Psychological Services Request For Prior Authorization

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STATE OF MISSOURI

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DEPARTMENT OF SOCIAL SERVICES

PSYCHOLOGICAL SERVICES REQUEST FOR PRIOR AUTHORIZATION

PARTICIPANT NAME (LAST, FIRST, M.I.)

PROVIDER NAME (AFFIX LABEL HERE)

PARTICIPANT NUMBER

BILLING PROVIDER IDENTIFIER

PROVIDER TAXONOMY CODE (IF REQUIRED)

DATE OF BIRTH

PROVIDER TELEPHONE NUMBER

PROVIDER FAX NUMBER

PROVIDER SIGNATURE

DATE

NUMBER OF HOURS USED ON CURRENT PA*

HOURS USED AS OF (DATE)

REQUESTED START DATE OF PA

1. Service Requested (If requesting Family Therapy please see reminder in instructions)

Services that always require a PA for all participants:

Children – Birth through 2 years old

Assessment

Hours ______

Testing

Hours ______

Therapy - Therapy Type _________________ Hours ______

All Ages

Individual Interactive Therapy

Hours ________

Family Therapy without patient present

Hours ________

Services that require PA per program guidelines:

Individual Therapy

Hours ________

Family Therapy**

Hours ________

Group Therapy

Hours ________

Individual and Family Therapy Combination**

Hours Individual ________

Hours Family ________

**If requesting Family Therapy, please list all members of the family, relationship to patient and DCN if available.

2. Has the patient/guardian agreed to his/her treatment plan?

Yes

3. Is the therapy court ordered?

Yes

4. Have you communicated with other involved therapist/health care practitioner about treatment?

Yes

5. If child is in state custody, have you provided a copy of the treatment plan to the Children’s Division casemanager

or contracted casemanager? If yes, date ____________

Yes

Casemanager Name ____________________________

Child not in state custody

6. Is therapy the result of an EPSDT screen? If yes, date of screen _________________

Yes

AXIS I: CLINICAL DISORDERS OR OTHER CONDITIONS THAT MAY BE A FOCUS OF CLINICAL ATTENTIONS

DIAGNOSTIC CODE

_____ _____ _____ - _____ _____

IS THERE EVIDENCE OF SUBSTANCE ABUSE?

Yes

AXIS II: PERSONALITY DISORDERS, MENTAL RETARDATION

DIAGNOSTIC CODE

_____ _____ _____ - _____ _____

AXIS III: GENERAL MEDICAL CONDITIONS

DOES THIS PATIENT HAVE A CURRENT GENERAL MEDICAL CONDITION THAT IS POTENTIALLY RELEVANT TO THE UNDERSTANDING OR MANAGEMENT OF THE CONDITION(S) NOTED IN AXIS I

OR II?

Yes

If Yes, list condition: _________________________________________________________________________________

_______________________________________________________________________________________________________________

AXIS IV: PSYCHOSOCIAL AND ENVIRONMENTAL PROBLEMS (PLEASE INDICATE ALL THAT APPLY)

Problems with primary support group

Other psychosocial and environmental problems

Occupational problems

Problems related to social environment

Problems related to interaction with legal system/crime

Educational problems

Problems with access to health care