Prior Authorisation / Child / Adolescent Day Treatment Attachment Page 4
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5PRIOR AUTHORIZATION / CHILD / ADOLESCENT DAY TREATMENT ATTACHMENT (PA/CADTA)
Page 4 of 5
F-11040 (07/12)
SECTION III — DOCUMENTATION (Continued)
12. Complete the checklist to determine whether an individual meets the criteria for severe emotional disturbance (SED). Criteria for
meeting the functional symptoms and impairments are found in the instructions. The disability must be evidenced by a, b, c, and
d listed below.
a. A primary psychiatric diagnosis of mental illness or severe emotional disorder. Document diagnosis using the most recent
version of the APA DSM.
______________________________________________________________________________________________
Primary Diagnosis Code and Description
b. The individual must meet all three of the following conditions:
Individual is under the age of 21.
Individual’s emotional and behavioral problems are severe in nature.
The disability for which the individual is seeking treatment is expected to persist for a year or longer.
c. Symptoms and functional impairments
The individual must have one of the following symptoms or two of the following functional impairments:
1.
Symptoms
Psychotic symptoms.
Suicidality.
Violence.
2.
Functional impairments
Functioning in self care.
Functioning in the family.
Functioning in the community.
Functioning at school / work.
Functioning in social relationships.
d. The individual is receiving services from two or more of the following service systems:
Mental health.
Juvenile justice.
Social services.
Special education.
Child protective services.
Eligibility criteria are waived under the following circumstances:
The individual substantially meets the criteria for SED, except that the severity of the emotional and behavioral problems
have not yet substantially interfered with the individual’s functioning but would likely do so without child/adolescent day
treatment services. Attach an explanation.
The individual substantially meets the criteria for SED, except that the individual has not yet received services from more
than one system and, in the judgment of the medical consultant, would be likely to do so if the intensity of treatment
requested was not provided.
13. Describe the treatment program that will be provided. Attach a day treatment program schedule, if available. Summarize the
proposed intervention in this section. The treatment plan should specify how program components relate to this member’s
treatment goals.
Continued
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