PSCD - Psychiatric Centers



PCSD

Psychiatric Centers at San Diego

UR Precertification Review for Inpatient Mental Health or Chemical Dependency

For Initial Authorization complete the form below and fax to 858-636-2242. Include any clinical notes you feel are pertinent to meet medical necessity criteria and/or to support urgent requests. This form only applies to the following payers: 1) Secure Horizons/UHC or Care 1st with the Medical Groups ARCH, SCMG, Graybill or SRS 2) Sharp Advantage Medicare with the Medical Groups of SRS or SCMG.

Urgent Request Routine

Urgent request definition: An enrollee, or any physician (regardless of whether the physician is affiliated with the Medicare health plan), may request that a Medicare health plan expedite an organization determination when the enrollee or his/her physician believes that waiting for a decision under the standard time frame could place the enrollee’s life, health, or ability to regain maximum function in serious jeopardy

|Current Date and Time: | |

|Name of Requester: | |

|Phone # of Requester: | |

|E-mail address of Requester: | |

|Admitting Facility: | |

|First and Last name of Patient: | |

|DOB: | |

|Name of Health Plan: | |

|Health Plan ID #: | |

|Date and Time of admission: | |

|Attending MD: | |

|Treatment Type Requested: | |

|Mental Health or CD | |

|Level of Care Requested: Inpatient, RTC, PHP or IOP | |

|Admitted through ER? Y or N | |

|List name of ER if Yes | |

|Prior Hospital Admissions: | |

| | |

|Prior Outpt Treatment: | |

| | |

|Compliant with Treatment: | |

|Current Risk of SI/HI: | |

|History of SI/HI: | |

|Diagnoses: | |

| | |

|Medications: | |

| | |

|Reason for Admission: | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download