Mental Health Support Initial Request May 2012



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Service Request Application (SRA) for:

MENTAL HEALTH SKILL-BUILDING SERVICES (MHSS)

INITIAL REQUEST- ADULT (Age 21 and over)

 

ALL ITEMS ARE REQUIRED

After response is entered, use the Tab key to advance to next item.

|MEMBER INFORMATION |PROVIDER INFORMATION |

|Member First Name |      |Provider Name |      |

|Member Last Name |      |Clinical Contact Name |      |

|Medicaid Number |      |Provider MIS# |      |

|Member Date of Birth |      |Provider Tax ID# |      |

| | |Provider NPI |      |

|Sex |Male Female |Provider Phone |      Ext:       |

|Member Phone |      |Provider Email |      |

|Member Address |      |Service Address |      |

|City, State & Zip Code |      |City, State & Zip Code |      |

|CLINICAL INFORMATION |

|Procedure Code |H0046 |

|Primary Diagnosis |      |

|Secondary Diagnosis |      |

|Requested Units |      |

|Requested Start Date |      |Retro Review Request:  Yes    No |

|Requested End Date |      |

|Place of Service |      |

 

Intake

1. Have you submitted an SRA for this service and for this individual within the last 30 days which was not approved? Yes No

a. If yes, describe what changes have occurred to indicate that this service is now necessary?      

2. At admission, was an appropriate face-to-face intake conducted, documented, signed and dated by an LMHP (or LMHP Supervisee/Resident)? Yes No

3. If there is a dual diagnosis of mental health and substance use disorders, are services integrated?

Yes No Not Applicable

4. Where does the individual currently reside?

a. Private Residence Yes No

i. If yes, with whom (family individual, caretaker, etc.)?      

b. Homeless or in a Shelter Yes No

i. If yes, please specify how this service will benefit the individual in these circumstances (i.e., is there a goal to move from a shelter to independent living?):      

c. If no to both 4a and 4b, please check one of the following:

i. Nursing Home (This service can only be authorized for up to 60 days prior to discharge from Nursing facilities)

ii. Assisted Living Facility (ALF)

iii. Intermediate Care Facility for persons with Intellectual Disabilities (ICF/ID)

iv. Hospital

v. In-home residential or congregate residential service through the ID or IFDDS waiver

vi. Other – Explain:      

d. If yes to any of the above in 4c, please answer the following questions:

i. What is the name of the Facility?      

ii. Does the agency/provider delivering MHSS to the individual have any affiliation with the above Facility? (Affiliation Definition: any entity or property in which a provider or facility has direct or indirect ownership interest of five percent or more, or any management, partnership or control of an entity.) Yes No

iii. What is the anticipated discharge date from the facility?      

5. Has the individual expressed suicidal ideation in the last 30 days? Yes No

a. If yes, what is the safety plan?      

Clinical

6. Does the individual have organic disorders, such as delirium, dementia, or other cognitive disorders not elsewhere classified? Yes No

a. If yes, is there a signed and dated statement from the individual’s physician that indicates the individual can benefit from this service? Yes No

b. If yes to 6a, please submit a copy of the signed and dated statement from the physician that explains how the member will benefit from this service and achieve and maintain community stability and independence.

7. Is the primary diagnosis schizophrenia/other psychotic disorder, Major Depressive Disorder-- Recurrent, or Bipolar I or II? Yes No Not Applicable

8. If the primary diagnosis is not one of the above has a physician documented any other mental health disorder within the last year resulting in all of the following?

a. Serious Mental Illness (SMI): Yes No Not Applicable

b. Severe and recurrent disability: Yes No Not Applicable

c. Functional limitations in the individual’s major life activities which are documented in the individual’s medical record: Yes No Not Applicable

d. Individual requires individualized training in order to achieve or maintain independent living in the community: Yes No Not Applicable

e. If yes to any of 8a-d, please submit a copy of the physician documentation that is dated within the last year.

9. Does the individual have a personality disorder, cognitive impairment, or intellectual disability?   Yes    No

a. If yes, describe how the individual is expected to actively participate in and benefit from services:      

10. Does individual require individualized training in acquiring basic living skills such as symptom management; adherence to psychiatric and medication treatment plans; development and appropriate use of social skills and personal support system; personal hygiene; food preparation; or money management? Yes No

a. If yes, please describe current symptoms and behaviors or other pertinent information which provides substantiation for the need for MHSS. (Identify the frequency, intensity and duration of each behavior and avoid using vague words such as ‘aggressive’):      

11. Does the individual have a prior history of any of the following: psychiatric hospitalization, crisis stabilization, Intensive Community Treatment (ICT) or Program of Assertive Community Treatment (PACT) services; placement in a psychiatric residential treatment facility (RTC Level C); or Temporary Detention Order (TDO) evaluation as a result of or decompensation related to serious mental illness? 

 Yes No

12. Has the individual had a prescription for anti-psychotic, mood stabilizing, or anti-depressant medications within the 12 months prior to the assessment date? Yes No

a. If no, does the physician or other practitioner who is authorized by his license to prescribe medications indicate that anti-psychotic, mood stabilizing, or antidepressant medications are medically contraindicated for the individual? Yes No

b. If yes to 12a, describe how the individual will be able to actively participate in and benefit from services without the assistance of medication:      

c. If yes to 12a, please submit a copy of the physician documentation that indicates that anti-psychotic, mood stabilizing or anti-depressant medications are medically contraindicated for the individual.

13. Date this individual was admitted to Mental Health Skill-Building Services:      

14. Describe mental health treatment goals for the individual as it relates to requested MHSS:      

15. List any physical health conditions which require treatment:      

16. List all medications (for physical and behavioral health conditions) that individual is taking:      

Care Coordination

17. Does individual have a Primary Care Physician (PCP)? Yes No

d. If yes, has your agency communicated with the PCP after the initial Service Specific Provider Intake (SSPI) to provide updates regarding treatment and to coordinate care? Yes No

e. If yes, name of PCP:      

f. If no, has your agency attempted to connect the individual with a PCP? Yes No

18. Has the local CSB been contacted to determine if Mental Health Case Management services are being provided? Yes No

g. Date of Contact:      

h. Name of CSB:      

19. Is the individual receiving Mental Health Case Management? Yes No

i. If yes, what is the name of the Mental Health Case Manager?      

j. If no, was a referral made to the CSB for Mental Health Case Management, with the consent of the parent or guardian if necessary?  Yes   No – If yes, date of referral:       If no, why not?      

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