Molina Behavioral Health Prior Authorization Form - Ohio Page 2

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Molina Healthcare of Ohio

Behavioral Health Prior Authorization Form

Phone Number: (800) 642- 4168

Fax Number: (866) 553-9262

Clinical Review - Initial and Concurrent

Functioning: Presenting/Current Symptoms that Necessitate Treatment (or Continued Treatment)

* Denotes Documentation of Safety Plan Completed under Additional Information

☐ *Suicidal ideations/plan/attempt

☐ Appetite Changes

☐ Impulsivity

☐ *Homicidal ideations/plan/attempt

☐ Significant Weight Gain/Loss

☐ Legal Issues

☐ *History of Suicidal/Homicidal actions

☐ Panic Attacks

☐ Problems with Performing ADL’s

☐ Hallucinations/Delusions/Paranoia

☐ Poor Motivation

☐ Poor Treatment Compliance

☐ Self-Mutilation (ex. cutting/burning self)

☐ Cognitive Deficits

☐ Social Support Problems

☐ Mood Lability

☐ Somatic Complaints

☐ Learning/School/Work Issues

☐ Anxiety

☐ Anger Outbursts/Aggressiveness

☐ Substance Use Interfering with Functioning

☐ Sleep disturbances

☐ Inattention

*Medication Administration Document can be submitted in lieu of completing the below

Medication Name

Dosage/

New from

Date Current

Compliant?

Lab/Plasma Level?

Frequency

Admit?

Dose Initiated

☐New

☐Yes

☐No

☐New

☐Yes

☐No

☐New

☐Yes

☐No

☐New

☐Yes

☐No

☐New

☐Yes

☐No

Additional Information (explanation of any checked symptoms or other pertinent information):

*For Inpatient, RTC, and Partial Hospitalization/Day Treatment - Please submit current (within the last 48 hours) Medical Progress Notes for

Clinical Review

*For ECT, Psychological/Neuropsych Testing-Applied Behavior Analysis, and non-Par OP Requests – see page 3 for additional information

required for review

Aftercare Plan/Follow-up Appointment

Expected Discharge Date: __________________________________

Follow-Up Appointment Scheduled: ☐YES

☐NO

(Complete if member is in Inpatient Hospitalization)

*NOTE: First follow-up apt must be scheduled within 7 (seven) days of discharge.

Provider Type

Provider Name

Telephone Number

Date of Appointment

Time of Appointment

Is treatment being coordinated with the Psychiatrist or Behavioral Health Practitioner?

☐ Yes

☐ No

If Yes, Name of Provider: ____________________________________________

Last Contact Date with Provider: __________________

If No, please explain: ____________________________________________________________________________________________________

NOTE: Level of Care coverage is subject to State Contract Specific Covered Services. Please refer to the State Specific Provider Handbook for a list of

covered levels of care. Authorization of services does not guarantee payment. Payments for services are pending eligibility at the time of service and

benefit coverage.

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Behavioral Health Prior Auth Form 2015 – CORP BH Revised 9/4/2014

46180OH1014