Member Name: ANTICIPATED AFTERCARE SERVICES FOR THE MEMBER (submitted upon admission and updates): Is the member returning to their own residence or a family residence? Family/Peer Support Interventions Servicing Type of Service Date Referral Date Decision Decision If Denied F/U Contact to Comments Provider Requested Made Notification Reason Negotiate Decision EXAMPLE Supportive Peers 01/01/2016 01/02/2016 Denied Member not Cindy Smith Need to find Hope, Inc. as Navigators resident of 555-5555 another peer Pima Pima County support in Yuma EXAMPLE Peer Support 01/03/2016 01/04/2016 Approved Hope, Inc. Yuma Outpatient Health Therapies Is Prior Auth needed? If yes, date submitted: Servicing Type of Service Date Referral Date Decision Decision If Denied F/U Contact to Comments Provider Requested Made Notification Reason Negotiate Decision Transitional Facility Placement Is Prior Auth needed? If yes, date submitted: Servicing Type of Service Date Referral Date Decision If Denied Reason F/U Comments Provider Requested Made Decision Contact to Notification Negotiate Decision
Member Name: ANTICIPATED AFTERCARE SERVICES FOR THE MEMBER (submitted upon admission and updates): Is the member returning to their own residence or a family residence? Family/Peer Support Interventions Servicing Provider Type of Service Requested Date Referral Made Date Decision Notification Decision If Denied Reason F/U Contact to Negotiate Decision Comments EXAMPLE Hope, Inc. Pima Supportive Peers as Navigators 01/01/2016 01/02/2016 Denied Member not resident of Pima County Cindy Smith 555-5555 Need to find another peer support in Yuma EXAMPLE Hope, Inc. Yuma Peer Support 01/03/2016 01/04/2016 Approved Outpatient Health Therapies Is Prior Auth needed? If yes, date submitted: Servicing Provider Type of Service Requested Date Referral Made Date Decision Notification Decision If Denied Reason F/U Contact to Negotiate Decision Comments Transitional Facility Placement Is Prior Auth needed? If yes, date submitted: Servicing Provider Type of Service Requested Date Referral Made Date Decision Notification Decision If Denied Reason F/U Contact to Negotiate Decision Comments