY: Wiley & Sons.

Lieberman, A., Wieder, S., & Fenichel, E., editors. DC:0 -3 Casebook, A Guide to the Use of ZERO TO THREE’s Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood in Assessment and Treatment Planning (1997). Washington, DC: ZERO TO THREE: National Center for Infants, Toddlers, & Families (formerly known as National Center for Clinical Infant Programs).

Wehman, Paul. Functional Living Skills for Mentally and Severely Handicapped Individuals. Texas: Pro-Ed.

Wieder, Serena, editor. Diagnostic Classification: 0-3, Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (1995). Arlington, VA: ZERO TO THREE/National Center for Clinical Infant Programs.

Zeanah, Charles, Jr. Handbook of Infant Mental Health. Guilford Press.

COMMON ACRONYMS

AOA = American Osteopathic AssociationBHCM = Behavioral Health Case ManagerBHRS = Behavioral Health Rehabilitation Specialist CACM = Certified Adult Case ManagerCJCM = Certified Juvenile Case ManagerCAR = Client Assessment RecordCARF = Commission on the Accreditation of Rehabilitative FacilitiesCF = Conversion FactorCM = Case management, or Case ManagerCMHC = Community Mental Health CenterCOA = Council on AccreditationCW = Child Welfare Division of DHS, or Case WorkerDHS = Oklahoma Department of Human Services DMHSAS = Oklahoma Department of Mental Health and Substance Abuse ServicesDSM-IV = Diagnostic and Statistical Manual, 4th Edition

DSM-IV-TR = Diagnostic and Statistical Manual, 4 th Edition, Text RevisionHCFA = Health Care Finance AdministrationHMO = Health Management OrganizationICF/MR = Intermediate Care Facility for the Mentally RetardedIN = Important NoticeINR = Important Notice ResponseIQC = Internal quality controlJCAHO = Joint Commission on the Accreditation of Healthcare OrganizationsMHP = Mental Health Professional MHSP = Mental Health Service PlanOAC = Oklahoma Administrative CodeOBHRS = Outpatient Behavioral Health Rehabilitative ServicesOHCA = Oklahoma Health Care AuthorityOFMQ = Oklahoma Foundation for Medical QualityPA = Prior AuthorizationPCPCM = Primary Care Physician Case ManagerQMB = Qualified Medical BenefitsRBMS = Residential Behavioral Management ServicesRC = Review CoordinatorREVS = Recipient Eligibility Verification SystemRTC = Residential Treatment CenterRVU = Relative Value Unit TFC = Therapeutic Foster Care

INSTRUCTIONS FOR COMPLETING PRIOR AUTHORIZATION REQUEST PACKET FORMS

A. General Instructions

All requests must be dated within 30 days of receipt by OFMQ.All forms must be filled out completely.Client Name and Date must be completed at the top of each page.If an item is not applicable to the client, then write “N/A” in the available space.If instructed to check which items apply, check only those that apply.If you need additional space for documentation, use the Interpretive Summary/Additional Information section. Incomplete or illegible forms will be returned to the facility, which will cause a delay in authorization.

B. Fax Cover Page

Fax Date = Record the date the request is faxed to OFMQ.Time = Record the time the request is faxed to OFMQ.Type of Fax = Record the type of request/response being submitted. Mark only one.Attention: = Record the name of the RC who has requested additional information for Important Notice Response, the Appeals Committee for Recon/Appeal Request, or Clerical for Provider Change of Demographic Information.From: Facility/Agency = Record the name of the facility, not an abbreviation, where this client will be treated.Contact Name = Record the name of the facility staff member who can be contacted for additional information.Provider ID# = Record the site-specific ID number and letter for the location code.Case Management ID# = Record the site-specific ID number and letter for the location code.Facility Address = Record the location where this client will be treated, corresponding with the site-specific Provider ID#.Fax Number = Record the facility fax #, corresponding with the fax # on file at OFMQ. Phone Number = Record the facility phone #.RE: Client Name = Record the full name of the client as it appears on his/her Medicaid/Recipient ID card, including middle initial and other designations (Sr., Jr., III, etc.).Recipient ID # = Record the client’s most current Recipient ID#. If the client’s eligibility has not been confirmed and a Recipient ID# has not been issued, write “Pending” in the space.PA # = Record the client’s current Prior Authorization #, if applicable.Number of Pages = Record the number of pages, including fax cover page, faxed to OFMQ.Comments = Record any additional comments. Do not use this space for clinical data.

B: Outpatient Request for Prior Authorization The client’s name and date at the top of each page should reflect the client’s name as it appears on his/her Medicaid/Recipient ID card and the date the specific page was completed.

Client Name = Record the full name of the client as it appears on his/her Medicaid card, including middle initial and other designations (Sr., Jr., III, etc.).Social Security # = Record the client’s 9-digit Social Security number.

Date of Birth = Record the client’s date of birth (month/day/year).Age = Record the client’s age.Sex = Record the client’s sex (M = male, F = female).Legal Guardian Name = Record the name of the client’s legal guardian. Relationship to client = record the legal guardian’s relationship to client.Current Residence = Check all that apply, and fill in applicable blanks.Level of Request = Mark only one based on current CAR scores or special criteria.

Admit Date to Current Facility = Note the most recent date the client was admitted to the facility.Treatment History = Document all that apply to this client, including Hospitalizations, PCP/Day TX, Outpatient TX, and or School Based Behavioral Health Service. Provide information regarding facility name, reason for treatment, and admit/discharge dates.

DSM Diagnoses = Complete all five axes, following DSM-IV or DSM-IV-TR guidelines. (refer to DSM as needed).

Axis I: Clinical Disorders/Other Conditions That May Be a Focus of Clinical Attention

Record the principle diagnosis code and corresponding title first. Other disorders are then listed in order of focus of attention and treatment. V codes and 900 codes are accepted only on

Level 1. A Deferred diagnosis (799.9) or a provisional diagnosis is not acceptable.

Axis II: Personality Disorders/Mental Retardation (MR)Record the diagnosis code and corresponding title. If the diagnosis is MR, the client’s IQ must also be documented. To diagnose a Personality Disorder in children less than 18 years of age, features must have been apparent for a minimum of one year. However, Antisocial Personality Disorder cannot be diagnosed under the age of 18.

Axis III: General Medical ConditionsRecord the client’s current medical conditions that are potentially relevant to understanding or managing the client’s mental disorder. It is generally not necessary to list minor problems or historical problems that are resolved.

Axis IV: Psychosocial and Environmental Problems Check all psychosocial and environmental stressors that are applicable and note any additional problems that may affect the diagnosis, treatment, and prognosis of the mental disorders listed on Axes II and I.

Axis V: Global Assessment of Functioning (GAF) Record the clinician’s judgment of the client’s Current overall level of functioning at time of assessment and the Highest Level of Functioning in the past year (may be an estimate).

D. Historical Information

Document historical data that is relevant to the current diagnosis and treatment of the client and family history should be recorded.

E. Client Assessment Record (CAR) The date at the top of the page should accurately reflect the date of the face-to-face interview/assessment of the client, not the date it was typed/written.

Record the Past and Current CAR scores for each domain. Do not span the numbers (e.g., 20-29). Document one specific number for Past score and one for Current score (e.g., 23 and 20). Current CAR scores are based solely on client functioning at the present time, not historical functioning. Check applicable problem areas and cite specific details of problem areas in the narrative portion of the domain. The descriptors supporting each score must be client-specific, age-appropriate, and developmentally appropriate. Documentation should contain descriptive detail to adequately reflect behavioral symptoms and rationale supporting the CAR scores. Frequency, duration and intensity should be noted for identified symptoms/behaviors.

Both the Low Complexity and Moderate Complexity Mental Health Service Plans require a CAR evaluation. The CAR must reflect current information and a completely new/updated CAR must be submitted with each request.

F. Interpretive Summary/Additional InformationInitial Requests should include an overall summary of the client’s current level of functioning, history of previous treatment, any current stressors not previously documented in the request and prognosis for treatment. Data should not be a duplicate of the information already documented in the CAR assessment. Document whether other family members are or will be receiving services from your agency.

Extension Requests should include a summary of overall treatment, compliance or noncompliance with treatment and prognosis for continued treatment. If family psychotherapy is provided, the family participation and progress in treatment should be described.

Any additional information that is relevant to the client’s treatment would also be noted.

G. Mental Health Service Plan Low Complexity or Moderate Complexity = Mark only one. Problem = Record the behavior/situation that is problematic to the client. The symptom pattern must be associated with the diagnostic criteria, but must not be the diagnosis. Goal = Record the client’s expected positive outcome.Current Objectives = Record the specific primary objectives that the client is presently working on in treatment in behaviorally measurable terms.)

Date Initiated = Record the date each objective began, i.e. the date it first appeared on the treatment plan.Target Date = Record the date (Month/Year) each objective is to be achieved.

Type of Service = Record each treatment service corresponding to the stated objective to be received by the client.

Progress on Current/Previous Goal Since Last Authorization = On extension request, record the client’s progress in treatment towards accomplishing goals and objectives. Reasons for lack of progress or regression should also be documented. This can be done by listing the progress on the specific objectives or in more general terms that relate to the client’s overall progress toward the treatment goal.

Signature PageClient Signatures = A valid treatment plan must be signed and dated by the client (age 14 and over), the parent/guardian (if under age 18, or age 18 and over if an client has a legal guardian), and must include a statement by the client and /or guardian regarding their involvement, understanding and comments on the plan. If the client does not complete the statement of involvement, the clinician must make a statement regarding the client’s involvement. If a client is unable to sign or make a witnessed mark, on his/her treatment plan, document the reason(s).Parent/Guardian Signature = If the client is in custody of the Oklahoma Department of Human Services (DHS), then the signature of either the DHS Case Worker or the Foster Parent is required. Providers are required to obtain a release of information on client’s records to DHS, for the client’s file.

Treatment Team Signatures = The dated signature and complete credentials of the responsible MHP, physician, and all other clinician’s providing direct client service. These signatures are required on the initial Mental Health Service Plan in order for it to be considered a valid service plan. If the physician’s signature is not required on the service plan for extension requests, mark the designated box indicating it is not required. Treatment team signatures must include all applicable credentials (degree, licensure, under supervision for licensure). Clinical staff should sign on the designated line indicating the type of service(s) they will be providing.

Note: All signatures must be dated at the time they are signed, by the person signing the official state document.

Type of Service and Frequency = The type of service is listed on the signature page. The frequency of the service should be noted beside each service type being requested. Frequency should be listed as hours/minutes per week/month or units per week/month if the service is individual or interactive psychotherapy.

H. RVU Request Page

Recipient ID # = Record the client’s current Recipient ID #. If the client’s eligibility has not been confirmed and an ID # has not been issued, write “Pending” in the space.Provider ID# = Record the Provider ID number and the letter indicating the location site and case management reference.Psychotherapy = Record the number of psychotherapy sessions by selecting the unit (time frame for individual) and the equivalent RVU’s per month for each service being requested. Total the number of psychotherapy RVU’s. Psychosocial Rehabilitation and Case Management = Record the number of rehabilitation and case management sessions and the equivalent RVU’s per month for each service being requested. Total the number of rehabilitation and case management RVU’s.Combined Total RVU’s = Record the total RVU’s requested per month.Requested Authorization Dates = Record the date (Month/Day/Year) you would like the authorization period to begin and mark whether a three or six month authorization period is requested.Additional/Optional Services = Record these services as needed, with supporting documentation in the request packet. No RVU calculation is required for these services.

Note: Additional documentation may be required based upon the level of care requested. Please carefully review the medical necessity criteria for each level of care. RC’s may request additional information and/or documentation to assist them in making a decision regarding the medical necessity of services.

Relative Value Unit

Each billing unit has a relative value associated with it to equalize the different services that are

available to clients based on the pay rate for these different units. For example, two different level III clients could each have 42 RVU’s. One client could have all the RVU’s authorized in the form of group psychosocial rehabilitation and the other client could have 42 RVU’s from a combination of psychotherapy and psychosocial rehabilitation, but the total payment for each client’s services would be approximately the same.

The RVU Page of the request form converts the units into RVU’s for the different services that are requested by the provider. This is done to obtain the total RVU’s for one month of service. This one-month total corresponds to the criteria pages to ensure that the total RVU’s per month do not exceed the maximum allowed for the level of care. The number of units to be provided during a one-month period is entered in the first blank for the type of service (____# of sessions per month). Multiple the number of units requested times the relative value unit (RVU). The result is the number of RVU’s per month. This calculation is completed for each service requested. The RVU’s for the different services are totaled to determine the Combined Total RVU’s. The services listed below the Combined Total RVU’s are not counted toward the maximum RVU’s allowed for the level. These services include, Medication Training and Support and Psychological Testing.

Enter the Start Date for the Requested Authorization Date and indicate whether a 3 or 6-month authorization period is being requested. The start date requested might be adjusted by OFMQ for several reasons, which are explained elsewhere in the Provider Manual outlining the types of decisions. The level of service may dictate whether a 3 or 6-month authorization is available.

There are three new billing codes for Individual Psychotherapy. Each one has a specific timeframe associated with it. The first one is a 20 – 30 minute session, the second a 45 – 50 minute session and the third a 75 – 80 minute session. There are also three new codes for Interactive Psychotherapy with the same timeframes. The RVU values have been calculated for each of the new codes and are listed under the different timeframes for Individual Psychotherapy and Interactive Psychotherapy. The provider is required to request the specific timeframe (unit) being requested for Individual or Interactive Psychotherapy. More than one timeframe for these services can be requested during the same authorization period. Remember that the provider can only bill one individual therapy unit per day. Selecting the right unit of service is important in the preauthorization system.

COMPUTING RVU’sTo compute the number of RVU’s needed for a request; determine the total number of sessions to be provided per month for each treatment service. Multiply the number of sessions per month by the RVU. For example, 8 sessions of family psychotherapy X 2.30 RVU’s = 18.4 RVU’s. Add the combined total number of RVU’s for each treatment service to determine the total RVU’s per month.

ADDENDUM

Completion of this page is not required for preauthorization of services and does not need to be submitted to OFMQ for review. The items noted on this page, however, may be required documentation for SURS reviews, CARF certification and /or JCHO certification.

TERMINOLOGY CHANGES

Previous Term Current TermTreatment Plan Development Mental Health Service Plan Development

Moderate ComplexityTreatment Plan Review Mental Health Service Plan

Low ComplexityIndividual Counseling Individual Psychotherapy or

Interactive PsychotherapyGroup Counseling Group PsychotherapyFamily Counseling Family PsychotherapyGroup Rehab Treatment Psychosocial RehabilitationIndividual Rehab Treatment Psychosocial RehabilitationMedication Review Medication Training and Support

OKLAHOMA FOUNDATION FOR MEDICAL QUALITYBEHAVIORAL HEALTH DEPARTMENTOutpatient Behavioral Health Program

14000 Quail Springs Pkwy Suite 400, Oklahoma City, OK 73134Phone (405) 858-9090 Fax (405) 858-9098

STATUS REQUEST

FAX DATE: TIME:

ATTENTION CLERICAL STAFF FAX NUMBER: (405) 858-9098

FROM FACILITY/AGENCY:

CONTACT NAME: PROVIDER #:

FAX NUMBER: ( ) PHONE NUMBER:( )

WE ARE REQUESTING STATUS ON: (Mark only ONE of the following) INITIAL REQUEST IMPORTANT NOTICE RESPONSE

EXTENSION REQUEST MODIFICATION REQUEST

______ MODIFICATION REQUEST

CORRECTION REQUEST RECONSIDERATION/APPEAL REQUEST

FOR THE FOLLOWING CLIENT

CLIENT NAME:

First MI Last Designation Medicaid#:(Sr., Jr., III, etc.)

THIS DOCUMENTATION WAS ORIGINALLY SENT ON

Date

If the Request needs to be resubmitted it should be received by OFMQ within 2 business days from the date Status Request Response was sent to your agency. If the Request is received at OFMQ within 2 business days, the Request will be backdated 3 business days from the ‘fax received’ date of this Status Request.

STATUS REQUEST RESPONSE FROM OFMQ CLERICAL STAFF

CONFIDENTIALITY The documents included in this transaction may contain confidential information from the Oklahoma Foundation for Medical

Quality, Inc. The information is intended for the use of the person or entity name on this transmittal sheet. If you are not the intended recipient, be aware that any disclosure, copying, distribution or use of the contents of this transmission is prohibited. If you have received this transmission in error, please immediately telephone the Oklahoma Foundation for Medical Quality, Inc. so that we can arrange for the disposition of the transmitted documents.

Revised 5/2004Oklahoma Foundation for Medical Quality, Inc.

14000 Quail Springs Parkway Suite 400 Oklahoma City, OK 73134-2600Phone (405) 858-9090 Fax (405) 858-9098

FAX DATE: ___________________________ TIME: __________________

TYPE OF FAX: (Mark only ONE of the following)

____INITIAL REQUEST ____IMPORTANT NOTICE RESPONSE (Attention: Reviewer)

____EXTENSION REQUEST ____PENDING ELIGIBILITY RESPONSE (Attention: Reviewer)

____MODIFICATION REQUEST ____PROVIDER CHANGE OF DEMOGRAPHIC (Attention: Reviewer) INFORMATION (Attention: Clerical Staff)

____CORRECTION REQUEST ____RECONSIDERATION REQUEST (Attention: Reviewer) (Attention: Appeals Committee)

____OTHER ___________________________________________________________________________________

TO: OFMQ – Medicaid Outpatient Preauthorization Unit ATTENTION: ____________________________________FAX NUMBER: (405) 858-9098 (Reviewer)

FROM: FACILITY/AGENCY: ___________________________________________________________________

CONTACT NAME: _____________________________________________________________________________

PROVIDER ID #: __ __ __ __ __ __ __ __ __ - __ CASE MGMT ID #: __ __ __ __ __ __ __ __ __ - __

FACILITY ADDRESS: _____________________________________________________________________________ Street City State Zip

FAX NUMBER: ( ___)_____________________ PHONE NUMBER: ( )___________________

RE: CLIENT NAME: ______________________________________________________________________________ First MI Last Designation (Sr., Jr., III, etc.)

RECIPIENT ID #: __ __ __ __ __ __ __ __ __ PA #: __ __ __ __ __ __ __ __ __ __ (If Applicable)

NUMBER OF PAGES INCLUDING THIS PAGE: _________

COMMENTS: (NO clinical information) ____________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

CONFIDENTIALITY

The documents included in this transaction may contain confidential information from the Oklahoma Foundation for Medical Quality, Inc. The information is intended for the use of the person or entity name on this transmittal sheet. If you are not the intended recipient, be aware that any disclosure, copying, distribution or use of the contents of this transmission is prohibited. If you have received this transmission in error, please immediately telephone the Oklahoma Foundation for Medical Quality, Inc. so that we can arrange for the disposition of the transmitted documents.

Page 1 of _____

Revised 5/2004 OUTPATIENT REQUEST FOR PRIOR AUTHORIZATION Date Completed:

_________________________

Client Name:_________________________________________________________________________________________________

First MI Last Designation (Sr., Jr., III, etc.)

Social Security # __ __ __ - __ __ - __ __ __ __ Legal Guardian Name: __________________________________________

Relationship to Client: ________________________________Date of Birth: ____________ Age: ____ Sex: ____ MM/DD/YY Current Residence: (Check ALL that apply) ___Systems of Care___Individual Home ___Residential Care Facility ___Group Home (Level_____) ___Nursing Home ___Shelter___ICF/MR (Admit Date:_____________) ___ DHS/OJA/IH Custody (Worker:________________ Phone#_____________) ___Foster Care (Placement Date:_________________) ___TFC Multiple placements in past 2 years (#________)LEVEL: ___ 1 ___2 ___3 ___4 ___Exceptional Case ___0-36 months ___ICF/MR ___RBMS

ADMIT DATE TO CURRENT FACILITY: _____________________TREATMENT HISTORY: (Admit / Discharge dates, facility, IP or OP, reason for treatment)____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

DSM DIAGNOSES: (Complete ALL five axes)

Principal Axis I (code): __________ Title:________________________________________________________________________

__________ ________________________________________________________________________

Second Axis I (code): __________ ________________________________________________________________________ Axis II (code): _________ ________________________________________________________________________

_________ ________________________________________________________________________

Axis III: __________________________________________________________________________________________________

___________________________________________________________________________________________________Axis IV: Problems related to: ___Primary support group ___ Social environment ___Education ___Housing ___Economic ___ Occupation ___ Access to health care services ___ Interaction with legal system/crime ___ Other

________________Axis V: Current GAF:____________ Highest Level in the Past Year:_________

HISTORICAL INFORMATION (relevant to current diagnosis and treatment): _______________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

of _____

Revised 5/2004Client Name: _______________________________________ Date Completed: ________________________CLIENT ASSESSMENT RECORD Past Current1. FEELINGS/MOOD/AFFECT Problem areas: ___Mood lability ___ Coping skills ___Suicidal/homicidal ideation/plan ___Depression SCORE ______ __________Anger ___Anxiety ___Euphoria ___Change in appetite/sleep patternsEvidenced by (specific examples, symptom frequency, duration and intensity, impact on daily functioning):_______________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

__________________________________________________________________________________________2. THINKING/MENTAL PROCESS SCORE ______ _______Oriented x _________ MMSE score (if administered) _________ IQ Score (if MR diagnosis) _________Problem areas: ___Memory ___Cognitive process ___Concentration ___Judgment ___Obsessions ___Delusions/hallucinations ___Belief system ___Learning disabilities ___Impulse ControlEvidenced by (specific examples, symptom frequency, duration and intensity, impact on daily functioning):_______________________

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

__________________________________________________________________________________________3. SUBSTANCE USE: SCORE ______ _______Drug of Choice Amount Used Frequency of Use First Used Last used ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Functional impact of current use, give examples of level of dependency:__________________________________________________

____________________________________________________________________________________________________________

__________________________________________________________________________________________4. MEDICAL/PHYSICAL SCORE ______

_______Current medical/physical

conditions:__________________________________________________________________________________________________________________________________________________________________________________________

Impact/limitations on day-to-day functioning:____________________________________________________________________________________________________________________________________________________________________________________MEDICATIONS Name of Rx Dosage/Frequency Reason for Rx ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. FAMILY SCORE ______ _______

Currently resides with ___biological family ___adoptive family ___foster family ___Alone ___Other_________________Problem areas: ___ Parenting ___Conflict ___Abuse/violence ___Communication ___Marital ___Sibling ___Parent/child Evidenced by (specific examples, frequency, duration and intensity, impact on daily functioning):______________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Page 3 of _____

Revised 5/2004Client Name: __________________________________ Date Completed: ___________________________

Past Current 6. INTERPERSONAL SCORE ______ _______Problem areas: ___Peers/friends ___Social interaction ___ Withdrawal ___Make/keep friends ___ConflictEvidenced by (specific examples, frequency, duration, intensity, impact on daily functioning):_________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

__________________________________________________________________________________________7. ROLE PERFORMANCE SCORE ______ _______Functional role: ___Employment/Volunteer ___School/daycare ___ Home management ___Other _______Effectiveness of functioning in identified role _________________________________________________

____________________________________________________________________________________________________________Evidenced by (specific examples, frequency, duration and intensity, impact on daily functioning):_______________________________

____________________________________________________________________________________________________________

_________________________________________________________________________________________8. SOCIO-LEGAL SCORE ______ _______Problem areas: ___Ability to follow rules/laws ___Authority issues ___Legal issues ___Aggression___Probation/parole ___Abides by personal ethical/moral value system ___Antisocial behaviorsEvidenced by (specific examples, frequency, duration and intensity, impact on daily functioning): ______________________________

____________________________________________________________________________________________________________

_________________________________________________________________________________________9. SELF-CARE/BASIC NEEDS SCORE ______ _______Problem areas: ___Hygiene ___Food ___Clothing ___Shelter ___Medical/dental needs ___TransportationEvidenced by (specific examples, frequency, duration and intensity, impact on daily functioning): _______________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________COMMUNICATION (required for ICF/MR level of care) ___ESL ___Hearing impaired ___Non-verbal___Uses interpreter ___Signs ___Uses mechanical device ___Speech impaired ___Fluency

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

INTERPRETIVE SUMMARY/ADDITIONAL INFORMATION : _____________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

______________________________________________________________________________________________________________

Page 4 of _____Revised 5/2004

Client Name: __________________________________________ Date Completed: ______________________

MENTAL HEALTH SERVICE PLAN

___Low Complexity ___Moderate Complexity

PROBLEM 1: _______________________________________________________________________________________________

GOAL 1: ___________________________________________________________________________________________________

CURRENT OBJECTIVES: (Must be behaviorally measurable)

1a: ________________________________________________________________________________________________________

1b: ________________________________________________________________________________________________________

1c: ________________________________________________________________________________________________________

1d: ________________________________________________________________________________________________________

1e: ________________________________________________________________________________________________________

1f: ________________________________________________________________________________________________________

TYPE OF SERVICE DATE INITIATED TARGET DATE

1a: ________________________________________________________________________________________________________

1b: ________________________________________________________________________________________________________

1c: ________________________________________________________________________________________________________

1d: ________________________________________________________________________________________________________

1e: ________________________________________________________________________________________________________

1f: _________________________________________________________________________________________________________

PROGRESS ON CURRENT/PREVIOUS GOAL SINCE LAST AUTHORIZATION:

(Extension Requests Only)

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Page 5 of _____Revised 5/2004

Client Name: ______________________________________________ Date Completed: __________________________

PROBLEM _____: __________________________________________________________________________________________

GOAL _____: ______________________________________________________________________________________________

CURRENT OBJECTIVES: (Must be behaviorally measurable)

_____a: ___________________________________________________________________________________________________

_____b: ___________________________________________________________________________________________________

_____c: ___________________________________________________________________________________________________

_____d: ___________________________________________________________________________________________________

_____e: ___________________________________________________________________________________________________

_____f: ___________________________________________________________________________________________________

TYPE OF SERVICE DATE INITIATED TARGET DATE

_____a: ___________________________________________________________________________________________________

_____b: __________________________________________________________________________________________________

_____c: ___________________________________________________________________________________________________

_____d: ___________________________________________________________________________________________________

_____e: ___________________________________________________________________________________________________

_____f: ___________________________________________________________________________________________________

PROGRESS ON CURRENT/PREVIOUS GOAL SINCE LAST AUTHORIZATION: (Extension Requests Only)

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Page _____ of _____

Client Name: Date Completed: Revised 5/2004

MENTAL HEALTH SERVICE PLAN

PROBLEM:

GOAL:

CURRENT OBJECTIVES: (Must be behaviorally measurable)a:

a – Intervention:

b:

b - Intervention:

c:

c - Intervention:

d:

d - Intervention:

e:

e - Intervention:

TYPE OF SERVICES DATE INITIATED TARGET DATEa:b:c:d:

e:Progress on current/previous goal since last authorization (extension requests only)

Page___ of___

Revised 5/2004Client Name: ____________________________________________ Date Completed: ______________________

I/We (client/guardian) have actively participated in the development of this service plan and understand the treatment goals and objectives listed. I have the following comments/response:

__________________________________________________________________________________________________________

__

I/We (___Agree) (___Disagree) with this service plan.

______________________________________________ _______________________________________________ Client Signature, 14 or older Date Parent/Guardian Signature Date

Witness: _______________________________________ Relationship to client: ______________________________

DateIf unable to sign, document

reason:_______________________________________________________________________________ TREATMENT TEAM:

__________________________________________________ ___________________________________________________

Responsible MHP Signature, Degree/License Date Physician, Credentials Date ____Physician signature not required

Type of Frequency Staff/Credentials Signature DateService (per week or month) (print)

Ind Psy ________Sessions per___________________________________________________________________________________

Int Psy ________ Sessions per___________________________________________________________________________________

Fam Psy _______Hour(s) per____________________________________________________________________________________

Grp Psy _______ Hour(s) per____________________________________________________________________________________

P/S Reh-G ______Hour(s) per____________________________________________________________________________________

P/S Reh-I _______Hour(s) per____________________________________________________________________________________

Psy Test ________Hour(s)_______________________________________________________________________________________

Med T/ S _______ Hour(s) per____________________________________________________________________________________

C/M ___________ Hour(s) per____________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

________________________________________________________________________________________________________

Page _____ of _____

Revised 5/2004Client Name: _________________________________________ Date Completed: _______________

Recipient ID #: ________________ Provider #: ______________________ Location: ____ Case Mgmt: _____

Psychotherapy:

Individual Psychotherapy: _____# of 20-30 min sessions per month= _____RVU’s per month(1 unit= .92 RVU’s)

_____# of 45-50 min sessions per month= _____RVU’s per month(1 unit = 1.76 RVU’s)


Interactive Psychotherapy: _____# of 20-30 min sessions per month= _____RVU’s per month(1unit = 0.96 RVU’s)



Family Psychotherapy: _____# of 60 min sessions per month= _____RVU’s per month(60 min = 2.30 RVU’s)

Group Psychotherapy: _____# of 60 min sessions per month= _____RVU’s per month (60 min = 1.10 RVU’s)

Total Psychotherapy RVU’s per month= ______________

Psychosocial Rehabilitation and Case Management:

Children Group Rehab: _____# of 60 min sessions per month= _____RVU’s per month(60 min = 0.68 RVU’s)

Adult Group Rehab: _____# of 60 min sessions per month= _____RVU’s per month(60 min = 0.52 RVU’s)

Individual Rehab: _____# of 60 min sessions per month= _____RVU’s per month(60 min = 1.80 RVU’s)

Case Management: _____# of 60 min sessions per month= _____RVU’s per month(60 min = 1.96 RVU’s)

Total Psychosocial Rehabilitation/Case Management per month =______________

Combined Total RVU’s =____________

Requested Authorization Dates: Start Date: ___________________ ___3 month ___6 month authorization period (check one) ___ Extended level of care

Additional / Optional Services:

Medication Training and Support: _____# of additional sessions per month

Psychological Testing: _____# of hours

Page _____ of _____ Revised 5/2004

Client Name: ______________________________________ Date Completed: _________________

ADDENDUMCompletion of this page of the request packet is optional for the provider and is not required for the preauthorization process at OFMQ. The items listed on this page, however, may be required documentation for SURS reviews, CARF certification and/or JCAHO certification. Please do not submit this form to OFMQ as part of the request packet unless instructed to do so on a specific request by an OFMQ review coordinator.

COMMUNITY INTEGRATION: ______________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

CAREGIVER RESOURCES (for clients under the age of 21): ______________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

CLIENT’S STRENGTHS/ABILITIES (in client’s own words): _____________________________________________________

____________________________________________________________________________________________________________

CLIENT’S LIABILITIES/NEEDS (in client’s own words): _________________________________________________________

____________________________________________________________________________________________________________

THEORETICAL APPROACH BEING UTILIZED WITH INDIVIDUAL PSYCHOTHERAPY:

____________________________________________________________________________________________________________

COLLABORATION WITH SCHOOL SYSTEM (school age children only): __________________________________________

____________________________________________________________________________________________________________

REFERRALS TO OTHER COMMUNITY SERVICES: ___________________________________________________________

____________________________________________________________________________________________________________

DISCHARGE PLAN:

a. CRITERIA (client-specific behaviors): ________________________________________________________________________

____________________________________________________________________________________________________________

b. ESTIMATED DATE OF DISCHARGE (M/Y): _________________________________________________________________

c. AFTERCARE PLAN: ______________________________________________________________________________________

____________________________________________________________________________________________________________

Client Name: Date Completed: Revised 5/2004INTERPRETIVE SUMMARY/ADDITIONAL INFORMATION: (CONTINUED)

(Page___ of___)

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