Prior Authorization / Intensive In-Home Treatment Attachment Form Page 2
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2PRIOR AUTHORIZATION / INTENSIVE IN-HOME TREATMENT ATTACHMENT (PA/ITA)
Page 2 of 2
F-11036 (07/12)
SECTION IV — SEVERELY EMOTIONALLY DISTURBED CRITERIA
13. Complete the checklist to determine whether or not the individual meets the criteria for 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 SED. Document diagnosis using the most recent version of the
Diagnostic and Statistical Manual of Mental Disorders (DSM) or Diagnostic Classification of Mental Health and
Developmental Disorders of Infancy and Early Childhood (DC:0-3).
.
Primary Diagnosis:
b.
The individual must meet all three of the following.
Be under the age of 21.
Have emotional and behavioral problems that are severe in nature.
This disability is expected to persist for a year or longer.
c.
The individual must have one symptom or two functional impairments.
1.
Symptoms (must have one).
2.
Functional impairments (must have two).
Psychotic symptoms.
Functioning in self care.
Suicidality.
Functioning in the community.
Violence.
Functioning in social relationships.
Functioning in the family.
Functioning at school / work.
d.
The individual is receiving services from one or more of the following service systems in addition to the mental health
service system. (The multi-agency treatment plan must be developed by representatives from all systems identified on the
SED eligibility checklist, address the role of each system in the overall treatment and the major goals for each agency
involved.)
Social Services.
Juvenile Justice.
Child Protective Services.
Special Education.
e.
Enrollment criteria may be waived under the following circumstances.
The member substantially meets the criteria for SED, except the severity of the emotional and behavioral problems
have not yet substantially interfered with the individual’s functioning, but would likely do so without in-home mental
health and substance abuse treatment services. Attach an explanation.
The member substantially meets the criteria for SED, except 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.
SECTION V — ATTACH SUPPORTING DOCUMENTATION
14. Attach and label all of the following.
a. The Prior Authorization Request Form (PA/RF), F-11018.
b. The assessment and recovery/treatment plan.
c. A copy of a physician’s prescription/order for in-home treatment services dated not more than one year prior to the requested
first date of service (DOS).
d. Documentation that the member had a comprehensive HealthCheck screening performed by a valid HealthCheck screener
dated not more than one year prior to the first DOS.
e. The Child and Adolescent Needs and Strengths assessment summary, Child and Adolescent Functional Assessment Scale,
or the Achenbach Child Behavior checklist.
f. A substance abuse assessment may be included. A substance abuse assessment must be included if substance abuse-
related programming is part of the member’s treatment program.
SECTION VI — SIGNATURE
I attest to the accuracy of the information on this PA request. I understand that I am responsible for the supervision of the other team
member(s) identified on this attachment. I, or someone with comparable qualifications, will be available to the other team member(s)
at all times when he or she is in the home alone working with the child/family.
15. SIGNATURE — Certified Psychotherapist / Substance Abuse Counselor
16. Credentials
17. Date Signed
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