Prior Authorization Substance Abuse Daily Treatment Attachment Page 3
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4PRIOR AUTHORIZATION / SUBSTANCE ABUSE DAY TREATMENT ATTACHMENT (PA/SADTA)
Page 3 of 4
F-11037 (07/12)
SECTION III — DOCUMENTATION (Continued)
12. Describe the member’s severity of illness using the following indicators. Individualize all information.
a. Loss of control / relapse crisis.
b. Physical conditions or complications.
c. Psychiatric conditions or complications. (Include psychiatric diagnosis, medications, current psychiatric symptoms.)
d. Recovery environment.
e. Life areas impairment. (Specify social / occupational / legal / primary support group.)
f.
Treatment acceptance / resistance.
13. Treatment Plan
•
Attach a copy of the member’s substance abuse day treatment plan (refer to intensity of service guideline in the substance
abuse day treatment criteria).
•
Describe any special needs of the member and indicate how these will be addressed (for example, educational needs, access
to treatment facility).
•
Describe the member’s family / personal support system. Indicate how these issues will be addressed in treatment, if
applicable. If family members / personal support system are not involved in treatment, explain why not.
Continued
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