CON is present and accurate. If none present, then contact provider and give a deadline to submit. If no response, “administratively deny” the request. (NOTE: The CON can only be signed Met Not Met by an Independent physician and LCSW or Licensed Psychologist.) CALOCUS/ASAM level noted 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 6* Met Not Met Recommended ASAM Level 1-3.7 *CALOCUS expected to decline as treatment progresses toward transition/discharge If necessary, Review and/or request CALOCUS/ASAM worksheet; If not present, can NOT administratively deny. Other Items of Review: Review for “stacked” services. If there are current authorizations for other services, consider if there are service exclusions and if so, review under EPSDT. Requires clinical denial if EPSDT Not Met N/A criteria not met. Met Note the services here: The Beneficiary’s Name, DOB, MRN and MID number are present and accurate in necessary Met Not Met places (ie. PCP, CCA, Service Notes, etc)? If not contact 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: anticipated discharge date barriers to discharge Met Not Met 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 Not implications of previous decisions/recommendations and need for clinical staffing. Met N/A 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 adjust authorized dates/units as Met Not Met requested by provider or educational notice to match Clinical Coverage Policy. Please note here: Length of stay in current service. Not Note here: Met N/A Met For concurrent request, ask for the following information: # of therapeutic leave days utilized Not # individual and/or family therapy sessions during previous auth. period Met N/A Met Previously requested documentation from prior authorizations Please note here: Evidence of use/intended use of Evidence Based Practices. Met Not N/A List EBP here: Met
Met Not Met CON is present and accurate. If none present, then contact provider and give a deadline to submit. If no response, “administratively deny” the request. (NOTE: The CON can only be signed by an Independent physician and LCSW or Licensed Psychologist.) Met Not Met CALOCUS/ASAM level noted 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 6* Recommended ASAM Level 1-3.7 *CALOCUS expected to decline as treatment progresses toward transition/discharge If necessary, Review and/or request CALOCUS/ASAM worksheet; If not present, can NOT administratively deny. Other Items of Review: Met Not Met N/A Review for “stacked” services. If there are current authorizations for other services, consider if there are service exclusions and if so, review under EPSDT. Requires clinical denial if EPSDT criteria not met. Note the services here: Met Not Met The Beneficiary’s Name, DOB, MRN and MID number are present and accurate in necessary places (ie. PCP, CCA, Service Notes, etc)? If not contact Provider for clarification. Report to appropriate HIPAA personnel if violation has occurred. Met Not Met 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 adjust authorized dates/units as requested by provider or educational notice to match Clinical Coverage Policy. Please note here: Met Not Met N/A Length of stay in current service. Note here: Met Not Met N/A For concurrent request, ask for the following information: # of therapeutic leave days utilized # individual and/or family therapy sessions during previous auth. period Previously requested documentation from prior authorizations Please note here: Met Not Met N/A Evidence of use/intended use of Evidence Based Practices. List EBP here:
PRTF-DAP-Service-Reveiw-Criteria08062015.docx