Community Based Services Request Form
Fax: 312-324-0649 |UM Department Phone: 888-211-6851
*** PLEASE TYPE or WRITE LEGIBLY OR REQUEST WILL BE RETURNED AS UNABLE TO PROCESS ***
Member: _________________________ Provider Name: __________________________ Provider Telephone: ___________________
Member DOB: _____________________ Provider Group/Clinic: _____________________ Provider Fax: _________________________
Member ID:_______________________ Service Address: __________________________ City/State/Zip: ________________________
Provider ID/NPI: ________________________________________ Tax ID# __________________________________________________
Start Date for this authorization request: ____________________________
Codes that do not require authorization:
H0002 LOCUS Assessment
H2011 Crisis Intervention
H0031 Mental Health Assessment
Please indicate the level of care requested:
ACT (Assertive Community
Treatment)- up to 6 month
auth range
Crisis Residential Servicesmust request within 72hrs of
admission- up to 14 days
Child/Adolescent Outpatient
Up to 6 month auth range
Yes
CST (Community Support Team)up to 6 month auth range
Community Support- Individual/Group
Up to 6 month auth range
CSR (Community Support
Residential)- up to 6 month auth
range
Supported Housing
Describe Type:
Adult Outpatient
Up to 6 month auth range
Other:
No Is this a request for a new level of care?
If yes, please attach summary of initial comprehensive assessment or updated comprehensive assessment indicating a new
level of care is clinically appropriate.
Yes No Is this an extension of the current level of care?
If yes, please provide the date services initiated:
If yes, please attach summary of updated LOCUS assessment and summary of progress toward treatment plan goals.
Diagnosis: primary ICD-10 or DSM-5 and other applicable co-occurring diagnoses- please provide code and description
Primary:
2nd:
3rd:
Please check box if present:
Community Based Services
1
Member: ______________________
ID#_______________________
Inability to consistently perform
ADLs
High use of psychiatric
emergency or crisis services
Inability to maintain stable
housing
Persistent severe major
symptoms (psychotic, SI, HI,
etc)
Co-existing SUD
Inability to maintain consistent
employment
Inability to succeed in traditional
office-based services
High use of IP hospitalizations
At risk of requiring more restrictive living
situation without intensive community
services
Primary diagnosis of personality disorder,
SUD, or mental retardation
Coordination of care with other providers, ex
PCP, specialists, IP, AOT, community support
Results of initial comprehensive assessment
or assessment updated every 6 months
Adjustment of treatment plan goals due to
lack of progress toward initial goals
Other:
Current risk or recent history of
criminal justice involvement
Demonstrated progress toward
treatment plan goals
Other:
Psychopharmacological
intervention initiated/evaluated
Risk Assessment (please check NO if not present- if checked, please provide additional information)
Yes
Yes
Yes
Yes
Yes
Yes
No
SUICIDAL RISK:
Ideation
Intent
Plan
Means
Attempt
Medication Name/Dosage/Frequency:
Yes
Yes
Yes
Yes
Yes
Yes
No
HOMICIDAL RISK:
Ideation
Intent
Plan
Means
Attempt
Yes
Yes
Yes
Yes
Yes
Yes
No
ABUSE RISK:
Verbal
Emotional
Physical
Sexual
Neglect
Not applicable:
1.
2.
3.
4.
Requested Codes and Amount Requested:
H0004 Individual/Group
Therapy- Units:
H0039- ACT
Units:
H2010- Med Monitoring
(Nurse) Units:
H2015- Community Support
Units:
H0032- Treatment Plan
Development, Review, or
Modification
Units:
H0034 Psychotropic
Medication Training
Units:
Other:
T1013- Oral Interpretation & Sign
Language- Units:
T1016 Case Management
Units:
T1502 Psychotropic Medication
Administration- Units:
Other:
Please specify 992 Code
Requested:
992_ _ + 90834
Visits:
Please specify 992 Code:
992_ _ + 90836
Visits:
Other:
90791 Initial Psychiatric Evaluation
90792 Initial Psychiatric Evaluation with Med
Management
99212 Medication Monitoring (MD)
Visits:
99213 Medication Monitoring (MD)
Visits:
99214 Medication Monitoring (MD)
Visits:
Please specify 992 Code:
992_ _+ 90838
Visits:
Other:
Printed: Clinician Name and Credential(s):_____________________________________________________
Clinician Signature and Date: _______________________________________________________________
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