If not met, contact the provider to request and give deadline to submit. If no response, “administratively deny” the request. The Comprehensive Clinical Plan is present and complete. If none present, then contact provider and give a deadline to submit. If no response, Met Not Met “administratively deny” the request. The Comprehensive Clinical Assessment and/or Addendum is present and supports request (to include DSM 5 diagnosis). If not included, then document Met Not Met call to provider. If not provided by deadline, administratively deny. LOCUS/ASAM level noted is in SAR or other documentation. If not, then contact the provider to request and give deadline to submit. If no response, Met Not Met “administratively deny” the request. Recommended CALOCUS Level 3-5 Recommended ASAM Level 1-2.1 If necessary, review and/or request CALOCUS/ASAM worksheet; If not present, can NOT administratively deny. Review for “stacked” services. If there are current authorizations for other services, consider if there are service exclusions and if so, contact Provider for Met Not Met clarification. If no response, “administratively deny” the request. Not the services here: Other Items for Review: If Medicaid beneficiary is under 21, review for EPSDT. Met Not N/A Met The Beneficiary’s Name, DOB, MRN, and MID number are present and accurate in necessary places (i.e. PCP, CCA, Service Notes, etc)? If not contact Met Not Met Provider for clarification. Report to appropriate HIPAA personnel if violation has occurred. Is there evidence of active discharge planning with any concurrent requests? Consider reviewing for the following elements: Met Not N/A anticipated discharge date Met barriers to discharge anticipated discharge level of care efforts made to coordinate discharge appointment If not, then make documented call to provider to request. Review for past denials or partial approvals within this current episode of care. Consider implications of previous decisions/recommendations and need for Met Not N/A clinical staffing. Met Please note here: Are the requested days/units within the MCO guidelines? If not, make documented contact with provider to verify intended request dates/units. Can Met Not Met
If not met, contact the provider to request and give deadline to submit. If no response, “administratively deny” the request. Met Not Met The Comprehensive Clinical Plan is present and complete. If none present, then contact provider and give a deadline to submit. If no response, “administratively deny” the request. Met Not Met The Comprehensive Clinical Assessment and/or Addendum is present and supports request (to include DSM 5 diagnosis). If not included, then document call to provider. If not provided by deadline, administratively deny. Met Not Met LOCUS/ASAM level noted is in SAR or other documentation. If not, then contact the provider to request and give deadline to submit. If no response, “administratively deny” the request. Recommended CALOCUS Level 3-5 Recommended ASAM Level 1-2.1 If necessary, review and/or request CALOCUS/ASAM worksheet; If not present, can NOT administratively deny. Met Not Met Review for “stacked” services. If there are current authorizations for other services, consider if there are service exclusions and if so, contact Provider for clarification. If no response, “administratively deny” the request. Not the services here: Other Items for Review: Met Not Met N/A If Medicaid beneficiary is under 21, review for EPSDT. Met Not Met The Beneficiary’s Name, DOB, MRN, and MID number are present and accurate in necessary places (i.e. PCP, CCA, Service Notes, etc)? If not contact Provider for clarification. Report to appropriate HIPAA personnel if violation has occurred. Met Not Met N/A Is there evidence of active discharge planning with any concurrent requests? Consider reviewing for the following elements: anticipated discharge date barriers to discharge anticipated discharge level of care efforts made to coordinate discharge appointment If not, then make documented call to provider to request. Met Not Met N/A Review for past denials or partial approvals within this current episode of care. Consider implications of previous decisions/recommendations and need for clinical staffing. Please note here: Met Not Met Are the requested days/units within the MCO guidelines? If not, make documented contact with provider to verify intended request dates/units. Can
Family-Centered-Treatment-Service-Review-Criteria-updated-05112016.docx