PSCD - Psychiatric Centers
PCSD
Psychiatric Centers at San Diego
UR Precertification Review for Inpatient Mental Health or Chemical Dependency
For all Initial Authorization complete the form below and fax to 619-398-2435 OR e-mail to 6193982435@. 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) Sharp Health Plan HMO 2) PCAMG with Humana, Secure Horizons/UHC, SCAN or Care 1st 3) Scripps Physicians with Blue Cross Senior or SCAN 4) Encompass with Blue Cross Senior or Secure Horizons/UHC
Urgent Request Routine
Urgent request: A request for care or services where application of the time frame for making routine or non-life threatening care determinations:
• Could seriously jeopardize the life, health or safety of the member or others, due to the member’s psychological state, or
• In the opinion of a practitioner with knowledge of the member’s medical or behavioral condition, would subject the member to adverse health consequences without the care or treatment that is the subject of the request.
|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: | |
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|Prior Outpt Treatment: | |
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|Compliant with Treatment: | |
|Current Risk of SI/HI: | |
|History of SI/HI: | |
|Diagnoses: | |
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|Medications: | |
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|Reason for Admission: | |
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