This form should be used to
request initial authorization of
payment for
County of San Diego Mental Health Plan
Initial Day Program Request
Day Program services.
fax/mail to: OptumHealth Public Sector,
PO Box 601340
San Diego, CA 92160 - 1340
Phone: (800) 798-2254, option #4
Fax: (866) 220-4495
RECEIVED:
****CONFIDENTIAL****
CLIENT INFORMATION
Client Name: (First & Last)
Client Anasazi ID#:
Date of Birth
DAY PROGRAM INFORMATION
Legal Entity & Day Program Name: Please print clearly
Phone:
Day Program Unit#
Subunit #
Assignment Open Date
Anticipated Date of Discharge
INITIAL AUTHORIZATION REQUEST:
Intensive Day Treatment
Begin Date for this Request:
mm/dd/yyyy
days a week
COMPLETE DIAGNOSIS and CHECK ALL CRITERIA THAT APPLY
TIP: Use DSM-IV Codes; include all Axes.
Axis I - Primary
Frequency :
mm/dd/yyyy
DAY PROGRAM SERVICE NECESSITY CRITERIA
DIAGNOSIS
Day Rehab
End Date for this Request:
Axis II -
Client must also meet Title 9 Medical Necessity Criteria
Axis III -
Secondary
Axis IV
Axis V (GAF) Current
Highest in last 12 months
For adult clients only: Day Program Services Medical Necessity #
(Please review Day Program Medical Necessity Grid to determine this number)
SERVICE NECESSITY CRITERIA
1) Client exhibits an impairment in functioning due to the above diagnosis as evidenced by one or more of the following:
A.
Substantial impairment in living arrangement, daily activities, social relationships, and/or age appropriate ADL skills as demonstrated by:
(describe)
B.
Risk factors such as recurring psychotic symptoms, suicidal or homicidal ideation, without evidence of plan, or other violent ideation or
behavior as demonstrated by:(describe)
C.
Demonstrative history that without day program services there is a substantial risk of recurrence of A. or B. (describe behavior/history
supporting risk.)
D.
(For children/youth) Probability that child will not progress developmentally as individually appropriate, or will deteriorate developmentally as
demonstrated by:
2) 2)
Client (and family for children) has been in, or is currently in lower level of care and the client has not demonstrated progress or stabilization
(describe progress or lack of progress)
3)
Client requires structured Day Program in order to move successfully from higher level of care to lower level of care or to prevent
4)
Present living situation and functioning indicate need for structured day program. Describe living situation & functioning that supports need
deterioration in functioning and admission to a higher level of care. (describe how is this determined)
for Day Program.
5)
(For children/youth) Recent troubling life events, such as a change of placement, arrest and incarceration, or child abuse. ( Describe
behaviors/functioning indicating need for Day Program. A formal assessment must confirm medical necessity within 30 days after
admission.)
Created by UBH: 01/21/05
Revised 9.01.10
CURRENT FUNCTIONING (CFARS Rating):
1
No problem
2
Less than
Slight
Depression
Depressed Mood
Sad
Irritable
3
Slight Problem
Happy
Hopeless
4
Slight to
Moderate
Sleep Problems
Lacks Energy /
Interest
Anti-Depression
Meds
Withdrawn
Hyper activity
Manic
Inattentive
Agitated
Sleep Deficit
Overactive / Hyperactive
Mood Swings
Pressured Speech
Relaxed
Impulsivity
ADHD Meds
Anti-Manic Meds
Cognitive Performance
Poor Memory
Low Self-Awareness
Poor Attention/Concentration
Developmental Disability
Insightful
Concrete Thinking
Impaired Judgment
Slow Processing
Traumatic Stress
Acute
Dreams/Nightmares
Chronic
Detached
Avoidance
Repression/Amnesia
Upsetting Memories
Hyper Vigilance
Interpersonal Relationships
Problems w/Friends
Diff. Estab./ Maintain
Poor Social Skills
Age-Appropriate Group
Adequate Social Skills
Supportive Relationships
Overly Shy
ADL Functioning
Handicapped
Not Age Appropriate In:
Permanent Disability
Self Care
Communication
No Known Limitations
Hygiene
Recreation
Mobility
Select:
Work
School
Absenteeism
Poor Performance
Regular
Dropped Out
Learning disabilities
Seeking
Employed
Doesn’t Read/Write
Tardiness
Defies Authority
Not Employed
Suspended
Disruptive
Terminated/ Expelled
Skips Class
Danger to Others
Violent Temper
Threatens Others
Causes Serious Injury
Homicidal Ideation
Use of Weapons
Homicidal Threats
Assaultive
Homicide Attempt
Cruelty to Animals
Accused of Sexual Assault
Does not appear dangerous to
Physically Aggressive
Others
5
6
Moderate
Moderate to
Problem
Severe
Anxiety
Anxious/Tense
Phobic
7
Severe
Problem
Calm
Worried/ Fearful
9
Extreme Problem
Guilt
Anti-Anxiety Meds
Panic
Obsessive/Compulsive
Thought Process
Illogical
Delusional
Hallucinations
Paranoid
Ruminative
Command Hallucination
Derailed Thinking
Loose Associations
Intact
Oriented
Disoriented
Anti-Psych Meds
Medical / Physical
Acute Illness
Hypochondria
Good Health
CNS Disorder
Chronic Illness
Need Med./Dental Care
Pregnant
Poor Nutrition
Enuretic/ Encopretic
Eating Disorder
Seizures
Stress-Related Illness
Substance Use
Alcohol
Drug(s)
Dependence
Abuse
Over Counter Drugs
Cravings/Urges
DUI
Abstinent
I.V . Drugs
Recovery
Interfere w/Functioning
Med. Control
Behavior in “Home” Setting
Disregards Rules
Defies Authority
Conflict w/Sibling or Peer
Conflict w/Parent or Caregiver
Conflict w/Relative
Respectful
Responsible
Socio-Legal
Disregards Rules
Offense/Property
Offense/Person
Fire Setting
Comm. Control/Reentry
Pending Charges
Dishonest
Use/Con Other(s)
Detention/ Commitment
Danger to Self
Suicidal Ideation
Current Plan
Past Attempt
Self-Injury
“Risk-Taking”
Serious Self-Neglect
Behavior
Security/ Management Needs
Home w/o Supervision
Behavioral Contract
Protection from Others
Home w/Supervision
Restraint
Time-Out
Monitored House Arrest
CLIENT INFORMATION
Client Name: (First & Last)
8
Severe to
Extreme
Incompetent to Proceed
Street Gang Member
Recent Attempt
Self-Mutilation
Inability to Care for Self
Suicide Watch
Locked Unit
Seclusion
Run/Escape Risk
Involuntary Exam/ Commitment
PRN Medications
One-to-One Supervision
****CONFIDENTIAL****
Client Anasazi ID #:
Date of Birth:
REQUIRED ATTACHMENTS
PLEASE SUBMIT THE FOLLOWING DOCUMENT WITH THIS INITIAL DAY PROGRAM REQUEST:
Specialty Mental Health Services DPR if the client receives ancillary services in addition to Day Program Services.
Day Program Clinician: (print)____________________________________________________________
Date:__________
Countersignature by Licensed Clinician:______________________________________________________
Date:_________
For OptumHealth Disposition Only: DOCUMENT AUTHORIZATIONS FOR DAY PROGRAM and ANCILLARY SERVICES
OptumHealth Clinician:____________________ Day Program Authorization Period: Begin Date:_______________ End Date:_________________
Approved # Days:_________ Frequency (# times/week) ________
Reduce DP Request:
Deny DP Request:
Review Date:_________
Date NOA Sent: ________ Reduce AS Request:
Date DP Auths Entered:____________ Date AS Auths Entered:____________
Created by UBH: 01/21/05
Revised 9.01.10
Circle approved AS on next page(s) Logged
Deny AS Request:
D/E Name:______________________
Date NOA Sent:______
Logged