PROVIDER MANUAL
2004
OUTPATIENT BEHAVIORAL HEALTH
REHABILITATIVE SERVICES
Updated 1/2004
Presented by
Oklahoma Foundation for Medical Quality Medicaid
Pre-Authorization Program
and the
Oklahoma Health Care Authority
OHCA and OFMQ recommend that all
staff receive a full copy of this new
material. Delays in prior authorizations
may occur if requests are submitted
without these changes incorporated.
Outpatient Behavioral Health Rehabilitative
Services Provider Manual
TABLE OF CONTENTS
OFMQ - OVERVIEW & OPERATIONS
PRIOR AUTHORIZATION OF BEHAVIORAL HEALTH SERVICES & REQUEST PROCESS
FORMS COMPLETION
PROVIDER ELIGIBILITY
RECIPIENT ELIGIBILITY
AUTHORIZATION NUMBERS
INTERNAL QUALITY CONTROL (IQC)
INTER-RATER RELIABILITY (IRR)
EDUCATIONAL OPPORTUNITIES
1
2-3
3
3
3
3
4
4
4
TYPES OF REQUESTS
Initial Request for Treatment
Extension Request
Modification of Current Authorization Request
Correction Request
Provider Change of Demographic Information Request
Provider Change of Demographic form
Status Request
4
4
5
5
5
6
7
TYPES OF RESPONSES
Important Notice
Important Notice Response
Modification Decision
Pending Eligibility Decision Notice
Pending Eligibility Decision Response
Eligibility Decision
Technical Denial
7
7
8
8
8
8
9
REFERRALS, RECONSIDERATIONS, & APPEALS PROCESS
Reconsideration Request
Reconsideration Decision
Referrals
Appeals To OHCA
OHCA LD-2 Provider/Physician Grievance Form
9
9
10
10
11
CLIENT CHANGES SERVICE PROVIDER FACILITIES
12
COLLABORATIONS BETWEEN PROVIDERS
Letter of Collaboration Form
12
13
CLIENT SERVICES REQUIRING NO PRIOR AUTHORIZATION
14
ARRAY OF SERVICES
15
MEDICAL NECESSITY CRITERIA
Adult Criteria
Level I
Level II
Level III
Level IV
16-19
16
17
18
19
Child Criteria
Criteria for Children 0-36 Months of Age
Level I
Level II
Level III
Level IV
Criteria for Children in RBMS
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Services Provider Manual
20-25
20
21
22
23
24
25
ICF/MR Criteria
26
Specialized Case Management Criteria
Adult
Psychological Evaluation Criteria
27
28
"Exceptional Case" Criteria
29
CLIENT ASSESSMENT RECORD
Introduction to The CAR
General Definitions
Level of Functioning Scales
Domains
1. Feeling/Mood/Affect
2. Thinking/Mental Process
3. Substance Abuse
4. Medical/Physical
5. Family
6. Interpersonal
7. Role Performance
8. Socio-Legal
9. Self Care/Basic Needs
CAR- Points to Remember
Activities of Daily Living Skills Check List
Emotional Indicators Behavior Check List
Criteria Reference Form
Mental Health Service Plan (MHSP) Definitions
SAMPLE MHSP PROB., GOALS, OBJ. & INTER.
SAMPLE MHSP SUMMARY
REQUEST CHECKLIST
HELPFUL REFERENCES
COMMON ACRONYMS
INSTRUCTIONS FOR COMPLETING REQUEST FORMS
RELALATIVE VALUE UNIT (RVU)
TERMINOLOGY CHANGES
STATUS REQUEST FORM
OUTPATIENT REQUEST PACKET
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Services Provider Manual
30
31-32
33
34
35
36
37
38
39
40
41
42
43-45
46
47
48
49
50-52
53
53-55
56
67
58-60
61
62
63
(Last eleven pages)
Revised - 1/2004 - 1
Outpatient Behavioral Health Rehabilitation Services
Pre-Authorization Program
Oklahoma Foundation for Medical Quality
OVERVIEW
In an effort to promote effective and efficient health care for Oklahoma fee-for-service Medicaid recipients receiving
behavioral health rehabilitative services, the Oklahoma Health Care Authority (OHCA) has contracted with the
Oklahoma Foundation for Medical Quality (OFMQ) to conduct prior authorization (PA) of Outpatient Behavioral
Health Rehabilitative Services. This program was implemented on December 2, 1996, for Outpatient Behavioral
Health Rehabilitative Services. Medicaid recipients enrolled in the SoonerCare Choice Primary Care Physician Case
Manager (PCPCM) program and traditional Fee-for-Service Medicaid must be prior authorized for these services by
OFMQ. The PCPCM does not have responsibility for referring, approving or gatekeeping these or any other
behavioral health services. This is the seventh edition of the Provider Manual and will be effective on January 1,
2004.
OPERATIONS
PA requests will be electronically reviewed via fax or mail. OFMQ office hours are from 8:00 a.m. to 5:00 p.m.
Monday through Friday, except holidays. Requests must be sent in on official OFMQ forms and should be typed or
neatly printed. Requests received before 3:00 p.m. will be dated that business day. Requests received after 3:00
p.m.or on a weekend day or holiday, will be dated the next scheduled business day. All new requests that have
complete documentation will be reviewed and responded to via fax or mail within 3 business days. Incomplete
and/or inappropriate requests will be returned to the provider for the needed corrections. All providers are
responsible for keeping records of the dates they successfully fax requests and responses to OFMQ. Providers are
encouraged to submit a status request on the third business day after submitting a request or response to OFMQ if
OFMQ has not already responded to the fax. All requests may be faxed to OFMQ at (405) 858-9098 or mailed to:
Oklahoma Foundation for Medical Quality, Inc.
14000 Quail Springs Parkway, Suite 400
Oklahoma City, Oklahoma 73134-2600
http://www.ofmq.com
The OFMQ E-mail address is providermail@ofmq.com. Please utilize this for inquiries, concerns, or comments
only. Do not send requests by E-mail. Please access the OFMQ web page, http://www.ofmq.com, for more
information about OFMQ. Providers may also call OFMQ at (405) 858-9090, for assistance in completing the
request forms, or any other questions regarding the PA process.
Forms and manuals are available on-line at
http://WWW.OFMQ.COM/html/publications.html
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PRIOR AUTHORIZATION OF BEHAVIORAL HEALTH SERVICES
All recipients are eligible to receive a Mental Health Assessment one time per client per provider when services are
first initiated. A Mental Health Service Plan Development of moderate complexity may also be provided without
prior authorization. OFMQ will conduct prior authorization of clients to receive Outpatient Behavioral Health
Rehabilitative Services beyond this one time Mental Health Assessment when the client is first admitted to a
program. The process to continue services beyond this initial assessment is explained in the following detailed
methodology for PAs.
All facilities must follow these PA guidelines for assessing Medicaid clients for the appropriate types and frequency
of outpatient services. Community Mental Health Centers (CMHCs), as identified by the Oklahoma Department of
Mental Health and Substance Abuse Services (DMHSAS), are not required to seek prior authorization from OFMQ,
but must carry out an internal process of assessment and assignment of clients to the appropriate level of care as
described herein. The CMHCs will be retrospectively reviewed by OFMQ.
OFMQ creates Prior Authorization numbers in the Electronic Data System (EDS). The specific services that are
authorized are entered individual. The PA is created using the provider number and the client’s recipient number.
During the data entry process services may be broken down into individual months of service or grouped into threemonth increments of service. The frequency by which the provider provides these services must not deviate
significantly from the treatment plan that was reviewed by OFMQ during the prior authorization process.
OFMQ frequently authorizes multiple treatment services over specific time frames. These services must be
identified and described in the provider's treatment plan. An example would be individual psychotherapy, family
psychotherapy, and group psychotherapy, one hour per week, over a three-month time frame. It is not acceptable to
bunch these services all in one day. While this practice may be convenient for the provider, therapeutic services are
designed to be spread over time and should not be overwhelming to the client due to the duration of multiple
sessions. Services should always be age and developmentally appropriate. OFMQ does recognize that some
programs are designed to offer multiple services in one day; these programs need to identify their intent to provide
multiple services in short periods of time on the preauthorization request. OHCA SURS Unit and OFMQ’s RetroReview Program will review these types of billing practices.
Billing questions (e.g., denied claims) should be directed to OHCA Customer Services at 1-800-522-0310. Prior
authorization questions should be directed to OFMQ at 405-858-9090.
It is the intent of OHCA that OFMQ will not retroactively authorize any Outpatient Behavioral Health Rehabilitative
Services. Requests older than 30 days will be technically denied. However, providers are not penalized for the
number of days it takes OFMQ to work responses; these are added into the authorization.
The requirements for prior authorization of services provided under the Medicaid services entitled “Outpatient
Behavioral Health Services" and "Targeted Case Management Services” apply to all Medicaid recipients assessed
for these services.
REQUEST PROCESS
Facilities will be required to request prior authorization of extended Outpatient Behavioral Health Rehabilitative
Services for clients they determine are in need of such services to maintain or improve their functioning within the
community at the level most appropriate for that particular client. "All services are to be for the goal of
improvement of functioning, independence, or well being of the client. The client must be able to actively
participate in the treatment. Active participation means that the client must have sufficient cognitive abilities,
communication skills, and short-term memory to derive a reasonable benefit from the treatment". (Part 21.317:30-5241)
It is necessary for the facility to request prior authorization no less than five (5) calendar days and no more than
fifteen (15) calendar days in advance of the expiration of the current authorization period to alleviate the possibility
of days occurring which have not been authorized. If the facility waits until the day before or the last day of the
current authorization period, there may be instances when non-covered days occur.
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FORMS COMPLETION
A member of the treatment team must complete the PA Request Packet. The Responsible MHP is responsible for the
accuracy and the appropriateness of the request. The request packet and any necessary supportive documentation
may be faxed, mailed, or hand delivered to the OFMQ Pre-Authorization Unit (see pg. 1 for fax number and mailing
address). All PA request packet forms must be dated within 30 days of receipt by OFMQ.
Since PA numbers are facility/site specific, all services and the corresponding facility/site must be identified in the
request packet. If more than one facility/site is responsible for providing services to a Medicaid recipient,
collaboration among facilities is necessary (See collaborations).
OFMQ has made every effort to develop PA request packet forms, including the Addendum, that comply with
JCAHO, CARF, AOA, COA, and DMHSAS standards, to assist providers in streamlining their paperwork and
avoiding duplication.
PROVIDER ELIGIBILITY
Each site must be clearly affiliated with and under the direct supervision and control of the contracting facility. Each
site operated by an outpatient mental health facility must have a separate provider number. Failure to obtain and
utilize site-specific provider numbers will result in disallowance of services.
NEWLY CERTIFIED FACILITIES/SITES: Immediately submit information (mailing address, telephone and fax
numbers) to the Outpatient Supervisor at OFMQ (See Provider Change of Demographic Information Request).
Facilities need to submit requests as soon as possible in order to prevent loss of days. Complete requests will receive
a “Pending Eligibility” decision which will suffice until the facility acquires the new provider number. When the
new provider number has been acquired, notify OFMQ immediately, by fax or mail, so that the authorization may be
completed. OFMQ will then send the facility a PA number.
RECIPIENT ELIGIBILITY
OFMQ will determine recipient eligibility by accessing the EDS eligibility file. If the EDS file shows eligibility for
the recipient to be pending, the request will be reviewed based on the information provided in the request packet and
a decision for authorizing services will be made. The decision will be pending eligibility. If EDS indicates a recipient
has Qualified Medical Benefits (QMB) only, the request will be reviewed based on the information provided in the
request packet and a decision “Pending Eligibility” will be issued. A PA number will not be assigned when the
recipient's eligibility status is pending. The PA will date back to when the request was received by OFMQ, subject
to the eligibility dates contained in the EDS system (e.g., PA request received 02/14/04 and eligibility determined
from 03/01/04, no services will be prior authorized before 03/01/04). The facility is responsible for checking the
OHCA Recipient Eligibility Verification System (REVS) at 1-800-522-0310, and notifying OFMQ when the
recipient becomes eligible. For instructions on using REVS, call 1-800-767-3949.
AUTHORIZATION NUMBERS
OFMQ will assign a recipient and provider site-specific PA number to each approved PA request. This recipient and
provider site-specific PA number will be entered in the EDS system via direct on-line entry. Each PA number will be
associated with from/through dates by service and month to indicate the length of service being authorized by
OFMQ. Once the facility has received an approval notice from OFMQ with the PA number identified, the facility
must utilize the EDS MS-MA-5 form when filing a claim for the stated services covered. (Submit the PA number on
the HCFA-1500 in Item 23.) Facilities must follow the OHCA Provider Manual for submitting claims requiring PA
numbers, as specific procedure codes are to be utilized when filing claims for Outpatient Behavioral Health
Rehabilitative Services.
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INTERNAL QUALITY CONTROL (IQC)
OFMQ has internal quality control measures for both the Review Coordinators and Clinical Consultants. OFMQ will
sample a specified number of cases monthly. The PA Program Manager, Supervisor, Quality Improvement
Coordinator or Consultant will review each case for the appropriateness of the decision. If inappropriate decisions
are found, the Program Manager, Supervisor, Quality Improvement Coordinator or Consultant will educate the RC or
Consultant regarding the clinical area of concern. A Corrective Action Plan specific to the identified problem may
also be developed.
INTER-RATER RELIABILITY (IRR)
OFMQ has an inter-rater reliability process to develop and maintain consistency among the review coordinators.
Cases are randomly selected and reviewed according to OHCA guidelines. All review coordinators participate in the
IRR process on a monthly basis. The results are reviewed and analyzed for consistency; and discrepancies are
addressed collectively.
OFMQ’s Medicaid Pre-authorization Program staff consists of Master’s level clinicians with Oklahoma licensure
(LPC, LMFT, LSW/C, LBP) and/or registered nurses (RN’s) with a minimum of 3 years psychiatric experience.
EDUCATIONAL OPPORTUNITIES
OFMQ offers free monthly meetings at the OFMQ offices on the 2nd Wednesday of each month to educate providers
about the PA process. If a facility appears to be having specific problems with the PA process, OFMQ may initiate
contact - or the facility may contact OFMQ - and arrange for designated staff to attend an educational session.
OHCA will also be available (based on an agreeable date) to attend a requested educational session with OFMQ and
a facility. If a large group of providers want to meet with OFMQ and/or OHCA, arrangements may be made to
satisfy that request.
TYPES OF REQUESTS
INITIAL REQUEST FOR TREATMENT
An initial request is required when a client has not received outpatient behavioral health services in the fee-forservice system within the last six (6) months. OFMQ processes these requests within 3 business days.
Forms to Submit: The fax cover marked “Initial Request” and the entire request packet.
EXTENSION REQUEST
The client has been receiving outpatient behavioral health services in the fee-for-service system within the last six (6)
months, whether your or another facility has been providing the services. If the client changes levels of care to or
from a specialized level such as RBMS or ICF-MR during an authorization period, a new extension request and
treatment plan must be submitted to begin the new level of care. If the client has an inpatient behavioral health
admission during an authorization period, a new extension request is required when the client returns to outpatient
services. The treatment history section will need to be updated with the location and the service dates of the inpatient
admission. Reason(s) for the hospitalization should also be clearly documented. OFMQ processes these requests
within 3 business days.
Extension requests are also needed if a client transfers between agency locations with a different provider number or
transfers to another agency with a counselor who changes employment.
Forms to Submit: The fax cover marked “Extension Request” and the entire request packet.
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MODIFICATION OF CURRENT AUTHORIZATION REQUEST
The client would be better suited with a different array or additional units of services than previously authorized.
The Modification Request must be within the current PA period. Any changes that are approved will begin the date a
complete modification request is received at OFMQ. Services cannot be modified retroactively. The time period of
an authorization will not be modified. The number of Modification Requests submitted within an authorization
period should not exceed one per month. If the Modification Request is denied, a Reconsideration Request may be
submitted. (See Reconsideration Request)
The start date of the modified authorization will be the date the Modification Request is received by OFMQ. The
end date of the Modification Request will remain the same as the current authorization. Exception: Psychological
Evaluation requests are dated through December 31, of the current calendar year. OFMQ processes these requests
within 3 business days.
A Modification Request is not needed if a facility has decided not to utilize all of the services approved within an
authorization period (based upon the client’s need). However, if a separate facility wants to provide other needed
Outpatient Behavioral Health Services to the client, then it is expected that the two facilities will collaborate on the
use of the available RVU’s.
Forms to Submit: The fax cover marked “Modification Request”, and either an entire new request packet OR
the last request packet with updated information (CAR Assessment must be current within the last 30 days), initialed
and dated, that provides additional supportive documentation and reasons for the requested modification.
CORRECTION REQUEST
A Correction Request must be submitted when a provider finds any errors on a PA or discrepancies between the
OFMQ response and the EDS MS-MA 5 (i.e., typographical error, wrong provider number, wrong procedure code,
wrong Recipient ID number, etc.) regardless of who made the error. OFMQ processes these requests within three (3)
business days.
Forms to Submit: The fax cover marked “Correction Request”. Complete the entire fax cover including the PA
number that needs to be corrected. The Comments section should specify the type of correction being requested.
You may attach additional documentation such as the EDS MS-MA-5 or the OFMQ response that needs to be
corrected.
PROVIDER CHANGE OF DEMOGRAPHIC INFORMATION REQUEST
If there is a change in provider’s demographic information (e.g., name, address, phone and/or fax numbers, Provider
ID number(s), etc) a Provider Change of Demographic Information Request must be submitted.
Forms to Submit: Fax cover marked “Provider Change of Demographic Information”. List all changes on the
form provided.
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CHANGE OF INFORMATION
Please fill out any of the following information that has changed.
Name of Facility:___________________________
Provider Number:___________________________
Old Address:_______________________________
New Address:_______________________________
Old Fax Number:____________________________
New Fax Number:____________________________
Old Phone Number:___________________________
New Phone Number:__________________________
Additional
Information:_________________________________________
____________________________________________________
____________________________________________________
______________________________
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Revised - 1/2004 - 7
STATUS REQUEST
If a facility has not received a response from OFMQ on an Initial, Extension, or Modification Request, or on an
Important Notice Response within three (3) business days, a Status Request should be submitted. A Status Request
is the only way the provider can support a statement that the request was faxed to OFMQ three (3) business days
earlier, and hold the provider’s start date if the request is not on file at OFMQ.
Response to Status Requests:
1) If a facility receives a response reflecting that the Initial, Extension, or Modification Request, or
Important Notice Response was not received by OFMQ, the provider has 2 business days (from
the date the Status Request Response was faxed from OFMQ to the provider) to re-fax the
request/response. If the Initial, Extension, or Modification Request or Important Notice
Response is not re-faxed/re-submitted within 2 business days, the original fax date (as supported
by the Status Request) will not be held. If an Initial, Extension, or Modification Request or
Important Notice Response is faxed after the 2 business days allowed, the start date of services
assigned is the date the fax is received at OFMQ.
2) If a facility receives a response reflecting that the Initial, Extension, or Modification Request has
been processed and an Important Notice Decision was issued requesting additional
documentation and/or information, the provider has ten (10) calendar days (from the date the
Status Request Response was faxed from OFMQ to the provider) to fax/submit the required
Important Notice Response. If the Important Notice Response is not faxed within the allowed ten
(10) calendar days, a Technical Denial decision will be issued (i.e., due to no response within
time frame allowed).
Forms to Submit: The one page Status Request form. (See Request Forms) Complete the entire Status Request
form, marking the type of request for which the status is being requested. Fax transmittal forms are no longer
necessary, nor will they be accepted in lieu of a Status Request.
TYPES OF RESPONSES
IMPORTANT NOTICE
An OFMQ RC will assess each request for overall completeness of the required elements and all necessary
supporting documentation. If the request form and/or the supporting documentation is incomplete, or the RC needs
additional information to determine the medical necessity of the requested services, the facility responsible for the
request will receive a fax titled “Important Notice” stating what additional information is needed to process the
request. The facility has ten (10) calendar days from the date the Important Notice was faxed in which to respond. If
there is no response within the required 10 days, the request will be technically denied.
Note: All requests with an Important Notice generated will be dated from the date of receipt of requested
information, not the date of the original fax. In addition, please note that all requested information must be
addressed to avoid a Technical Denial.
IMPORTANT NOTICE RESPONSE
An Important Notice Response is required from a provider when responding to an OFMQ Important Notice decision.
Forms to Submit: OFMQ’s fax cover marked “Important Notice Response” and ALL requested information that
was listed in the Important Notice comments section. Send it “Attention” to the RC who signed those comments.
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MODIFICATION DECISION
An OFMQ RC will assess each request for overall completeness and clinical appropriateness. Based on the
information provided a reviewer may modify a provider’s request by reducing the total units/RVU’s requested for an
authorization period. Modifications are made based on the most appropriate array and frequency of services for each
request, utilizing the guidelines established in the Outpatient Manual including the Part 21 Administrative Code.
Some of the types of Modifications that a Provider might receive are as follows:



A gradual reduction of a particular service across an authorization period (i.e., approval of the 12 sessions
requested for the first month, with a decrease to 10 sessions the second month, and then 8 sessions the third
month).
A set reduction of a service for the entire authorization period (i.e., requested 12 sessions, but modified to 8
sessions for each month of the authorization period).
A denial of one requested treatment service, but Approval or Modification of another requested treatment
service (i.e., requested 20 sessions of Psychosocial Rehabilitation, & 8 sessions of Individual
Psychotherapy- Modified to authorize of 20 sessions of Psychosocial Rehabilitation only; Individual
Psychotherapy denied).
PENDING ELIGIBILITY DECISION
An OFMQ RC will determine recipient eligibility by accessing the EDS eligibility file. If the EDS file shows
eligibility for the recipient to be pending or having Qualified Medical Benefits (QMB) only, the request will be
reviewed based on the information provided in the request packet and a decision of either Pending EligibilityApproved or Pending Eligibility- Modified will be issued. A PA number will not be assigned when the recipient’s
eligibility status is pending. The PA will date back to when the request was received by OFMQ, subject to the
eligibility dates contained in the EDS system (e.g., PA request received 02/14/04 and eligibility determined from
03/01/04, no services will be prior authorized before 03/01/04).
A Pending Eligibility Decision will also be used in situations where a provider submits a request for services prior to
receiving their Medicaid provider identification number.
PENDING ELIGIBILITY DECISION RESPONSE
A Pending Eligibility Response is required from a provider when responding to an OFMQ Pending Eligibility
decision notice.
Forms to Submit: The fax cover marked “Pending Eligibility Response” and requested information regarding
client’s eligibility. The Pending Eligibility Response notifies OFMQ that the client is eligible for services, and
requests a PA number for the services that have been authorized.
ELIGIBLE DECISION
An Eligible Decision is OFMQ’s notification to the Provider that a client’s eligibility has been verified in EDS and
that a PA number has been generated for services that had been approved pending eligibility.
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TECHNICAL DENIAL DECISION
An RC will issue a Technical Denial decision when a request does not meet the guidelines set forth in this manual,
including the Part 21 Administrative Code established by OHCA for outpatient behavioral health services. An RC
may also issue a Technical Denial when a provider fails to show that a client meets the Medical Necessity Criteria
for the services they are requesting. An RC can issue a Technical Denial in response to Initial, Extension, and
Modification Requests, as well as in response to an Important Notice Response.
RECONSIDERATIONS, REFERRALS, AND APPEALS PROCESS
RECONSIDERATION REQUEST
If a request has been denied or if the units of service requested have been modified for any requested outpatient
behavioral health service, a PA decision may be appealed by the provider or the client (or parent/guardian) if filed,
by fax or mail, within five (5) business days of receipt of the decision. This is considered a reconsideration request.
Note: This does not apply when you have received an approval for only part of the requested authorization period.
For example, your request for three (3) months was modified to a one (1) month authorization. In those cases, you
must resubmit a whole new request packet as instructed by the RC.
An Important Notice decision cannot be appealed for reconsideration. The provider must first submit an Important
Notice Response and/or receive a Technical Denial or Modification of services from OFMQ on the request. The
provider must show an attempt to respond fully and completely to the RC's request for additional information before
a request for reconsideration is made.
A Technical Denial due to not providing requested documentation within the 10 calendar days allowed cannot be
reconsidered unless your appeal is based upon a Status Request documenting you have faxed forms that OFMQ
states they did not receive. Providers must submit a new request if they failed to submit an Important Notice
Response within the 10 calendar days.
A reconsideration decision may be appealed to OHCA through its standard grievance process. Prior to submitting an
appeal to OHCA, the provider must first utilize the reconsideration process at OFMQ, which is the first level of the
appeal process.
Forms to Submit: Fax cover marked “Reconsideration Request”. Complete response to any requests for
information by the previous RC, specific reasons for requesting a reconsideration and any new, additional supporting
documentation.
RECONSIDERATION DECISIONS
The start date (when the original request was faxed) will be held only if the decision to overturn a Review
Coordinator’s decision is based on information already submitted with the original request. This also includes
information submitted with an Important Notice Response.
If the reason to overturn the Review Coordinator’s decision is based on any new information submitted with the
Reconsideration Request, the start date for services approved through the reconsideration process will be the date the
Reconsideration Request was received.
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REFERRAL TO A CONSULTANT
If the RC is unable to determine the medical necessity of a request based upon the criteria, the case will be referred
to a Clinical Consultant (Board Certified Licensed Psychiatrist, Licensed Clinical Psychologist, or Licensed
Psychopharmacologist). OFMQ will provide notification back to the provider within 5 business days of receiving
the completed request concerning the outcome of the REFERRAL. The referral decision may be an approval of the
original request, a modification of the requested services, or a denial of services. When a consultant requires more
information, the RC will fax the consultant’s request for additional information to the provider. The provider has ten
(10) calendar days to submit the needed information to OFMQ. The start date for services will be the date the request
was submitted to OFMQ or the date the Important Notice Response was received if the RC issued an Important
Notice decision prior to sending the request to a consultant.
RECONSIDERATION OF A REFERRAL
If the Clinical Consultant’s decision resulted in a modification or denial of the original requested services/RVU’s,
the facility does have the opportunity to request a reconsideration of the initial determination. A referral decision
may be appealed by the provider or the client (or parent/guardian) if filed, by fax or mail, within five (5) business
days of receipt of the decision. The request for reconsideration must include rationale as to the disagreement with
the consultant’s decision or new information that was not included when the initial determination was made by the
consultant. A second clinical consultant who was not involved with the original decision will review the information
submitted in the initial request along with the information submitted with the reconsideration request. The facility
will receive a faxed notification of the reconsideration decision from OFMQ within five (5) business days. A
reconsideration decision may then be appealed to OHCA through its standard grievance process.
APPEALS PROCESS
If the facility or the recipient (or parent/guardian of a minor) wishes to appeal the OFMQ determination after a
reconsideration review, a hearing with OHCA may be requested. This request must be filed within twenty (20) days
of receipt of the reconsideration decision. Contact the Docket Clerk, OHCA,
(405) 522-7217. Providers will be further instructed on filing appeals through the Oklahoma Health Care Authority
and the appropriate forms necessary for completion. An OHCA LD-2 Form for Provider/Physician Grievances is
provided in this manual.
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OKLAHOMA HEALTH CARE AUTHORITY (OHCA)
PROVIDER/PHYSICIAN GRIEVANCE FORM
In order to process your grievance request, all of the requested information must be supplied. Failure to provide
all of the information will result in a slower response from the OHCA.
Provider Information:
Company Name (if any):
Provider ID#: _____________________
Individual Name (if any):
Federal Tax ID#: __________________
Mailing Address:
Number
Street
_________________________________________________________________________________
State
Zip Code
Phone Number: (
City
) _____________________
Date of Adverse Action: ____________________
Authorized Representative Information (if any): ___________________________________________
Name: ____________________________________________________
Mailing Address: __________________________________________________________________
Number
Street
_________________________________________________________________________________
State
Zip Code
Phone Number: (
City
)______________________
Please give a complete narrative explanation of the problem you have encountered. Include the names of
OHCA personnel you have dealt with, and the dates that specific events occurred. Use additional paper if
necessary. Attach copies of any documents you would like to be considered. If your appeal involves a recipient
denial, please include the pertinent case number.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________
PLEASE SEND THIS FORM TO:
OKLAHOMA HEALTH CARE AUTHORITY
GRIEVANCE DOCKET CLERK
LEGAL DIVISION
P.O. DRAWER 18497
OKLAHOMA CITY, OKLAHOMA
73154-0497
OHCA Fax Number: (405) 522-7471
OHCA Docket Clerk Telephone Number: (405) 522-7217
Outpatient Behavioral Health Rehabilitative
Services Provider Manual
Revised - 1/2004 - 12
CLIENT CHANGES SERVICE PROVIDER FACILITIES
There are several instances when a client may change service provider facilities. A client may choose to discontinue
receiving behavioral health services from one facility and receive those services from another facility. When this
occurs, the latter facility submits a complete PA request and a letter of termination signed and dated by the client
and/or legal guardian that indicate his/her desire to change behavioral health service providers. The letter needs to
have a requested start date for the new provider; however, services cannot be started prior to receiving the request
from the new provider. If a facility submits a PA request for a client who has a current authorization with another
facility, an Important Notice will be sent to the facility requesting a termination letter. The current PA will be enddated and a new PA will be issued.
A client may choose to transfer to another site/location with the same agency, because of a clinician transfer,
convenience of location, or some other reason. Each site operated by an outpatient mental health facility must have a
site-specific provider identification number. **Authorizations are client and site-specific. Therefore, the site the
client transfers to, submits a complete PA request and a termination letter signed and dated by the client and/or legal
guardian that indicates his/her desire to change provider sites, including an effective date. Since this is an intraagency transfer, the Extension Request documentation must reflect the client’s progress and any changes in the
client’s treatment plan. The current PA will be end-dated and a new PA will be issued.
From time to time, facilities will close a site and transfer clients to another site or clients may choose to move to
another facility with their clinician. Again, authorizations are client and site-specific. Therefore, the site the client
transfers to, submits a complete PA request and a letter of termination signed and dated by the client and/or legal
guardian that indicates his/her desire to change provider sites, including an effective date. Since this is another form
of intra-agency transfer, the Extension Request documentation must be modified to reflect the client’s progress and
any changes in the client’s treatment plan. The current PA will be end-dated and a new PA will be issued.
Forms to Submit: The fax cover marked “Extension Request”, the entire request packet, AND the appropriate
letter of termination from the client. See the example below.
Letter of Termination
I, (client’s name), wish to discontinue receiving services with any other provider and begin receiving services from
(agency name) as of (MM/DD/YY).
____________________________________
(14 and over must sign)
Date
_______________________________________ Client
Legal Guardian
Date
COLLABORATION BETWEEN PROVIDERS ON CLIENT CARE
Many facilities are not able to provide a full array of services to clients in need and/or clients may not choose to
receive all of their services from one facility. It is expected that facilities will collaborate on behalf of the client’s
best interests and choice of facility.
When there are two agencies (or separate sites for the same agency having different provider identification numbers)
providing behavioral health services for a client, a letter of collaboration is required, regardless of the funding source
for those services (not just for facilities providing services under Medicaid). The letter of collaboration should be
signed and dated by the client and/or legal guardian indicating his/her desire for services to be provided by both
facilities. The letter must indicate which types of services and the frequency of the services each facility will provide.
When the two collaborating facilities are both facilities for which prior authorization of Medicaid service is required,
ideally, these facilities would send their requests in together so that they can be reviewed simultaneously. In most
cases, these requests will be sent/faxed in separately to OFMQ. The second facility to submit a request is
responsible for submitting a letter of collaboration.
The collaboration letter is not required when one of the agencies is only providing medication training and support
and the other agency is not providing these services.
Forms to Submit: Facilities are asked to utilize the OFMQ Letter of Collaboration Form in order to expedite
these requests for collaboration information.
Outpatient Behavioral Health Rehabilitative
Services Provider Manual
Revised - 1/2004 - 13
Letter of Collaboration Between
and
(Facility B)
(Facility A)
It is agreed that __________________________________and__________________________________
(Facility A)
(Facility B)
will collaborate on services provided to _____________________________________________________
(Client's Name)
Recipient ID # ___ ___ ___ ___ ___ ___ ___ ___ ___ , for the duration of the attached prior authorization request.
This collaboration occurs through two service plans (a Facility A service plan and a Facility B service plan)
developed collaboratively by the facilities' treatment teams. Each facility retains clinical control of and
responsibility for its portion of the treatment. The progress in treatment will be coordinated through inter-agency
staffing and consultations. The signatures of the respective clinicians below constitute agreement to collaborate.
_____________________________________
Facility B Clinician, Credentials
Date
Facility A Clinician, Credentials Date
As a client, I agree to this treatment approach.
____________________________________________________________________________
Client (14 or older)
Date
As the parent/guardian of
, I agree to this treatment approach.
_________________________________________________________________________ Parent/Guardian (and
Relationship to Client)
Date
The anticipated/estimated division of services is as follows:
Facility A
Facility B
Type of Service
Hours per week
Individual Psychotherapy
__________
__________
Family Psychotherapy
__________
__________
Group Psychotherapy
__________
__________
Individual Psychosocial Rehab
__________
__________
Group Psychosocial Rehab
___
__________
Case Management
___
__________
________________
_________
Hours per week
_________
Other (specify)
This is an estimate subject to negotiated change and is included here for reference purposes.
Outpatient Behavioral Health Rehabilitative
Services Provider Manual
Revised - 1/2004 - 14
CLIENT SERVICES REQUIRING NO PRIOR AUTHORIZATION
ALLOTTED PER CALENDAR YEAR
The following Basic Array and Additional/Optional Services for each Medicaid fee-for-service client require no
preauthorization. The annual (calendar year) maximum allotted is identified.
Crisis Intervention Services
8 units per month and
40 units per year
Mental Health Assessment
1 per client, per provider
Mental Health Service Plan
Development
1 per year
The client will receive a PA number on the MS-MA-5 form from EDS for Treatment Plan Review, and for services
exceeding the initial basic array for Individual and Family Counseling.
Medication Training and Support.
This service now requires prior authorization. In the past (prior to 2004) this service could be done once each month
without prior authorization. The current revision of this manual was initially published incorrectly with Medication
Training and Support not needing prior authorization if the service did not exceed once per month. Currently
providers must document medical necessity criteria to receive a PA number for Medication Training and Support.
Non-compensable Client Services for ICF/MR
+ Medication Training and Support
+ Mental Health Service Plan Development
+ Case Management Services
+ Psychosocial Rehabilitation (Individual and Group)
Non-compensable Services for Residential Behavioral Management Services
(Therapeutic Foster Care or Group Home)
+ Mental Health Service Plan Development
+ Case Management Services
+ Psychosocial Rehabilitation (Individual and Group)
Outpatient Behavioral Health Rehabilitative
Services Provider Manual
Revised - 1/2004 - 15
ARRAY OF SERVICES
The following array of services is available for both adults and children, levels I through IV. For the
ICF/MR, RBMS and 0-36months levels of care, some of these services are excluded. Exclusions are specifically
noted under the level of care criteria listed on the following pages.
Psychotherapy Services:
Individual
Interactive
Family
Group
20-30 minute session
45-50 minute session
75-80 minute session
20-30 minute session
45-50 minute session
75-80 minute session
60 minute session
60 minute session
1 unit = 0.92 RVU’s
1 unit = 1.76 RVU’s
1 unit = 2.86 RVU’s
1 unit = 0.96 RVU’s
1 unit = 1.85 RVU’s
1 unit = 3.00 RVU’s
1 unit = 2.30 RVU’s
1 unit = 1.10 RVU’s
Psychosocial Rehabilitation Services:
Children/Group
15 minute session
Adult/Group
15 minute session
Individual
15 minute session
1 unit = 0.17 RVU’s
1 unit = 0.13 RVU’s
1 unit = 0.45 RVU’s
Case Management
15 minute session
1 unit = 0.49 RVU’s
Mental Health Service Plan
Low Complexity
1 per authorization
1 unit = 2.50 RVU’s
Psychological Testing
60 minute units
1 unit = 2.17 RVU’s
Medication Training
and Support
Outpatient Behavioral Health Rehabilitative
Services Provider Manual
1 unit = 0.70 RVU’s
Revised - 1/2004 - 16
ADULT (21 years or older): LEVEL I CRITERIA
General Requirements
A. Treatment
1. Appropriate (Must meet ALL of the following conditions)
a) Experiencing slight to moderate functional impairment; AND
b) Able to actively participate in and derive a reasonable benefit from treatment as evidenced by
sufficient affective, adaptive and cognitive abilities, communication skills and short-term memory
2. Inappropriate
a) Imminent danger to self and/or others (medically unstable)
B. Assessment Results (Must meet ONE condition in BOTH 1 AND 2)
1. DSM-IV or DSM-IV-TR Diagnosis (a OR BOTH a AND b)
a) Axis I primary diagnosis (INCLUDING V and 900 codes, EXCLUDING Deferred Diagnosis, 799.9, &
Provisional Diagnosis)
b) Axis II personality disorders
2. CAR Scores (A minimum of ONE of the following)
a) 20 - 29 in 4 or more domains (domains 1 - 9); OR
b) 30 - 39 in 2 domains (domains 1 - 9); OR
c) 20 - 29 in 3 domains AND 30 - 39 in 1 domain or more (domains 1 - 9)
Regimen
A. Amount/Array of Services
1. 1 - 12 RVU’s per month, allotted based upon documentation and determined need
B. Length of Services
1. Initial
2. Extensions (based on continued need & improvement)
Outpatient Behavioral Health Rehabilitative
Services Provider Manual
= 6 month authorization
= 1 - 6 month authorization
Revised - 1/2004 - 17
ADULT (21 years or older): LEVEL II CRITERIA
General Requirements
A. Treatment
1. Appropriate (Must meet ALL of the following conditions)
a) Experiencing moderate impairments in functioning; AND
b) Able to actively participate in and derive a reasonable benefit from treatment as evidenced by
sufficient affective, adaptive and cognitive abilities, communication skills and short-term memory
2. Inappropriate
a) Imminent danger to self and/or others (medically unstable)
B. Assessment Results (Must meet ONE condition in BOTH 1 AND 2)
1. DSM-IV or DSM-IV-TR Diagnosis (a OR BOTH a AND b)
a) Axis I primary diagnosis (EXCLUDING V and 900 codes, Deferred Diagnosis, 799.9, & Provisional
Diagnosis)
b) Axis II personality disorders
2. CAR Scores (A minimum of ONE of the following)
a) 30 - 39 in 3 domains (domains 1 - 9); OR
b) 40 - 49 in 1 domain (domains 1 - 9)
Regimen
A. Amount/Array of Services
1. 1 - 20 RVU’s per month, allotted based upon documentation and determined need
B. Length of Services
1. Initial
2. Extensions (based on continued need & improvement)
Outpatient Behavioral Health Rehabilitative
Services Provider Manual
= 1 - 6 month authorization
= 1 - 3 month authorization
Revised - 1/2004 - 18
ADULT (21 years or older): LEVEL III CRITERIA
General Requirements
A. Treatment
1. Appropriate (Must meet ALL of the following condition)
Currently experiencing moderate to severe functional impairment; AND
a)With therapy, significant functional improvement is possible; AND
b)Able to actively participate in and derive a reasonable benefit from treatment as evidenced by
sufficient affective, adaptive, and cognitive abilities, communication skills, and short-term memory
2. Inappropriate
a) Imminent danger to self and/or others (medically unstable)
B. Assessment Results (Must meet ONE condition in BOTH 1 AND 2)
1. DSM-IV or DSM-IV-TR Diagnosis (a OR BOTH a AND b)
a) Axis I primary diagnosis (EXCLUDING V and 900 codes, Deferred Diagnosis, 799.9, & Provisional
Diagnosis)
b) Axis II personality disorders
2. CAR Scores (A minimum of ONE of the following)
a) 30 - 39 in 4 domains, with 2 domains being in 1, 6, 7, or 9; OR
b) 40 in 2 domains, with 1 domain being in 1, 6, 7, or 9; OR
c) 30 - 39 in 2 domains AND 40 in 1 domain,
with EITHER the 40 OR 2 of the 30's being in domains 1, 6, 7, or 9
Regimen
A. Amount/Array of Services
1. 1 - 42 RVU’s per month, allotted based upon documentation and determined need
B. Length of Services
1. Initial
2. Extensions (based on continued need & improvement)
= 1-3 month authorization
= 1-3 month authorization
EXTENDED CARE LEVEL (1-6 month authorization)
Must meet 1 - 3, documented in the request:
1) Diagnosis of Major Mood Disorder, Schizophrenia/Psychotic Disorder, and/or Personality disorder; AND
2) A minimum of 2 years with significant mental health impairment with current or other related diagnosis;
AND
3) Appears to be stabilized AND demonstrating progress in treatment.
4) OPTIONAL: Possible co-morbid conditions exacerbating mental health diagnosis (i.e., medical conditions,
substance abuse, mental retardation, etc.).
Outpatient Behavioral Health Rehabilitative
Services Provider Manual
Revised - 1/2004 - 19
ADULT (21 years or older): LEVEL IV CRITERIA
General Requirements
A. Treatment
1. Appropriate (Must meet ALL of the following conditions)
a) Currently experiencing very severe functional impairment; AND
b) Potential risk for hospitalization without intensive outpatient services; AND
c) Able to actively participate in and derive a reasonable benefit from treatment as evidenced by sufficient
affective, adaptive and cognitive abilities, communication skills, and short-term memory
2. Inappropriate
a) Imminent danger to self and/or others (medically unstable); AND/OR
b) Extreme level of functional impairment, meeting medical necessity criteria for inpatient hospitalization.
B. Assessment Results (Must meet ONE condition in BOTH 1 AND 2)
1. DSM-IV or DSM-IV-TR Diagnosis (a OR BOTH a AND b)
a) Axis I primary diagnosis (EXCLUDING V and 900 codes, Deferred Diagnosis, 799.9, & Provisional
Diagnoses)
b) Axis II personality disorders
2. CAR Scores
a) 40 in 4 domains, with 1 domain being in 1, 6, 7, or 9
Regimen
A. Amount/Array of Services
1. 1 - 62 RVU’s per month, allotted based upon documentation and determined need
B. Length of Services
1. Initial =
2. Extensions (based on continued need & improvement) =
1 - 3 month authorization
1 - 3 month authorization
EXTENDED CARE LEVEL (1-6 month authorization)
Must meet 1 - 3, documented in the request:
1) Diagnosis of Major Mood Disorder, Schizophrenia/Psychotic Disorder, and/or Personality disorder; AND
2) A minimum of 2 years with significant mental health impairment with current or other related diagnosis; AND
3) Appears to be stabilized AND demonstrating progress in treatment.
4) OPTIONAL: Possible co-morbid conditions exacerbating mental health diagnosis (i.e., medical conditions,
substance abuse, mental retardation, etc.).
Outpatient Behavioral Health Rehabilitative
Services Provider Manual
Revised - 1/2004 - 20
CHILD (0-36 MONTHS OF AGE): CRITERIA
All prior authorization decisions will be based upon the following criteria for children 0-36 months of age:
1. Therapist’s credentials must include degree and licensure:
a) Early Childhood Development, diagnosis, and treatment
b) Infant Mental Health, diagnosis, and treatment.
c) Clinical experience with this age group.
d) Under supervision with clinician with training/experience with this age group.
2. Treatment plan goals and objectives must be age and developmentally appropriate.
3. Developmental Level of the Client/Child, including a copy of how this was assessed.
(Sooner Start Form, statement from pediatrician, County Health Department, Clinical Assessment Summary)
The Developmental assessment is not required if the only service requested is family psychotherapy.
4. DSM-IV diagnosis for the Client/Child. Diagnosis is for the child, not the parent.
5. Presenting Problem(s) listed.
6. Individual Counseling is considered appropriate when:
a) The above conditions (#1-5) are met
b) For short-term assessment sessions
c) Clear evidence that the child can engage in symbolic play
7. CAR domains 1 - 9 must be completed and Caregiver Resources as noted on the Addendum page as part of
the client record
REGIMEN
A. Amount/array of services: 1 - 27 RVU’s/month
FOR CHILDREN 0-18 MONTHS of Age (IN ADDITION TO #1-6 above):
1. Developmentally APPROPRIATE therapeutic modalities, services, and/interventions must have a primary
focus on the attachment between the child and parental figure(s):
a) Family Psychotherapy
2. Developmentally INAPPROPRIATE therapeutic services:
a) Individual Psychotherapy
b) Group Psychotherapy
c) Psychosocial Rehabilitation (Individual or Group)
3. Mental Health Service Plan will be authorized one (1) per authorization period (2.50 RVU’s).
FOR CHILDREN 19-36 MONTHS of Age (IN ADDITION TO #1-6 above):
1. Developmentally APPROPRIATE therapeutic modalities, services, and/or interventions:
a) Family Psychotherapy
2. The following MAY be deemed developmentally APPROPRIATE in SOME cases:
a) Individual Psychotherapy (Limited - primarily used for observation for assessment purposes)
b) Psychosocial Rehabilitation (Individual) (FOR PARENTING SKILLS TRAINING ONLY)
3. Mental Health Service Plan will be authorized one (1) per authorization period (2.50 RVU’s).
B. Length of Services
1. Initial
2. Extensions (based on continued need & improvement)
Outpatient Behavioral Health Rehabilitative
Services Provider Manual
=1 - 3 month authorization
=1 - 3 month authorization
Revised - 1/2004 - 21
CHILD (under 21 years): LEVEL I CRITERIA
General Requirements
A. Treatment
1. Appropriate (Must meet ALL of the following conditions)
a) Experiencing slight to moderate functional impairment; AND
b) Able to actively participate in and derive a reasonable benefit from treatment as evidenced by sufficient
affective, adaptive and cognitive abilities, communication skills, and short-term memory
2. Inappropriate
a) Imminent danger to self and/or others (medically unstable)
B. Assessment Results (Must meet ONE condition in BOTH 1 AND 2)
1. DSM-IV or DSM-IV-TR Diagnosis (a OR BOTH a AND b)
a) Axis I primary diagnosis (INCLUDING V and 900 codes, EXCLUDING Deferred Diagnosis, 799.9, &
Provisional Diagnosis)
b) Axis II personality disorders, ONLY for 18 - 20 years of age
(If younger than 18, must include well documented psychiatric supporting evidence)
2. CAR Scores (A minimum of ONE of the following)
(CAR descriptors for domains 1 – 9 and must be appropriately documented. Caregiver Resources
be documented as noted on the Addendum as part of the client record.)
a) 20 - 29 in 4 domains (domains 1 - 9); OR
b) 30 - 39 in 2 domains (domains 1 - 9); OR
c) 20 - 29 in 3 domains (domains 1 - 9) AND 30 - 39 in 1 domain (domains 1 - 9)
Regimen
A. AMOUNT/ARRAY OF SERVICES
1. 1 - 18 RVU’s per month, allotted based upon documentation and determined need
B. Length of Services
1. Initial
2. Extensions (based on continued need & improvement)
Outpatient Behavioral Health Rehabilitative
Services Provider Manual
= 6 month authorization
= 1 - 6 month authorization
must
Revised - 1/2004 - 22
CHILD (under 21 years): LEVEL II CRITERIA
General Requirements
A. Treatment
1. Appropriate (Must meet ALL of the following conditions)
a) Experiencing moderate functional impairment; AND
b) Able to actively participate in and derive a reasonable benefit from treatment as evidenced by sufficient
affective, adaptive and cognitive abilities, communication skills, and short-term memory
2. Inappropriate
a) Imminent danger to self and/or others (medically unstable)
B. Assessment Results (Must meet ONE condition in BOTH 1 AND 2)
1. DSM-IV or DSM-IV-TR Diagnosis (a OR BOTH a AND b)
a) Axis I primary diagnosis (EXCLUDING V and 900 codes, Deferred Diagnosis, 799.9, & Provisional
Diagnosis)
b) Axis II personality disorders, ONLY for 18 - 20 years of age
(If younger than 18, must include well documented psychiatric supporting evidence)
2. CAR Scores (A minimum of ONE of the following)
(CAR descriptors for domains 1 – 9 and must be appropriately documented. Caregiver Resources
be documented as noted on the Addendum as part of the client record.)
a) 30 - 39 in 3 domains (domains 1 - 9); OR
b) 40 in 1 domain (domains 1 - 9)
Regimen
A. Amount/Array of Services
1. 1 - 27 RVU’s per month, allotted based upon documentation and determined need
B. Length of Services
1. Initial
2. Extensions (based on continued need & improvement)
Outpatient Behavioral Health Rehabilitative
Services Provider Manual
=1 - 6 month authorization
=1 - 3 month authorization
must
Revised - 1/2004 - 23
CHILD (under 21 years): LEVEL III CRITERIA
General Requirements
A. Treatment
1. Appropriate (Must meet ALL of the following conditions)
a) Experiencing moderate to severe functional impairment; AND
b) Able to actively participate in and derive a reasonable benefit from treatment as evidenced
by sufficient affective, adaptive and cognitive abilities, communication skills, and
short-term memory
2. Inappropriate
a) Imminent danger to self and/or others (medically unstable)
B. Assessment Results (Must meet ONE condition in BOTH 1 AND 2)
1. DSM-IV or DSM –IV-TR Diagnosis (a OR BOTH a AND b)
a) Axis I primary diagnosis (EXCLUDING V and 900 codes, Deferred diagnosis, 799.9, & Provisional
Diagnosis)
b) Axis II personality disorders, ONLY for 18 - 20 years of age
(If younger than 18, must include well documented psychiatric supporting evidence)
2. CAR Scores (A minimum of ONE of the following)
(CAR descriptors for domains 1 – 9 must be appropriately documented. Caregiver Resources
must be documented as noted on the Addendum as part of the client record.)
a) 30 - 39 in 4 domains, with 2 domains being in 1, 6, 7, or 9; OR
b) 40 in 2 domains, with 1 domain being in 1, 6, 7, or 9; OR
c) 30 - 39 in 2 domains AND 40 in 1 domain, with the 40 or 2 -30's being in 1, 6, 7, or 9
Regimen
A. Amount/Array of Services
1. 1 - 44 RVU’s per month, allotted based upon documentation and determined need
period (2.50 RVU’s).
B. Length of Services
1. Initial
2. Extensions (based on continued need & improvement)
Outpatient Behavioral Health Rehabilitative
Services Provider Manual
=1 - 3 month authorization
=1 - 3 month authorization
Revised - 1/2004 - 24
CHILD (under 21 years): LEVEL IV CRITERIA
General Requirements
A. Treatment
1. Appropriate (Must meet ALL of the following conditions)
a) Experiencing severe functional impairment;
b) Potential risk for hospitalization without intensive outpatient services; AND
c) Able to actively participate in and derive a reasonable benefit from treatment as evidenced
by sufficient affective, adaptive and cognitive abilities, communication skills, and short-term memory
2. Inappropriate
a) Imminent danger to self and/or others (medically unstable); AND/OR
b) Extreme level of functional impairment, meeting medical necessity criteria for inpatient hospitalization.
B. Assessment Results (Must meet ONE condition in BOTH 1 AND 2)
1. DSM-IV or DSM-IV-TR Diagnosis (a OR BOTH a AND b)
a) Axis I primary diagnosis (EXCLUDING V and 900 codes, Deferred Diagnosis, 799.9, & Provisional
Diagnosis)
b) Axis II personality disorders, ONLY for 18 - 20 years of age
(If younger than 18, must include well documented psychiatric supporting evidence)
2. CAR Scores
(CAR descriptors for domains 1 – 9 must be appropriately documented. Caregiver Resources
must be documented as noted on the Addendum as part of the client record.)
a) 40 in 3 domains, with 1 domain being in 1, 6, 7, or 9
Regimen
A. Amount/Array of Services
1 - 62 RVU’s per month, allotted based upon documentation and determined need
B. Length of Services
1. Initial
2. Extensions (based on continued need & improvement)
Outpatient Behavioral Health Rehabilitative
Services Provider Manual
=1 - 3 month authorization
=1 - 3 month authorization
Revised - 1/2004 - 25
CRITERIA FOR CHILDREN IN
RESIDENTIAL BEHAVIOR MANAGEMENT SERVICES (RBMS)
THERAPEUTIC FOSTER CARE (TFC) AND THERAPEUTIC GROUP HOMES (Levels C, D, D+, and E)
General Requirements
A. Treatment
1. Appropriate (Must meet ALL of the following conditions)
a) Experiencing severe functional impairment, illustrating the need for additional
treatment beyond the RBMS's required services; AND
b) Demonstrates the need for specialized treatment to augment the services provided by the RBMS; AND
c) Able to actively participate in and derive a reasonable benefit from treatment as
evidenced by sufficient affective, adaptive and cognitive abilities, communication skills,
and short-term memory
2) Inappropriate
a) Imminent danger to self and/or others (medically unstable); AND/OR
b) Extreme level of functional impairment, meeting medical necessity criteria for acute inpatient
hospitalization
B. Assessment Results (Must meet ONE condition in BOTH 1 AND 2
1. DSM-IV or DSM-IV-TR Diagnosis
a) Axis I primary diagnosis (EXCLUDING V and 900 codes, Deferred Diagnosis, 799.9, & Provisional
Diagnosis)
b) Axis II personality disorders, ONLY for 18 - 20 years of age
(If younger than 18, must include well documented psychiatric supporting evidence)
2. CAR Scores (A minimum of ONE of the following)
(CAR descriptors for domains 1 – 9 must be appropriately documented. Caregiver Resources
must be documented as noted on the Addendum as part of the client record.)
a) 30 - 39 in 4 domains, with 2 domains being in 1, 6, 7, or 9; OR
b) 40 in 2 domains, with 1 domain being in 1, 6, 7, or 9; OR
c) 30 - 39 in 2 domains AND 40 in 1 domain, with the 40 or 2 -30's being in 1, 6, 7, or 9
3. Submission of the RBMS individual treatment plan, with each request, reflecting the need for the
requested additional service and an explanation of the need for the specialized treatment or therapeutic
intervention employed by the therapist.
Regimen
A. Amount/Array of Services
1. 1 - 22 RVU’s per month, allotted based upon documentation and determined need
2. Services NOT allowed for fee-for-service Medicaid clients receiving RBMS
a) Case Management
b) Psychosocial Rehabilitation (Individual or Group)
c) Mental Health Service Plan Development
B. Length of Services
1. Initial
2. Extensions (based on continued need & improvement)
Outpatient Behavioral Health Rehabilitative
Services Provider Manual
= 1 - 3 month authorization
= 1 - 3 month authorization
Revised - 1/2004 - 26
ICF/MR CRITERIA
General Requirements
A. Treatment
1. Appropriate (Must meet ALL of the following conditions)
a) Functional improvement is a realistic expectation; AND
b) Potential risk for hospitalization without intensive outpatient services; AND
c) Able to actively participate in and derive a reasonable benefit from treatment as
evidenced by sufficient affective, adaptive and cognitive abilities, communication skills,
and short-term memory
2. Inappropriate
a) Imminent danger to self and/or others (medically unstable); AND/OR
b) Inability to actively participate in treatment
B. Assessment Results (Must meet ALL of the following conditions)
1. DSM-IV or DSM-IV-TR Diagnosis (BOTH a AND b)
a) Axis I primary diagnosis (EXCLUDING V and 900 codes, Deferred Diagnosis, 799.9, & Provisional
Diagnosis)
b) Axis II diagnosis, with documented IQ score
2. Submission of a letter from the ICF/MR facility indicating the DSM-IV or DSM-IV-TR multi-axial
diagnoses, specific behavioral concerns, reason for referral, and signed by an ICF/MR representative.
3. Submission of the Individual Habilitation Plan that reflects the client’s need for the requested behavioral
health services. The current annual plan is required including signature page and legible date of most
recent update/revision.
4. Major discrepancies between information obtained from the ICF-MR and provider’s documentation are to
be resolved by the provider. It must be clear the client can benefit from outpatient counseling services.
5. Submission of Psychological Testing documenting IQ Score, Vineland Adaptive Scale, and any additional
clinical assessment reports that support the requested services.
6. Communication domain at the end of the CAR must be completed; AND
7. For SEVERE or PROFOUND MR diagnosis, the approach(es) to treatment, such as behavior modification,
applied behavior analysis, or another widely accepted theoretical framework for treating clients with this
diagnosis, must be noted in the Addendum as part of the client record.
Regimen
A. Amount/Array of Services
1. 1 - 24 RVU’s per month, allotted based upon documentation and determined need.
2. Services NOT allowed for fee-for-service Medicaid clients in a 24-hr setting
a) Case Management
b) Psychosocial Rehabilitation (Individual or Group)
c) Medication Training and Support
B. Length of Services
1. Initial
2. Extensions (based on continued need and improvement)
= 1 - 3 month authorization
= 1 - 3 month authorization
EXTENDED CARE LEVEL (1-6 month authorization)
Must meet 1 - 3, documented in the request:
1) Diagnosis of Major Mood Disorder, Schizophrenia/Psychotic Disorder, and/or Personality disorder; AND
2) A minimum of 2 years with significant mental health impairment with current or other related diagnosis; AND
3) Appears to be stabilized AND demonstrating progress in treatment.
4) OPTIONAL: Possible co-morbid conditions exacerbating mental health diagnosis (i.e., medical conditions,
substance abuse, etc.).
Outpatient Behavioral Health Rehabilitative
Services Provider Manual
Revised - 1/2004 - 27
ADULT (21 years or older): SPECIALIZED CASE MANAGEMENT CRITERIA
General Requirements
A. Treatment
1. Appropriate (Must meet a AND c, OR b AND c of the following conditions)
a) Client is being discharged from an Inpatient hospital (psychiatric);
b) Client meets Levels 1 - 4 criteria;
c) Case Management (CM) will be provided to assist a client's gaining access to needed medical, social,
educational and other services essential to meeting basic human needs. The CM works with the client in
gaining access to appropriate community resources. The CM may provide advocacy, linkage, and/or
referral.
2. Inappropriate
a) Client is residing in a Nursing Home or ICF/MR; AND/OR
b) Physically escorting or transporting a client to scheduled appointment or staying with the client during
an appointment, monitoring financial goals, providing specific services (e.g., shopping or paying bills), or
delivering bus tickets, food stamps, money, etc. AND/OR
c) CM must not be used in lieu of psychotherapy or psychosocial rehabilitation services.
B. Assessment Results (MUST meet conditions in BOTH 1 AND 2)
1. DSM-IV or DSM-IV-TR Diagnosis
a) Axis I primary diagnosis (EXCLUDING V and 900 codes, Deferred diagnosis, 799.9, and provisional
diagnosis)
2. Submission of a mental health service plan that specifically addresses the goals of advocating,
linking, and referring the client in behaviorally measurable terms and time frames.
C. Submission Requirements
1. Adult Levels 1 - 4
a) Submitted as part of a complete prior authorization packet for other
outpatient behavioral health services.
2. Client discharging from Inpatient
a) Inpatient: discharge date, if applicable; AND
b) Mental health service plan signed by the client, parent/guardian, and Case Manager with history of CM
involvement supporting the need to follow through; AND when appropriate, discharge goals from the
inpatient stay and CM follow through; AND
submitted as part of a complete prior authorization packet, either as part of a request for
other behavioral health services or as a separate request.
Regimen
A. Amount/Array of Services (15 minutes/1 unit/1 RVU)
1. Inpatient discharge
a) Total maximum allotment for initial requests = 1 - 24 RVU's per month
b) No extensions
2. Levels 1 - 4
a) Total maximum allotment for initial requests = 1 - 12 RVU's per month
b) Total maximum allotment for extension requests = 1 - 8 RVU's per month
B. Length of Services
1. One (1) month authorization for clients who are discharging from Inpatient
a) Dates authorized will be 2 weeks before the discharge date and 2 weeks after.
2. 3 month authorization for Levels 1 - 4
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PSYCHOLOGICAL EVALUATION CRITERIA
General Requirements
A. Evaluation
1. Appropriate (Must meet ALL of the following conditions)
a) Client is experiencing difficulty in functioning with origins not clearly determined; AND
b) An evaluation has been recommended and/or requested by a psychiatrist, psychologist,
or a licensed mental health professional; AND
c) Results of evaluation will directly impact current treatment strategies.
2. Inappropriate
a) Evaluation results will not directly impact current treatment or discharge; AND/OR
b) Evaluation results will be utilized for academic placement/purposes only; AND/OR
c) Evaluation has been conducted by another provider (including private psychologists) within the current
calendar year.
B. Assessment Results
1. DSM-IV or DSM-IV-TR Diagnosis
a) Axis I primary diagnosis (INCLUDING V and 900 codes, Deferred, and provisional diagnosis).
C. Submission Requirements (must include ALL of the following information)
1. Entire prior authorization form; AND
2. Treatment plan must document:
a) What tests will be used?
b) How many hours will the testing require?
c) Who will be performing the tests, and what are their credentials?
d) What is the reason for the testing?
e) How will evaluation results specifically affect goals and objectives for the client?
Regimen
A. Amount/Array of Services
1. The MAXIMUM allotment is 6 hours/13.02 RVU’s per calendar year.
NOTE: A psychological technician is defined by the State Board of Examiners of Psychologists as being "under
the direct supervision of a licensed psychologist" (Title 59 O.S. 1991, Section 1353.6) and "the Rules of the Board
(Section 575:10-1-7) describe the hiring of a psychological technician, a dependent assistant to the psychologist."
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EXCEPTIONAL CASE CRITERIA
It is recognized that there may be cases in which the client’s condition is severe enough to require a higher
intensity of services than is allowed by the Medical Necessity Criteria in the Level(s) of Care. Providers may request
additional services beyond the maximum number of RVU’s allowed in the Level(s) of Care when cases would fit into
this category. These cases will be considered “Exceptional” and will not be maintained at this same level of intensity
each PA period. Requests for this level of service will be covered for a period of one (1) month. Prior authorization
will be required monthly.
This level of care is being allowed for exceptional cases in which the child or adult's condition requires more
RVU’s than is offered in the Level(s) of Care, but who are not in need of the level of services provided at the
Inpatient level of care.
The provider must submit a request to OFMQ using the standard PA Request Packet and specify that this is a
request for services beyond the Level(s) of Care. The services to be rendered must be identified specifically as well
as the number of RVU’s being requested. An RC will review the first request. Subsequent, additional requests for
exceptional case will be automatically referred to Clinical Consultants to evaluate the appropriateness of the
requested services for the clinical manifestations identified. Supporting documentation will be required to
substantiate the additional requested services above and beyond the Level(s) of Care.
Appropriate (Any/or all of the following)
a) Experiencing extreme functional impairment, but does not meet medical necessity criteria for inpatient
hospitalization;
b) Medically stable (i.e., not an imminent danger to self and/or others);
c) Stepping down from a higher level of care (Acute/RTC/Inpatient.);
d) Without intensive services, there is an escalation of symptoms (e.g., an increase in aggressive behavior or a
decreased ability to perform ADL’s, but is medically stable).
Inappropriate
a) Imminent danger to self and/or others (medically unstable); AND/OR
b) Extreme level of functional impairment, meeting medical necessity criteria for inpatient hospitalization.
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CLIENT ASSESSMENT RECORD (CAR)
The CAR is a useful tool for assessing a client’s current functioning and for tracking progress. General definitions
for each domain and level of functioning scales are provided. Based on these definitions, the clinician can acquire a
reasonably clear idea of the types and intensity of behaviors required to meet the criteria for each scale in each domain, as
well as which behaviors to document in each domain to support the score.
The CAR descriptors should include information obtained in a face-to-face interview/assessment with the client on the
date noted at the top of each page. Client specific behavioral examples should be included, as well. Submitting a CAR
that is a duplicate of a previous CAR or that is a duplicate of the CAR of another client, could result in a technical denial
or audit exceptions.
Note: revisions to the original CAR document have been made to help clarify OFMQ and OHCA’s understanding of the
intent of the assessment.
INTRODUCTION TO THE CLIENT ASSESSMENT RECORD (CAR)
This manual was developed to assist the clinician in using the Client Assessment Record (CAR) to evaluate the
functioning level of their clients. The nine (9) domains and six (6) levels of functioning contained within the CAR
provide the clinician with a comprehensive overview of the client’s capacity to adapt to the environment and survive
in the community.
The following conditions are prerequisites for using the scale in the most effective and reliable manner:
The clinician must have knowledge of the client’s behavior and adjustment to his/her community. The knowledge
must be gained either through direct contact (face-to-face interview) and experience with the client, or by systematic
review of the client’s functioning with individuals who have observed and are acquainted with the client (Utilize the
review in lieu of a face-to-face interview only when a face-to-face interview is not possible, i.e., small child.
Document that the CAR is not the result of a face-to-face interview, noting the reason)
The clinician should be trained in the administration of the CAR prior to using it as the basis for clinical decisions.
The CAR levels of functioning have been structured within a "normal curve" format, ranging from Above Average
Functioning (1-10) to Extreme Psychopathology (50). Pathology begins in the 20-29 range. The CAR format
provides a broad spectrum of functioning and permits a range within which clients can be described. Descriptors
must be current, client specific, age appropriate, and developmentally appropriate. Only current data can be scored.
Historical information is documented in the designated section of the request packet.
The clinician’s description of the client’s behavior in each domain needs to include 1) the frequency of the behavior
(How often does the behavior occur?); 2) the intensity of the behavior (How severe is the behavior?); 3) duration of
the behavior (How long does the behavior last?); and 4) the impact the symptoms/behaviors have on daily
functioning, to establish the severity of the client’s current condition. A clear focus on the behaviors that are relevant
to each domain, as described in this manual, will help communicate the clinician’s assessment of the client’s current
condition. The documentation should be specific to the particular client rather than a duplication of the general
definitions or examples noted in this manual.
If the clinician does not have the immediate experience to rate the client on any of the scales, consultation must be
made with the client’s family and/or other staff members to acquire information sufficient to make a reliable
estimation. (This fact would be documented in the descriptor, i.e., “According to client’s father,”)
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GENERAL DEFINITIONS
1. FEELING/MOOD/AFFECT: Measures the extent to which the person’s emotional life is well moderated or out of
control. Consider the appropriateness of emotional responses to immediate and long range situational factors
compared to others of the same age, gender, culture, and life circumstances and how able the client is to use his/her
coping skills and emotional responses to enhance personal and interpersonal satisfaction. Document how well the
person responds emotionally, as well as the ability to use his/her coping skills.
2. THINKING/MENTAL PROCESS: Measures the extent to which the person is capable of and actually uses clear,
well-oriented thought processes. Adequacy of memory and overall intellectual functioning are also to be considered
in this scale. This domain includes consideration of thinking style common for the person’s age, gender, culture,
and life circumstances. Document how the person’s judgment, beliefs and logical thought processing is impacted by
identified emotional and interpersonal stressors.
3. SUBSTANCE USE: Measures the extent to which a person’s current use of synthetic or natural substances is
controlled and adaptive for general well-being and functioning. Although alcohol and illegal drugs are obvious
substances of concern, any substance can be subjected to maladaptive use or abuse, especially if compounded by
special medical or social situations.
4. MEDICAL/PHYSICAL: Measures the extent to which a person is subject to illness, injury and/or disabling
physical conditions, regardless of causation. Demonstrable physical effects of psychological processes are included,
but not the effects of prescribed psychotropic medications. Physical problems resulting from assault, rape, or abuse
are included. List the medications the client is currently taking, including the name, dosage, frequency and reason
for taking the medication. The impact of the client’s medical/physical condition on his/her daily functioning must be
described.
5. FAMILY: Measures the adequacy with which the client functions within his/her family and current living
situation. Relationship issues with family members are included as well as the adequacy of the family constellation
to function as a unit. Document attachment or bonding issues, adequacy of communication and structure within the
family system, areas of conflict and the presence of any abuse or violence.
6. INTERPERSONAL: Measures the adequacy with which the person is able to establish and maintain interpersonal
relationships. Relationships involving persons other than family members should be compared to similar
relationships by others of the same age, gender, culture, and life circumstances. Document the client’s ability to
respond to affection and human contact, their capacity for empathy and ability to engage in social interaction.
7. ROLE PERFORMANCE: Measures the effectiveness with which the person manages the role most relevant to his
or her contribution to society. The choice of whether job, school, or home management (or some combination) is
most relevant for the person rated, depends on that person’s age, gender, culture and life circumstances. If disabled,
intellectually, mentally or physically, the client would be scored relative to others with the same disability and in the
same situation. Whichever role is chosen as most relevant, the scale is used to indicate the effectiveness of
functioning within the role at the present time.
8. SOCIO-LEGAL: Measures the extent and ease with which the person is able to maintain conduct within the limits
prescribed by societal rules and social mores. It may be helpful to consider this scale as a continuum extending from
pro-social to anti-social functioning . Document lack of consideration for others; intentional destruction of property ;
defiance of authority; lying, cheating, and/or stealing; temper tantrums; run away behavior; compliance with one’s
personal ethical/moral value system; abusiveness and/or aggressiveness to others and/or self; and inappropriate
sexual behavior.
9. SELF CARE/BASIC NEEDS: Measures the adequacy with which the person is able to care for him/herself and
provide his/her own needs such as food, clothing, shelter and transportation. Document the person’s ability to make
reliable arrangements appropriate to his/her age, gender, culture and life circumstances. If the client lives in a
supportive or dependent situation for reasons other than lack of ability (e.g. confined on criminal sentence), estimate
the ability to make arrangements independently and freely. Children, the disabled and elderly persons who are cared
for by others should also be rated on their own ability to make arrangements compared to others their age.
Document whether the person can be left alone for a period of time; makes known medical/dental needs; tend to selfgrooming and appropriate dress; and take medication as prescribed.
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COMMUNICATION: Attempts to describe the person’s PRIMARY METHOD of communication and their ability
to communicate, both verbally and nonverbally. Document whether the client understands and responds
appropriately to verbal and/or written or nonverbal communication; participates in social conversation; primary
method of communication; requests assistance as needed; exhibits unusual speech patterns or expresses thoughts that
are/are not sensible; and responds to the presence of familiar persons or caretakers. This domain is mandatory for
ICF/MR clients. It is optional for all other clients. There is no score given.
The following two domains are not required or scored as part of the CAR assessment for preauthorization. This
documentation, however, may be required for audit purposes and may be documented on the Addendum to the
request packet.
COMMUNITY INTEGRATION: Attempts to describe the person’s ability to connect/engage within the community.
The person’s ability to function within the community appropriately/acceptably as compared to others of the same
age, gender, culture and life circumstances. This documentation fulfills CARF and JCAHO assessment standards.
CARE GIVER RESOURCES: Attempts to describe the extent to which the care giver has difficulties in providing
for the child’s basic needs (e.g., housing) or developmental needs (e.g., emotional, social, etc.) such that there is a
negative impact on the child’s level of functioning. This documentation is mandatory for clients under 21 years of
age. It is optional for all other clients.
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LEVEL OF FUNCTIONING SCALES
GENERAL ABSTRACT ANCHOR GUIDES
1 - 9 (Above Average)
Functioning in the particular domain is consistently better than that which is typical for age, gender, and subculture,
or consistently average with occasional prominent episodes of superior, excellent functioning. Functioning is never
below typical expectations for the average person.
(Over-conforming)
10 - 19 (Average)
Functioning in the particular domain as well as most people of same age, gender, and subculture. Given the same
environmental forces is able to meet usual expectations consistently. Has the ability to manage life circumstances.
20 - 29 (Mild to Moderate)
Functioning in the particular domain falls short of average expectation most of the time, but is not usually seen as
seriously disrupted. Dysfunction may not be evident in brief or casual observation and usually does not clearly
influence other areas of functioning. Problems require assistance and/or interfere with normal functioning.
30 - 39 (Moderate to Severe)
Functioning in the particular domain is clearly marginal or inadequate, not meeting the usual expectations of current
life circumstances. The dysfunction is often disruptive and self-defeating with respect to other areas of functioning.
Moderate dysfunction may be apparent in brief or casual interview or observation. Serious dysfunction.
40 - 49 (Incapacitating)
Any attempts to function in the particular domain are marked by obvious failures, usually disrupting the efforts of
others or of the social context. Severe dysfunction in any area usually involves some impairment of other areas.
Hospitalization or other external control may be required to avoid life-threatening consequences of the dysfunction.
Out of control all or most of the time.
50 (EXTREME)
The extreme rating for each scale, suggests behavior or situations totally out of control, unacceptable, and potentially
life threatening. This score indicates issues that are so severe it would not be generally used with someone seeking
outpatient care.
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1. FEELING/MOOD/AFFECT
1 - 9 (ABOVE AVERAGE): Anxiety, depression, or disturbance of mood is absent or rare. The person’s
emotional life is characterized by appropriate cheer and optimism given a realistic assessment of his/her situation.
Emotional control is flexible, with both positive and negative feelings clearly recognized and viewed as within
his/her own control. Reactions to stressful situations are clearly adaptive and time limited.
10 - 19 (AVERAGE): No disruption of daily life due to anxiety, depression or disturbance of mood. Emotional
control shows consistency and flexibility. A variety of feelings and moods occur, but generally the person is
comfortable, with some degree of pleasant or warm affect. When strong or persistent emotions occur, the object and
approximate causes are readily identified.
ADULT: Able to cope, either alone or with the help of others, with stressful situations. Not overwhelmed when
circumstances seem to go against him/her. Does dwell on worries; tries to work out problems. Frustration, anger,
guilt, loneliness, and boredom are usually transient in nature and resolve quickly. Considers self a worthy person.
CHILD: Not overwhelmed when circumstances seem to go against him/her. Frustration, anger, guilt,
loneliness, and boredom are usually transient in nature and resolve quickly. Reactions to stressful events are age
appropriate.
20 - 29 (Mild to Moderate): Occasional disruption due to intense feelings. Emotional life is occasionally
characterized by volatile moods or persistent intense feelings that tend not to respond to changes in situations.
Activity levels may occasionally be inappropriate or there may be disturbance in sleep patterns.
ADULT: Tends to worry or be slightly depressed most of the time. Feels responsible for circumstances but
helpless about changing them. Feels guilty, worthless and unloved, causing irritability, frustration and anger.
CHILD: Frustration, anger, loneliness, and boredom persist beyond the precipitating situation. May be slightly
depressed and/or anxious MOST OF THE TIME.
30 - 39 (Moderate to Severe)): Occasional major (severe) or frequent moderate disruptions of daily life due to
emotional state. Uncontrolled emotions are clearly disruptive, affecting other aspects of the person’s life. Person
does not feel capable of exerting consistent and effective control on own emotional life.
ADULT: The level of anxiety and tension (intense feelings) is frequently high. There are marked frequent,
volatile changes in mood. Depression is out of proportion to the situation, frequently incapacitating. Feels worthless
and rejected most of the time. Becomes easily frustrated and angry.
CHILD: Symptoms of distress are pervasive and do not respond to encouragement or reassurance. May be
moderately depressed and/or anxious most of the time or severely anxious/depressed occasionally.
40 - 49 (Incapacitating): Severe disruption or incapacitation by feelings of distress. Unable to control one’s
emotions, which affects all of the person’s behavior and communication. Lack of emotional control renders
communication difficult even if the person is intellectually intact.
ADULT: Emotional responses are highly inappropriate most of the time. Changes from high to low moods
make person incapable of functioning. Constantly feels worthless with extreme guilt and anger. Depression and/or
anxiety incapacitate person to a significant degree most of the time.
CHILD: Emotional responses are highly inappropriate most of the time. Reactions display extreme guilt and
anger that is incapacitating.
50 (EXTREME): Emotional reactions or their absence appears wholly controlled by forces outside the
individual and bears no relationship to the situation.
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2. THINKING/MENTAL PROCESS
This domain refers to the person’s intellectual functioning and thought processes only. If there is a lowering of
functioning level in either one, please rate the more severe of the two.
1 - 9 (ABOVE AVERAGE): Superior intellectual capacity and functioning. Thinking seems consistently clear,
well organized, rational, and realistic. The person may indulge in irrational or unrealistic thinking, or fantasy, but is
always able to identify it as such, clearly distinguishing it from more rational realistic thought.
10 - 19 (AVERAGE): No evidence of disruption of daily life due to thought and thinking difficulties. Person
has at least average intellectual capacity. Thinking is generally accurate and realistic. Judgment is characteristically
adequate. Thinking is rarely distorted by beliefs with no objective basis.
ADULT: Capable of rational thinking and logical thought processes. Oriented in all spheres. No memory loss.
CHILD: Intellectual capacity and logical thinking are developed appropriately for age.
20 - 29 (Mild to Moderate): Occasional disruption of daily life due to impaired thought and thinking processes.
Intellectual capacity slightly below average (“Dull Normal” to Borderline) and/or thinking occasionally distorted by
defensive, emotional factors and other personal features. Poor judgment may occur often, but is not characteristic of
the person. Communications may involve misunderstandings due to mild thought disorders. Includes specific
impairments of learning or attention and the ability to generalize from acquired knowledge.
ADULT: Borderline retardation, but can function well in many areas. Peculiar beliefs or perceptions may
occasionally impair functioning. Occasionally forgetful, but is able to compensate.
CHILD: Borderline retardation or developmentally delayed, but can function well in many areas. Inability to
distinguish between fantasy and reality may, on occasion, impair functioning.
30 - 39 (Moderate to Severe)): Frequent or consistent interference with daily life due to impaired thinking. Mild
to moderate mental retardation and/or frequent distortion of thinking due to emotional and/or other personal factors
may occur Frequent substitution of fantasy for reality, isolated delusions, or infrequent hallucinations may be
present. Poor judgment is characteristic at this level.
ADULT: Mild to moderate retardation, but can function with supervision. Delusions and/or hallucinations
interfere with normal daily functioning. Frequently disoriented as to time, place, or person. Person is unable to
remember recent or past events.
CHILD: Mild to moderate retardation. May be preoccupied by unusual thoughts or attachments.
40 - 49 (Incapacitating): Incapacitated due to impaired thought and thinking processes. Severe to profound
mental retardation and/or extreme disruption or absence of rational thinking may exist. Delusions or frequent
hallucination that the person cannot distinguish from reality may occur. Communication is extremely difficult.
ADULT: Unable to function independently. Severely disoriented most of the time. Significant loss of memory.
CHILD: Severely disoriented most of the time. Loss of memory. If speech is present, it may manifest itself in
peculiar patterns.
50 (EXTREME): Profound retardation, comatose, or vegetative. No process that would ordinarily be
considered “thinking” can be detected, although person may appear to be conscious. Communication is virtually
impossible. Extreme catatonia.
Note: A score of 40 or more in this domain must include a statement indicating the client’s ability to participate in
treatment planning and benefit from the OP services requested.
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3. SUBSTANCE USE
1 - 9 (ABOVE AVERAGE): All substances are used adaptively with good control. Substances known to be
harmful are used sparingly, if at all.
10 - 19 (AVERAGE): No impairment of functioning due to substance use. Substance use is controlled so that it
is not apparently detrimental to the person’s over-all functioning or well-being. Substances used and amount of use
are within commonly accepted range of the person’s subculture. Infrequent excesses may occur in situations where
such indulges have no serious consequences.
ADULT: No functional impairment noted from any substance use. Reports occasional use of alcohol with no
adverse effects.
CHILD: No effects from intake of alcohol, drugs, or tobacco other than possibly one occurrence of
experimentation.
20 - 29 (Mild to Moderate): Occasional or mild difficulties in functioning due to substance use. Weak control
with respect to one or more substances. May depend on maladaptive substance use to escape stress or avoid direct
resolution of problems, occasionally resulting in increased impairment and/or financial problems.
ADULT: Occasional apathy and/or hostility due to substance use. Occasional difficulty at work due to hangover
or using on the job.
CHILD: Occasional incidence of experimentation with alcohol, drugs or other substance with potential adverse
effects.
30 - 39 (Moderate to Severe)): Frequent difficulties in functioning due to substance use. Has little control over
substance use. Lifestyle revolves around acquisition and abuse of one or more substances. Has difficulty covering
up the detrimental effects of substance abuse. Shows serious deterioration in function when deprived of substance.
ADULT: Needs alcohol, drugs or other substances to cope much of the time, without them feels upset and
irritable. Frequent hangovers/highs or other effects of substance abuse that are causing difficulty on the job, at home
and/or in other situations.
CHILD: Repeated use of alcohol, drugs, or other substances causing difficulty at home and/or school.
40 - 49 (Incapacitating): Disabled or incapacitated due to substance use. Substance abuse dominates the
person’s life to the almost total exclusion of other aspects. Serious medical and/or social consequences are accepted
as necessary inconveniences. Control is absent, except as necessary to avoid detection of an illegal substance.
ADULT: Major focus on obtaining desired substance. Other functions ignored. Unable to hold job due to use
of alcohol, drugs or other substances.
CHILD: Unable to function at home or in school due to substance use. Life revolves around obtaining desired
substance.
50 (EXTREME): Constantly high or intoxicated with no regard for basic needs or elemental personal safety.
May include extreme vegetative existence.
Note: The use of substances by family members is recorded in domain #5 , as it relates to the family’s ability to
operate as a functional unit.
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4. MEDICAL/PHYSICAL
1 - 9 (ABOVE AVERAGE): Consistently enjoys excellent health. Infrequent minor ills cause little discomfort,
and are marked by rapid recovery. Physical injury is rare and healing is rapid. Not ill or injured at this time of rating
and in good physical condition.
10 - 19 (AVERAGE): No physical problems that interfere with daily life. Generally good health without undue
distress or disruption due to common ailments and minor injuries. Any chronic medical/physical condition is
sufficiently controlled or compensated for as to cause no more discomfort or inconvenience than is typical for the
age. No life-threatening conditions are present.
ADULT: Occasional colds, fatigue, headaches, gastrointestinal upsets, and common ailments that are endemic in
the community. No sensory aids required. No medications.
CHILD: Occasional common ailments. Rapid recovery with no long-term effects. No sensory aids required.
No medications.
20 - 29 (Mild to Moderate): Occasional or mild physical problems that interfere with daily living. Physical
condition worse than what is typical of age, sex, and culture and life circumstances; manifested by mild chronic
disability, illness or injury, or common illness more frequent than most. Includes most persons without specific
disability, but frequent undiagnosed physical complaints. Disorders in this range could become life threatening only
with protracted lack of care.
ADULT: Controlled allergies. Needs glasses, hearing aid, or other prostheses, but can function without them.
Needs medication on a regular basis to control chronic medical problem.
CHILD: Illnesses more frequent than average. Controlled allergies. Needs glasses, hearing aid, or other
prostheses, etc.
30 - 39 (Moderate to Severe): Frequent and/or chronic problems with health. Person suffers from serious injury,
illness or other physical condition that definitely limits physical functioning (though it may not impair psychological
functioning or productivity in appropriately selected roles). Includes conditions that would be life threatening
without appropriate daily care. Cases requiring hospitalization or daily nursing care should be rated 30 or above, but
many less critical cases may be in this range also.
ADULT: Diabetes, asthma, moderate over/underweight or other evidence of eating disorder. Cannot function
without glasses, hearing aid or other prostheses. Heavy dependence on medications to alleviate symptoms of chronic
illness.
CHILD: Diabetes, asthma, moderate over/underweight or other evidence of eating disorder. Cannot function
without glasses, hearing aid, or other prostheses. Physical problems secondary to abuse. Heavy dependence on
medication.
40 - 49 (Incapacitating): Incapacitated due to medical/physical health. The person is physically incapacitated
by injury, illness, or other physical condition. Condition may be temporary, permanent or progressive, but all cases
in this range require at least regular nursing-type care.
ADULT: Medical/physical problems are irreversible and incapacitating. Must have special medication in order
to survive.
CHILD: Medical/physical problems are irreversible and incapacitating.
50 (EXTREME): Critical medical/physical condition requiring constant professional attention to maintain life.
Include all persons in a general hospital intensive care unit.
Note: Include how the medical condition limits the client’s day-to-day function for score of 20 and above.
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5. FAMILY
1 - 9 (ABOVE AVERAGE): Family unit functions cohesively with strong mutual support for its members.
Individual differences are valued.
10 - 19 (AVERAGE): Major conflicts are rare or resolved without great difficulty. Relationships with other
family members are usually mutually satisfying.
***** DEFAULT TO AVERAGE RATING IF ADULT HAS NO FAMILY OR LACK OF FAMILY CONTACT.
Feelings about lack of contact would be noted in domain # 1. *****
ADULT: Primary relationships are good with normal amount of difficulties. Feels good with family
relationships and secure in parent role. Destructive behavior among family members is rare.
CHILD: Conflicts with parents or siblings are transient; family is able to resolve most differences promptly.
Parenting is supportive and family is stable.
20 - 29 (Mild to Moderate): Relationships within the family are mildly unsatisfactory. May include evidence of
occasional violence among family members. Family disruption is evident. Significant friction and turmoil
evidenced, on some consistent basis, which is not easily resolved.
ADULT: Family difficulties such that client occasionally thinks of leaving. Some strife with children.
CHILD: Problems with parents or other family members are persistent, leading to generally unsatisfactory
family life. Evidence of recurring conflict or even violence among siblings.
30 - 39 (Moderate to Severe): Occasional major or frequent minor disruption of family relationships. Family
does not function as a unit. Frequent turbulence and occasional violence involving adults and children.
ADULT: Turbulent primary relationship or especially disturbing break-up. Adult rage and/or violence directed
toward each other or children.
CHILD: Family inadequately supportive of child. Constant turmoil and friction. Family unit is disintegrating.
40 - 49 (Incapacitating): Extensive disruption of family unit. Relationships within family are either extremely
tenuous or extremely destructive.
ADULT: Not capable of forming primary relationships. Unable to function in parenting role. Abusive or
abused.
CHILD: Isolated. Lacking family support. Abused or neglected.
50 (EXTREME): Total breakdown in relationships within family. Relationships that exist are physically
dangerous or psychologically devastating.
Note: For adults, note and score current, ACTIVE family problems only.
For children report and score the behavior of the current family as it affects the child.
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6. INTERPERSONAL
1 - 9 (ABOVE AVERAGE): Relationships are smooth and mutually satisfying. Conflicts that develop are easily
resolved. Person is able to choose among response styles to capably fit into a variety of relationships. Social skills
are highly developed.
ADULT: Has wide variety of social relationships and is sought out by others.
CHILD: Social skills highly developed for age.
10 - 19 (AVERAGE): Interpersonal relationships are mostly fruitful and mutually satisfying. Major conflicts are
rare or resolved without great difficulty. The person appears to be held in esteem within his or her culture.
ADULT: Good relationship with friends. Forms good working relationships with co-workers.
CHILD: Client is able to relate well to peers or adults without persistent difficulty.
20 - 29 (Mild to Moderate): Occasional or mild disruption of relationships with others. Relationships are mildly
unsatisfactory although generally adequate. May appear lonely or alienated although general functioning mostly
appropriate.
ADULT: Some difficulty in developing or keeping friends. Problems with co-workers occasionally interfere
with getting work done.
CHILD: Some difficulty in forming or keeping friendships. May seem lonely or shy.
30 - 39 (Moderate to Severe): Occasional major or frequent disruption of interpersonal relationships. May be
actively disliked or virtually unknown by many with whom there is daily contact. Relationships are usually fraught
with difficulty.
ADULT: Has difficulty making and keeping friends such that he/she has few friends or tenuous, strained
relationships. Generally rejects or is rejected by co-workers; tenuous job relationships.
CHILD: Unable to attract friendships. Persistent quarreling or social withdrawal. Has not developed age
appropriate social skills.
40 - 49 (Incapacitating): Serious disruption of interpersonal relationships or incapacitation of ability to form
relationships. No close relationships; few, if any, casual associations which are satisfying.
ADULT: Socially extremely isolated. Argumentative style or extremely dependent style makes work
relationships virtually impossible.
CHILD: Socially extremely isolated. Rejected, unable to attach to peers appropriately.
50 (EXTREME): Relationship formation does not appear possible at the time of the rating.
Note: Relationships with family members are reported in domain # 5.
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7. ROLE PERFORMANCE
1 - 9 (ABOVE AVERAGE): The relevant role is managed in a superior manner. All tasks are done effectively
at or before the time expected. The efficiency of function is such that most of the tasks appear easier than for others
of the same age, sex, culture, and role choice.
10 - 19 (AVERAGE): Reasonably comfortable and competent in relevant roles. The necessary tasks are
accomplished adequately and usually within the expected time. There are occasional problems, but these are
resolved and satisfaction is derived from the chosen role.
ADULT: Holds a job for several years, without major difficulty. Student maintains acceptable grades with
minimum of difficulty. Shares responsibility in childcare. Home chores accomplished.
CHILD: Maintains acceptable grades and attendance. No evidence of behavior problems.
20 - 29 (Mild to Moderate): Occasional or mild disruption of role performance. Dysfunction may take the form
of chronic, mild overall inadequacy or sporadic failures of a more dramatic sort. In any case, performance often falls
short of expectation because of lack of ability or appropriate motivation.
ADULT: Unstable work history. Home chores frequently left undone; bills paid late.
CHILD: Poor grades in school. Frequent absences. Occasional disruptive behavior at school.
30 - 39 (Moderate to Severe): Occasional major or frequent disruption of role performance. Contribution in the
most relevant role is clearly marginal. Client seldom meets usual expectations and there is a high frequency of
significant consequences, i.e. firing, suspension.
ADULT: Frequently in trouble at work, or frequently fired. Home chores ignored; some bills defaulted.
CHILD: Failure or suspension from school. Persistent behavior problems in school.
40 - 49 (Incapacitating): Severe disruption of role performance due to serious incapacity or absent motivation.
Attempts, if any, at productive functioning are ineffective and marked by clear failure.
ADULT: Client not employable. Is unable to comply with rules and regulations or fulfill ANY of the
expectations of the client’s current life circumstance.
CHILD: Expelled from school. Constantly disruptive and unable to function in school.
50 (EXTREME): Productive functioning of any kind is not only absent, but also inconceivable at the time of
rating.
Note: Identify and assess only the client’s primary role. Family role would be described in domain 5. If residing
in an RCF, RCF resident would be considered the primary role. Score functioning relative to others in the same
life circumstance.
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8. SOCIO-LEGAL
1 - 9 (ABOVE AVERAGE): Almost always conforms to rules and laws with ease, abiding by the “spirit” as well
as the “letter” of the law. Any rare deviations from rules or regulations are for altruistic purposes.
10 - 19 (AVERAGE): No disruption of socio-legal functioning problems. Basically a law-abiding person. Not
deliberately dishonest, conforms to most standards of relevant culture. Occasional breaking or bending of rules with
no harm to others.
ADULT: No encounters with the law, other than minor traffic violations.
CHILD: Generally conforms to rules. Misbehavior is non-repetitive, exploratory or mischievous.
20 - 29 (Mild to Moderate): Occasional or mild disruption of socio-legal functioning. Occasionally bends or
violates rules or laws for personal gain, or convenience, when detection is unlikely and personal harm to others is not
obvious. Cannot always be relied on; may be in some trouble with the law or other authority more frequently than
most peers; has no conscious desire to harm others.
ADULT: Many traffic tickets. Creates hazard to others through disregard of normal safety practices.
CHILD: Disregards rules. May cheat or deceive for own gain.
30 - 39 (Moderate to Severe): Occasional major or frequent disruption of socio-legal functioning. Conforms to
rules only when more convenient or profitable than violation. Personal gain outweighs concern for others leading to
frequent and/or serious violation of laws and other codes. May be seen as dangerous as well as unreliable.
ADULT: Frequent contacts with the law, on probation, or paroled after being incarcerated for a felony. Criminal
involvement. Disregard for safety of others.
CHILD: Unable to consider rights of others at age appropriate level. Shows little concern for
consequences of actions. Frequent contact with the law.
40 - 49 (Incapacitating): Serious disruption of socio-legal functioning. Actions are out of control without regard
for rules and law. Seriously disruptive to society and/or pervasively dangerous to the safety of others.
ADULT: In confinement or imminent risk of confinement due to illegal activities. Imminent danger to others or
property.
CHILD: In confinement or imminent risk of confinement due to delinquent acts.
50 (EXTREME): Total uncontrolled or antisocial behavior. Socially destructive and personally dangerous to
almost all unguarded persons.
Note: Since danger to others is a clear component of scores of 20 and over, a clear statement as to the client’s
danger to others must be included in the request.
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9. SELF CARE/BASIC NEEDS
1 - 9 (ABOVE AVERAGE): Due to the fundamental nature of this realm of behavior, “above average” may be
rated only where needs can be adequately and independently obtained in spite of some serious obstacle such as
extreme age, serious physical handicap, severe poverty or social ostracism.
10 - 19 (AVERAGE): Client is able to care for self and obtain or arrange for adequate meeting of all basic needs
without undue effort.
ADULT: Able to obtain or arrange for adequate housing, food, clothing and money without significant
difficulty. Has arranged dependable transportation.
CHILD: Able to care for self as well as most children of same age.
20 - 29 (Mild to Moderate): Occasional or mild disruption of ability to obtain or arrange for adequate basic
needs. Disruption is not life threatening, even if continued indefinitely. Needs can be adequately met only with
partial dependence on illegitimate means, such as stealing, begging, coercion or fraudulent manipulation.
ADULT: Occasional assistance required in order to obtain housing, food and/or clothing. Frequently has
difficulty securing own transportation. Frequently short of funds.
CHILD: More dependent upon family or others for self care than would be developmentally appropriate for age.
30 - 39 (Moderate to Severe): Occasional major or frequent disruption of ability to obtain or arrange for at least
some basic needs. Include denial of need for assistance or support, or meeting needs wholly through illegitimate
means. Unable to maintain hygiene, diet, clothing and/or prepare food.
ADULT: Considerable assistance required in order to obtain housing, food, and/or clothing. Consistent
difficulty in arranging for adequate finances. Usually depends on others for transportation. May need assistance in
caring for self.
CHILD: Ability to care for self considerably below age and developmental expectation.
40 - 49 (Incapacitating): Severe disruption of ability to independently meet or arrange for the majority of basic
needs by legitimate or illegitimate means. Unable to care for self in a safe and sanitary manner.
ADULT: Housing, food and/or clothing must be provided or arranged for by others. Incapable of obtaining any
means of financial support. Totally dependent on others for transportation.
CHILD: Cannot care for self. Extremely dependent for age and developmental level.
50 (EXTREME): Person totally unable to meet or arrange for any basic needs. Would soon die without
complete supportive care.
Note: When rating a child in this domain, rate on child’s functioning only, without regard to adequacy of
parent’s provisions for basic needs. The developmental level of the child must also be considered.
CLIENT ASSESSMENT RECORD (CAR)
Points To Remember
ALL CAR Domains:
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
To establish the severity of the client’s current condition, examples of the client’s current
behavior/symptoms must include: frequency of behavior/symptoms (how many times hourly,
daily, weekly, etc.), intensity of the behavior/symptoms (how severe is the behavior- pouts,
yells, breaks things, hits, harms others, etc.), time frame (when and for how long does the
behavior occur), and the impact the behavior/symptoms have on client’s daily functioning (no
impact, conflict with co-workers, reprimands at work, fired from job, etc.)
For Example: CAR Domain 1: Anxious 3 or 4 times per week lasting up to 3 hours at a
time as evidenced by motor tension, autonomic hyperactivity, apprehension, and vigilance.
When anxious, client talks non-stop and interrupts others 3 or more times daily. Doesn’t
respond to encouragement and/or redirection. Client’s behavior has put him at risk of being
dropped from college courses and is causing conflict at work.

Specific examples should be given to support the assessments documented in the descriptors.

Descriptors should be relevant to the domain in which they are documented (i.e., family
interactions should be documented in domain 5- the family domain, not in domain 6 which
addresses interactions/relationships outside of the family).

Only current information is to be scored, not historical information. Relevant historical
information is documented in the Historical Information section of the request.

Descriptors should be scored considering reasonable expectations for the person’s age,
gender, culture and life circumstance to differentiate between expected behavior/symptoms
and pathological behavior/symptomology.
CAR Domain 1:

Does the depression, worry, anxiety cause “occasional” (20-29) or “occasional major” (30-39)
disruption to daily functioning? The key is to determine whether or not the feelings are out of
control for the client. A score in the 20-29 range can include descriptors such as “can be
persistent and fail to respond to changes in situations, change in activity levels, disturbance of
sleep, helplessness, worthlessness, irritability, frustration and anger”. Therefore, a full-blown
depressive episode or anxiety disorder could score 20-29. A score in the 30-39 range would
have to demonstrate that the client’s lack of emotional control occurs frequently. A score in
the 40-49 range must demonstrate that the client’s lack of emotional control is functionally
incapacitating.
Common Problems:

Using relative terms like sometimes, occasionally, usually, constantly, always, never etc.,
instead of including specific frequency statements such as 3 times weekly, 5 times daily, etc.

Not providing adequate descriptors, such as severity and duration of symptoms and the impact
they have on client’s daily functioning, to support the degree of the client’s lack of emotional
control. Particularly when scoring in 40-49 range, adequate descriptors/specific examples are
not provided to support that the client is “unable to control one’s emotions, which affects all
of the person’s behavior and communication.
CAR Domain 2:
The phrase “poor judgment” is used in both the 20-29 and 30-39 ranges. The 30-39 range indicates
that “poor judgment is characteristic”. Therefore, it is necessary to demonstrate that poor judgment
occurs more than just “often” which is descriptive of 20-29. In order to score 40-49, descriptors
need to clearly demonstrate that the client is “severely disoriented most of the time”. It is
questionable that a client who scores 40-49 in this domain could benefit from insight oriented
counseling services or would be able to actively participate in treatment planning. A score of 40 or
more in CAR Domain 2 must include a statement indicating the client’s ability to participate in
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treatment planning and benefit from the OP services requested.
Common Problems:

Scoring in 40-49 range when descriptors do not support that client is “severely disoriented
most of the time”.
CAR Domain 3:
Client’s substance use alone does not rate a score of even 20-29, which would require at least a
low level of dependence. Descriptors in CAR 3 need to reflect current level of
abuse/dependence. In addition to the substance(s) used, amount and frequency of use, duration
of use, and how use impacts the client’s daily functioning should also be documented. The
substance use of persons other than the client (parents, spouse, etc.) would not be noted or scored
in this domain.
Common Problems:

Scoring a child based on parents substance use.

Scoring history of use rather than current use and/or current level of dependence.
CAR Domain 4:
The impact of the client’s medical condition on day-to-day life/functioning is key to determining
the level of incapacitation. For example, a person with arthritis that causes painful joints would
be scored lower than one who is wheel chair bound or bed ridden.
Common Problems:

Behavioral health issues are scored rather than medical/physical issues. .

Impact on daily functioning is omitted, which is necessary to determine level of incapacitation.
CAR Domain 5:
A clear picture of the client’s current family situation must be provided to determine the
appropriate score. Historical information is valuable, but must not be scored and should be
documented in the Historical Information section of the request. Some dysfunction can be
normal. For adult’s, what the family actually does would be scored, rather than what they fail to
do (i.e., visit/contact client regularly).
Common Problems:

Adult’s that have little or no contact with their family are scored for “missing or grieving”
their family in CAR domain 5, instead of in CAR domain 1 (feelings) where it should be
documented.

Adults with no family or lack of family contact are scored above the average rating, rather
than defaulting to the average rating (10-19) as instructed in the manual.

Recurring conflict or even violence among siblings is scored as supporting 30-39, rather than
the 20-29 reflected in the manual.

Client’s previous family system is scored, rather than current family system (i.e., scoring
family system child was removed from, rather than current foster family).
CAR Domain 6:
Scores the client’s ability to make and keep friends. If a client is geographically
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isolated or isolated due to physical/medical problems (i.e., client is bedridden), this would not be
scored as pathological.
Common Problems:

Client’s poor judgment regarding choice of friends is scored in CAR 6, rather than CAR 2
where poor judgment should be documented.

Relationships with family members are scored in CAR 6, rather than CAR 5 where family
information should be scored.
CAR Domain 7:
The provider must determine the most relevant role and that role should be scored. Senior
citizens, the disabled, and children are not generally expected to work and would not be rated for
the role of employee. A disabled client that has not worked for years, and there is no expectation
of working in the near future, would not be rated as an employee. The primary role for most
school age children is student.

Common Problems:
Specific role is not identified.

Specific examples of poor role performance are not given.

The role for which descriptors reflect performance is not the primary role of the client
indicated (i.e., descriptors reflect performance based on expectations of someone living
independently for someone residing in an RCF).

Family role is described in Domain 7 rather than Domain 5, where family information should
be scored.
CAR Domain 8:
This domain measures pro-social vs. anti-social behavior. Although this domain scores more
than just criminal behavior, the examples of criminal behavior can be a good guide as to the
severity required to qualify for each level. A child who does not follow rules at home would not
equate to a person who disregards the safety of others and has frequent contact with the law.
Common Problems:

DHS involvement with the family, or parent/s going to court for custody or other legal reasons
is scored, rather than client’s ability to follow rules/laws, which should be scored. Only the
client’s behavior is to be scored in this domain.
CAR Domain 9:
The client’s developmental level and functioning compared to others the same age must be
considered in scoring the domain. The expectations for a small child and for a person in an RCF
are much different than for that of a healthy adult. Receiving TANF, Social Security, Medicaid,
Medicare, etc. to provide needed services are legitimate forms of self-care and must not be
scored. If a person is in need, but refuses the services they clearly need, this would be described
and scored.


Common Problems:
A parent’s inability to provide needed resources for a child’s self care are scored (i.e., client
has poor hygiene due to parents not providing shelter with running water), when only the
child’s ability to arrange for age appropriate self care should be scored.
Client self care is scored based on unrealistic expectations, (i.e., a minor child is expected to
rely on parent/guardian for food and shelter) rather than age appropriate expectations.
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ACTIVITIES OF DAILY LIVING SKILLS LIST
Schedule
Community resources
________ Using an alarm clock, calendar.
________ City, county, state.
Personal Hygiene
________ Social services agencies.
________ Brushing teeth daily.
________ Hospitals, Clinics, Physicians.
________ Shaving.
________ Religious service organizations.
________ Bath/shower.
________ Travel: Public, private.
________ Washing hands, nail care, hair care.
Housing
Appropriate Dress/Clothing maintenance
________ Rental, Utilities.
________ Weather/circumstance.
________ Safety and security in living environment.
________ Replacing, washing, ironing, repairing.
________ Keeping clean, making a bed.
Financial
Food
________ Income, expenses, savings, budget.
________ Healthy eating.
Social interaction
________ Shopping, Storage.
________ Social hygiene, washing hands, coughing, smoking.
________ Preparation.
________ Trust, honesty, rules.
Social skills
________ Manipulation attempts of others
________ Active listening.
________ Law enforcement.
________ Taking turns, Sharing.
________ Opinions and Tolerance.
________ Using quiet voices.
________ Anger management
________ Staying on task.
Medication knowledge
________ Rules for acceptable or unacceptable behaviors.
________ Medication, informed consent.
________ Eye contact, body space.
________ Physicians directions.
________ Facial and body language.
________ Alcohol/non-prescriptions agents.
________ Conversation techniques (openers and closers).
Employment
________ Interacting with authority figures
________ Job applications.
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EMOTIONAL INDICATORS BEHAVIOR CHECK LIST
(Developed by the Oklahoma Private Mental Health Providers Association)
Optional checklist to assist providers in completing the CAR. Numbers in parentheses refer to CAR domains.
____Exhibits anxiety (1)
____Teases/bullies others (8)
____Cries/laughs too easily; emotionally labile (1)
____Shows a lack of consideration
for others (8)
____Appears unhappy; depressed (1)
____Lies, cheats, or steals (8)
____Stubborn and/or sullen (1)
____Physically aggressive toward others (8)
____Unduly impulsive (2)
____Runs away if not supervised (8)
____Has excessive and/or peculiar preoccupations
with objects/activities (2)
____Removes clothing in inappropriate places (8)
____Expresses thoughts that are not sensible (2)
____Engages in inappropriate sexual behavior (8)
____Appears to be attending and/or responding to
internal stimuli, e.g., possible hallucinatory activity (2)
____Displays self abuse and/or self-injurious
behavior (8)
____Unaware of happenings in immediate
environment (2)
____Intentionally destroys property of own/others (8)
____Uses bizarre speech (2, )
____Inability to follow simple instructions (2)
____Unresponsive to redirection by caregiver (2)
____Does not respond to presence of familiar
caretakers; minimal attachment/bonding
behavior (5, 6)
____Exhibits facial/body tics (4)
____Grinds teeth (4)
____Exhibits peculiar mannerisms/ habits;
stereotypical behavior (4)
____Rocks back and forth when sitting/standing (4)
____Incontinent for urine and/or feces (4, 9)
____Eating difficulties (4, 9)
____Sleep disturbance (4, 9)
____Does not allow anyone to touch; tactile
defensiveness (5, 6)
____Unable to recognize the rewarding aspects of
human contact (5, 6)
____Withdraws from contact with others; isolates (6)
____Poor eye contact (6)
____Refuses scheduled activities (7)
____Overly active (7)
____Refuses work assignments (7)
____Has temper tantrums (8)
____Negativistic and/or defiant (8)
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____Unresponsive to positive statements/
behavior from caretakers with smiles,
laughter, etc. (1, 5, )
____Makes no effort to communicate needs (9)
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REVISED CRITERIA REFERENCE FORM
LEVEL OF CARE
CAR SCORES
Child (0-36 mos)
Complete all domains (1-11)
INITIAL
EXTENSION
1 - 3 months
1 - 3 months
1 – 27 RVU’s/mo
Child Level 1
1 - 18 RVU’s/mo
20 - 29 in 4 domains (1 - 9); OR
30 - 39 in 2 domains (1 - 9); OR
20 - 29 in 3 domains AND
30 - 39 in 1 domain (1 - 9)
6 months
1 - 6 months
Child Level 2
1- 27 RVU’s/mo.
30 - 39 in 3 domains (1 - 9); OR
40 - 49 in 1 domain (1 - 9)
1 - 6 months
1 – 3 months
Child Level 3
1- 44 RVU’s/mo.
30 – 39 in 4 domains, w/ 2 in 1, 6, 7 or 9; OR
40 – 49 in 2 domains, w/ 1in 1, 6, 7 or 9; OR
30 - 39 in 2 domains AND
40 - 49 in 1 domain, w/ 1-40 OR 2-30s in 1, 6, 7 or 9
40 - 49 in 3 domains,
with 1 in 1, 6, 7 or 9
1 – 3 months
1 – 3 months
1 - 3 months
1 - 3 months
Child RBMS
1 - 22 RVU’s/mo.
30 - 39 in 4 domains, w/ 2 in 1, 6, 7 or 9; OR
40 - 49 in 2 domains, w/ 1 in 1, 6, 7 or 9; OR
30 - 39 in 2 domains AND
40 - 49 in 1 domain,
1-40 or 2-30s in 1, 6, 7 or 9
1 – 3 months
1 – 3 months
Adult Level 1
1 - 12 RVU’s/mo.
20 - 29 in 4 domains (1 - 9); OR
30 - 39 in 2 domains (1 - 9); OR
20 - 29 in 3 domains (1 - 9) AND
30 - 39 in 1 domain (1 - 9)
6 months
1 - 6 months
Adult Level 2
1 - 20 RVU’s/mo
30 - 39 in 3 domains (1 - 9); OR
40 - 49 in 1 domain (1 - 9)
1 - 6 months
1 - 3 months
Adult Level 3
1 - 42 RVU’s/mo.
30 – 39 in 4 domains, w/ 2 in 1, 6, 7 or 9; OR
40 – 49 in 2 domains, w/ 1in 1, 6, 7 or 9; OR
30 - 39 in 2 domains AND 40 - 49 in 1 domain,
w/ EITHER 1-40 OR 2-30s in 1, 6, 7 or 9
1 - 3 months
1 - 3 months
Extended Care Level:
1 - 6 months
Adult Level 4
1 - 62 RVU’s/mo.
40 - 49 in 4 domains (1 - 9), with 1 in 1, 6, 7 or 9
1 - 3 months
1 - 3 months
Extended Care Level:
1 - 6 months
ICF/MR
1 - 24 RVU’s/mo.
Complete all domains
1 - 3 months
1 - 3 months
Extended Care Level:
1 - 6 months
Child Level 4
1- 62 RVU’s/mo.
Note: In many cases, although symptoms are severe, intense treatment may not be the most prudent or productive
treatment strategy, particularly over many months or years of service. For example, a severely depressed or highly
anxious person might be overwhelmed with several hours of treatment per week. A chronically mentally ill person may
become overly dependent on the support of an agency, decreasing rather than increasing independence.
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MENTAL HEALTH SERVICE PLAN
DEFINITIONS

PROBLEM - The behavior or situation that is problematic to the client. The symptom pattern must be
associated with the diagnostic criteria, but the problem should not be a restatement of the diagnosis.

GOAL - General outcome statement of what the client will ultimately attain through treatment that is
important to the client; focuses on the positive; is realistic and achievable; and is perceived as worthwhile
by the client. A positive statement that is, in effect, the opposite of the problem to which it relates.

CURRENT OBJECTIVE - The primary short-term steps required for the client to attain the long-term
treatment goal, which can be realistically achieved within the treatment review period. The objectives are
to identify what the client and/or family will do while in session and are to be stated in behaviorally
measurable terms. Objectives may be stated using the client’s own words.

TYPE OF SERVICE - The specific type of treatment intervention identified to treat client’s symptoms.
Treatment services can include: Individual, family and group psychotherapy, individual and group
psychosocial rehabilitation, and case management. A treatment service is to be listed for each service plan
objective.

DATE INITIATED – The date the objective was first listed on the mental health service plan. The month
and year should be noted. This date remains the same as long as this objective is continued on the service
plan.

TARGET DATE – The expected date the objective is to be completed within the current authorization
period being requested, typically one to six months. This date is revised if the treatment objective is not met
and is continued on the following service plan extension.

PROGRESS ON CURRENT/PREVOUS GOAL SINCE LAST AUTHORIZATION -- Summary of
specific progress the client has made toward achieving the stated goal since the previous authorization. This
is completed only for Extension Requests.

STATEMENT OF INVOLVEMENT- A statement regarding client’s participation in the service plan
development. If client has no comment, the clinician must make a statement regarding client’s involvement.
If the client is under the age of 14 or has a legal guardian, the guardian may complete the statement of
involvement on behalf of the client.

HISTORICAL INFORMATION – A brief summary of historical data relevant to current diagnosis and
treatment. Relevant family history would be included.

INTERPRETIVE SUMMARY/ADDITIONAL INFORMATION -Initial Requests: An overall summary of client’s current level of functioning, history of previous
treatment, any current stressors not mentioned elsewhere in the request, and prognosis for treatment.
Extension Requests: A summary of client’s overall compliance or noncompliance with treatment,
prognosis for continued treatment and any other relevant data not previously documented in the request.
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MENTAL HEALTH SERVICE PLAN EXAMPLES
INDIVIDUAL PSYCHOTHERAPY- Individual psychotherapy typically includes exploring/processing
client’s thoughts and feelings, and requires client to have insight.
EXAMPLES (ADULT):
Diagnosis- Bereavement
Problem- Grief/loss related to death of spouse.
Goal- Begin the process of acceptance of the loss.
Objective A- Identify and process 3 ways the loss has affected life. Target Date: 11/04
Objective B- Identify and process 3 memories. Target Date: 11/04
Treatment Service A- Individual Psychotherapy
Treatment Service B- Individual Psychotherapy
EXAMPLES (CHILD):
Diagnosis- Post Traumatic Stress Disorder
Problem- Recurring, traumatic memories
Goal- “Be able to go to sleep, stop nightmares”
Objective A- “Talk about one scary thing to help me not be so scared” Target Date: 11/04
Objective B- “Play/talk about 2 safe places in the doll house where a kid can go and not be hurt, and find a
place like it at my home and school” Target Date: 11/04
Treatment Service A- Individual Psychotherapy
Treatment Service B- Interactive Psychotherapy
FAMILY PSYCHOTHERAPY- Family psychotherapy focuses on treatment of the family system. Objectives
should reflect family participation and identify the measurable steps that the family needs to accomplish during
sessions. Objectives reflecting what the client needs to accomplish, even when family members are present, is
considered individual psychotherapy.
EXAMPLES (CHILD-FAMILY): Diagnosis- Adjustment Disorder with Depressed Mood
Problem- Client experiencing depressive symptoms in response to parent’s divorce.
Goal- Process acceptance of parent’s divorce and decrease depression
Objective A- Client/Family will identify and process 3 feelings related to change in the family system. Target
Date: 11/04
Objective B- Client/Family will identify and process 3 ways to maintain effective communication even though
family members do not all live in the same home.
Target Date: 11/04
Treatment Service A- Family Psychotherapy
Treatment Service B- Family Psychotherapy
GROUP PSYCHOTHERAPY- Group psychotherapy is similar to individual psychotherapy in that it also
typically entails exploring/processing thoughts and feelings, and requires client insight. However, group
psychotherapy is utilized when it is felt that the client would benefit from processing feelings and thoughts within a
group of individuals with similar issues.
EXAMPLES (ADULT):
Diagnosis- Schizophrenia, Undifferentiated Type
Problem- Auditory hallucinations interfere with daily living
Goal- Decrease auditory hallucinations
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Objective A- Client will identify 3 triggers that make voices worse and will process with the group. Target
Date: 11/04
Objective B- Client will problem solve with group 3 ways to avoid or diffuse the triggers identified in objective
A. Target Date: 11/04
Treatment Service A- Group Psychotherapy
Treatment Service B- Group Psychotherapy
EXAMPLES (CHILD):
Diagnosis- Adjustment Disorder with Depressed Mood
Problem- Client experiencing depressive symptoms in response to parent’s divorce
Goal- Process acceptance of parents divorce and decrease depression
Objective A- Client will identify and process with group 3 feelings related to parent’s divorce.
Target
Date: 11/04
Objective B- Client will identify and process with group 3 changes in family routine since parent’s divorce.
Target Date: 11/04
Treatment Service A- Group Psychotherapy
Treatment Service B- Group Psychotherapy
GROUP PSYCHOSOCIAL REHABILITATION- Group Psychosocial Rehab includes learning
information/skills and/or practicing skills. Content of education/learning/practicing can include basic living skills,
social skills (re)development, independent living skills, interdependent living skills, self-care, lifestyle change and
recovery principles and practices. Rehab objectives should not require client insight, or include processing thoughts
and feelings, as this is content for therapy.
EXAMPLES (ADULT):
Diagnosis- Schizophrenia, Undifferentiated Type
Problem- Social isolation due to negative symptoms of schizophrenia
Goal- Increase social contact
Objective A- Client will learn 3 effective ways to initiate a conversation. Target Date: 11/04
Objective B- Client will initiate 1 conversation each rehab session, utilizing the conversation starters learned
in Objective A. Target Date: 11/04
Treatment Service A- Group Psychosocial Rehabilitation
Treatment Service B- Group Psychosocial Rehabilitation
EXAMPLES (CHILD):
Diagnosis- Oppositional Defiant Disorder
Problem- Client argues frequently with adults
Goal- Decrease arguments and increase positive communication
Objective A- Client will learn and practice 3 ways to effectively handle a disagreement. Target Date: 11/04
Objective B- Client will learn and practice 3 ways to positively present an idea and/or a request. Target Date:
11/04
Treatment Service A- Group Psychosocial Rehabilitation
Treatment Service B- Group Psychosocial Rehabilitation
INDIVIDUAL PSYCHOSOCIAL REHABILITATION- Individual Psychosocial Rehabilitation includes
learning information/skills and/or practicing skills. However, individual rehabilitation is utilized when one on one
attention is needed. It includes educational and supportive services regarding independent living, self-care, social
skills (re)development, lifestyle changes and recovery principles. Rehab objectives should not require client insight,
or include processing thoughts and feelings, as this is content for therapy.
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EXAMPLES (ADULT):
Diagnosis- Schizophrenia, Undifferentiated Type
Problem- Poor hygiene due to negative symptoms of Schizophrenia
Goal- Improve hygiene
Objective A- Client will learn 3 ways poor hygiene can negatively impact his life.
Target Date: 11/04
Objective B- Client will learn 3 ways to improve hygiene. Target Date: 11/04
Treatment Service A- Individual Psychosocial Rehabilitation
Treatment Service B- Individual Psychosocial Rehabilitation
EXAMPLES (CHILD):
Diagnosis- Social Phobia
Problem- Client avoids contact with peers due to fear that she will act “wrong” or say something “wrong”
Goal- Decrease anxiety and increase contact with peers
Objective A- Client will learn 3 relaxation skills to use to decrease anxiety in social situations. Target Date:
11/04
Objective B- Parents will learn 2 symptoms of social phobia and 3 ways to assist client in managing anxiety in
a social setting. . Target Date: 11/04
Treatment Service A- Individual Psychosocial Rehabilitation
Treatment Service B- Individual Psychosocial Rehabilitation
CASE MANAGEMENT- Case Management includes referral, linkage, and/or advocacy on behalf of the client,
to help access appropriate community resources. The psychosocial and environmental problems identified in Axis IV
diagnosis should indicate potential need for access to community resources. Case Management objectives must be
measurable and time-limited. Case Management does not include: physically escorting, transporting or staying with
the client for scheduled appointments; monitoring financial goals; providing specific services such as shopping or
paying bills; delivering bus tickets, food stamps, money, etc.; psychotherapy or rehabilitation services; filling out
forms, applications, etc., on behalf of the consumer when the consumer is not present; filling out Medicaid forms,
applications, etc.; mentoring or tutoring; services being provided or available from DHS/OJA caseworker; services
to children receiving residential behavior management services in foster homes or group home settings; or services to
consumers residing in ICF/MR facilities.
EXAMPLES (ADULT):
Problem- Lacks adequate food supply to meet the nutritional needs of self and family
Goal- Adequately meet the nutritional needs of self and family
Objective A- Apply for food stamps within 1 week. Target Date: 11/04
Objective B- Access local food bank for grocery assistance. Target Date: 11/04
Treatment Service A- Case Management
Treatment Service B- Case Management
EXAMPLES (CHILD):
Problem- Inadequate clothing and medical care
Goal- Obtain clothing and medical care to adequately meet needs of child/family.
Objective A- Refer client/family to 3 resources for new and used clothing.. Target Date: 11/04
Objective B- Link client/family to medical clinic and assist in application process for reduced cost medication.
Target Date: 11/04
Treatment Service A- Case Management
Treatment Service B- Case Management
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SAMPLE HISTORICAL INFORMATION
The client is the third of three children. The biological mother abandoned the children when the client was
4 years of age, approximately one year ago and has made no attempts to visit or contact the children since then. All
three children were placed with the maternal aunt. The child has never had contact with his biological father.
SAMPLE INTERPRETIVE TREATMENT SUMMARY (INITIAL)
He appears to be suffering from an adjustment disorder following abandonment by the mother and placement
with the maternal aunt. The biological mother reportedly has substance abuse problems and was extremely neglectful
of the children. He will be starting kindergarten. He does not appear to be suffering from any developmental
problems or delays. He reportedly functioned within normal limits in preschool this past year. The client’s
kindergarten teacher has been contacted and there are plans to collaborate on a monthly basis regarding limit setting
and anger management. The client’s Aunt is having difficulty with parenting issues. She describes the client as
having angry outbursts 3 or 4 times per week, and they seem to occur at times of limit setting. During the outbursts,
he will scream, cry uncontrollably, break objects, and is inconsolable. The severe angry outbursts started after he
was abandoned. He is also aggressive with his older siblings. He will hit his siblings for no apparent cause. The
aggressive behavior occurs on a daily basis. There is no goal for reunification with the biological mother at this time.
The aunt indicates that she is willing to participate in family therapy and is anxious to learn new ways to help the
client overcome his behavioral problems. The client appears to have insight and is willing to participate in therapy
and attend sessions. Both the aunt and client appear able to meet the treatment objectives. The prognosis is good
and measurable improvement in functioning is expected during this initial authorization period. The client will be
treated in family and individual therapy. The focus being to help him with the adjustment to living with the aunt,
process of dealing with the abandonment issues, and helping the aunt develop effective ways to deal with the client’s
behavioral problems. The siblings are not receiving mental health services at this time, but will be participating in
family psychotherapy sessions with the client.
SAMPLE INTERPRETIVE TREATMENT SUMMARY (EXTENSION)
Client has attended 15 of 20 scheduled sessions during the past authorization period. Depressive symptoms
have decreased, but are still evident. For example, client reports crying for “no reason” 3-4 x per week. She also has
problems sleeping 2-3 nights per week. This is an improvement over past daily crying and daily insomnia. She states
her appetite is improving, and while she still does not leave the house much, she is thinking of places she would like
to go (church). Client reports she is meeting goal of taking medication as prescribed. She lists church, her sister,
and a friend as support, but she wasn’t attending church or actually using her sister or friend as support; she is now
beginning these interactions. She has begun using relaxation techniques and knitting, which she enjoys and reports
an improved ability to regulate her anxiety. Client reports she has not talked to ex-husband in three weeks, but he
has written to her. Client says she cannot decide if she wants to stay divorced or try to get back together with exhusband. One of the client’s 2 children is also receiving services from this agency, which includes family
psychotherapy (1 hr per week)
REQUEST CHECKLIST

Are all request pages present, complete, and dated?

Is client name, Recipient ID d #, Social Security #, and birth date documented correctly?

Is Provider ID #, provider name, address and contact person documented correctly?

Is DSM-IV or DSM-IV-TR diagnoses and codes recorded for all 5 Axes codes?

Is the principal Axis I diagnosis, a diagnosis that is allowed for the level of care requested?

If MR is diagnosed on Axis II, is the client’s IQ score documented?

If Dementia is diagnosed on Secondary Axis I, is a rating included?

Is the request documentation less than 30 days old, per the dates on the request?
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
Is all required additional documentation present?

Some requests require additional documentation to support medical necessity criteria. Examples:
RBMS requests: RBMS plan with each request
ICF/MR requests: Current IHP on file with OFMQ dated within the past year, Psych Testing with
initial requests
0-36 months requests: Requests should include the developmental assessment of the child, including
a copy of how this was assessed. This can include: Sooner Start Form, Statement from Pediatrician,
Information from County Health Department, and/or clinical assessment summary. Therapist’s
credentials for working with this age group should also be included.
Adult requests: If diagnoses include any form of dementia or OBS, MMSE required with each
request.
Adult/child requests: A score of 40 or higher in CAR domain 2,
must include a statement demonstrating the client’s ability to participate in
treatment planning and benefit from outpatient services requested.
Danger to Self/Others: If request documentation reflect thoughts/statements of self-harm, or threats
of harm to others, additional comments indicating the client is not in imminent danger to self or others
needs to be provided. This should include information regarding whether or not client has been
assessed for a higher level of care (inpatient, etc.), who made the assessment (psychiatrist, inpatient
psychiatric clinical review coordinator, etc.) and the outcome.
Child requests: Family psychotherapy is viewed as CRITICAL in the treatment of minors. If there is
no family psychotherapy requested , information should be provided to support that family
psychotherapy is either not needed or not possible for child/family.
Letter of Collaboration: A letter of collaboration is required when a
client is receiving services from 2 or more facilities, or 2 or more
separate sites for the same agency (different Provider ID #)). A letter of
collaboration is required, regardless of funding source.
Termination Letter: A letter signed and dated by the client and/or
legal guardian that indicates his/her desire to change behavioral health service providers,
an effective date is required for the following:



including
Client is authorized for services with a specific agency, and chooses to discontinue
services with that agency and receive those services from a different agency.
Client chooses to transfer from one agency site to another (same agency, but different
Provider ID #s).
Agency closes a site and transfers clients to another site, or clients may choose to move to
another facility with their clinician.

Are ALL current CAR scores recorded?

Do CAR scores support the Level requested?

Do CAR descriptors support ALL scores given?

Is it clear that the CAR is an assessment of current information (descriptors reflect new/current
information, and scores have been updated)?

Is the CAR documentation congruent with client’s diagnoses?
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
Do the RVU’s requested on the RVU page fall within the RVU range allowed for the level supported
by the CAR?

If the current service plan objectives have been worked on for 6 months or longer, does clinical
documentation support the need to continue with the same objectives, rather than revising the
objectives on the service plan?

Are ALL objectives related to their problem/goal?

Are target dates present for each objective?

Are objectives congruent with the type of treatment service(s) requested

Is there a treatment service identified for each objective?

Does the frequency of service noted match the number of sessions requested for each treatment
service on the RVU page?

Are ALL objectives behaviorally measurable?

Does the content of the objectives on the Mental Health Service Plan support the frequency of service
requested?

Is the Mental Health Service Plan congruent with the client’s diagnosis and CAR assessment?

Is the staff providing services identified for each treatment service?

Is client/guardian statement regarding participation in development of the Mental Health Service
Plan present?

Are ALL required signatures, credentials, and dates present on the Mental Health Service Plan
signature page?

Is the information provided in the Interpretive Treatment Summary congruent with the information
provided in the rest of the request?

If request documentation reflects client neglect and/or abuse, does documentation reflect whether or
not it has been reported, and/or DHS involvement?

If client was hospitalized for psychiatric reasons during the previous authorization period, is this
information, (including actual dates of hospitalization, included in the request?
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HELPFUL REFERENCES
NOTE: The following references are not endorsed by OFMQ, nor does use of these references guarantee
authorization. These are merely resources that OFMQ staff are aware of as available tools in treatment plan
development. This is not an exhaustive list.
Birren and Schaie, Handbook of the Psychology of Aging, 5th edition (2001). NY: Academic Press.
DeGood, Douglas E., Crawford, Angela L., & Jongsma, Arthur E. The Behavioral Medicine Treatment Planner
(1999). NY: Wiley & Sons.
Diagnostic and Statistical Manual of Mental Disorders, 4th edition Text Revision (2000). Washington, DC:
American Psychiatric Association.
Evosevich, J. M. & Michael Avriette. The Gay and Lesbian Psychotherapy Treatment Planner (1999). NY: Wiley
& Sons.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO). A Practical Guide to Clinical
Documentation in Behavioral Health Care. Oakbrook Terrace, IL: JCAHO.
Jongsma, Arthur E., Jr. and L. Mark Peterson. The Complete Adult Psychotherapy Treatment Planner, 2nd edition
(1999). NY: Wiley & Sons.
Johnson, Sharon L. Therapist’s Guide to Clinical Intervention: The 1-2-3s of Treatment Planning (1997). San
Diego, CA: Academic Press.
Jongsma, Arthur E., Jr., L. Mark Peterson, & William P. McInnis. The Adolescent Psychotherapy Treatment
Planner, 2nd Ed. (1999). NY: Wiley & Sons.
Jongsma, Arthur E., Jr., L. Mark Peterson, & William P. McInnis. The Child Psychotherapy Treatment Planner, 2nd
Ed. (1999). NY: Wiley & Sons.
Lieberman, A., Wieder, S., & Fenichel, E., editors. DC:0 -3 Casebook, A Guide to the Use of ZERO TO THREE’s
Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood in
Assessment and Treatment Planning (1997). Washington, DC: ZERO TO THREE: National Center for Infants,
Toddlers, & Families (formerly known as National Center for Clinical Infant Programs).
Wehman, Paul. Functional Living Skills for Mentally and Severely Handicapped Individuals. Texas: Pro-Ed.
Wieder, Serena, editor. Diagnostic Classification: 0-3, Diagnostic Classification of Mental Health and
Developmental Disorders of Infancy and Early Childhood (1995). Arlington, VA: ZERO TO THREE/National
Center for Clinical Infant Programs.
Zeanah, Charles, Jr. Handbook of Infant Mental Health. Guilford Press.
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COMMON ACRONYMS
AOA = American Osteopathic Association
BHCM = Behavioral Health Case Manager
BHRS = Behavioral Health Rehabilitation Specialist
CACM = Certified Adult Case Manager
CJCM = Certified Juvenile Case Manager
CAR = Client Assessment Record
CARF = Commission on the Accreditation of Rehabilitative Facilities
CF = Conversion Factor
CM = Case management, or Case Manager
CMHC = Community Mental Health Center
COA = Council on Accreditation
CW = Child Welfare Division of DHS, or Case Worker
DHS = Oklahoma Department of Human Services
DMHSAS = Oklahoma Department of Mental Health and Substance Abuse Services
DSM-IV = Diagnostic and Statistical Manual, 4th Edition
DSM-IV-TR = Diagnostic and Statistical Manual, 4th Edition, Text Revision
HCFA = Health Care Finance Administration
HMO = Health Management Organization
ICF/MR = Intermediate Care Facility for the Mentally Retarded
IN = Important Notice
INR = Important Notice Response
IQC = Internal quality control
JCAHO = Joint Commission on the Accreditation of Healthcare Organizations
MHP = Mental Health Professional
MHSP = Mental Health Service Plan
OAC = Oklahoma Administrative Code
OBHRS = Outpatient Behavioral Health Rehabilitative Services
OHCA = Oklahoma Health Care Authority
OFMQ = Oklahoma Foundation for Medical Quality
PA = Prior Authorization
PCPCM = Primary Care Physician Case Manager
QMB = Qualified Medical Benefits
RBMS = Residential Behavioral Management Services
RC = Review Coordinator
REVS = Recipient Eligibility Verification System
RTC = Residential Treatment Center
RVU = Relative Value Unit
TFC = Therapeutic Foster Care
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INSTRUCTIONS FOR COMPLETING PRIOR AUTHORIZATION
REQUEST PACKET FORMS
A. General Instructions
All requests must be dated within 30 days of receipt by OFMQ.
All forms must be filled out completely.
Client Name and Date must be completed at the top of each page.
If an item is not applicable to the client, then write “N/A” in the available space.
If instructed to check which items apply, check only those that apply.
If you need additional space for documentation, use the Interpretive Summary/Additional Information section.
Incomplete or illegible forms will be returned to the facility, which will cause a delay in authorization.
B. Fax Cover Page
Fax Date = Record the date the request is faxed to OFMQ.
Time = Record the time the request is faxed to OFMQ.
Type of Fax = Record the type of request/response being submitted. Mark only one.
Attention: = Record the name of the RC who has requested additional information for Important Notice
Response, the Appeals Committee for Recon/Appeal Request, or Clerical for Provider Change of Demographic
Information.
From: Facility/Agency = Record the name of the facility, not an abbreviation, where this client will be treated.
Contact Name = Record the name of the facility staff member who can be contacted for additional information.
Provider ID# = Record the site-specific ID number and letter for the location code.
Case Management ID# = Record the site-specific ID number and letter for the location code.
Facility Address = Record the location where this client will be treated, corresponding with the site-specific Provider
ID#.
Fax Number = Record the facility fax #, corresponding with the fax # on file at OFMQ.
Phone Number = Record the facility phone #.
RE: Client Name = Record the full name of the client as it appears on his/her Medicaid/Recipient ID card,
including middle initial and other designations (Sr., Jr., III, etc.).
Recipient ID # = Record the client’s most current Recipient ID#. If the client’s eligibility has not been confirmed
and a Recipient ID# has not been issued, write “Pending” in the space.
PA # = Record the client’s current Prior Authorization #, if applicable.
Number of Pages = Record the number of pages, including fax cover page, faxed to OFMQ.
Comments = Record any additional comments. Do not use this space for clinical data.
B: Outpatient Request for Prior Authorization
The client’s name and date at the top of each page should reflect the client’s name as it appears on his/her
Medicaid/Recipient ID card and the date the specific page was completed.
Client Name = Record the full name of the client as it appears on his/her Medicaid card, including middle initial
and other designations (Sr., Jr., III, etc.).
Social Security # = Record the client’s 9-digit Social Security number.
Date of Birth = Record the client’s date of birth (month/day/year).
Age = Record the client’s age.
Sex = Record the client’s sex (M = male, F = female).
Legal Guardian Name = Record the name of the client’s legal guardian.
Relationship to client = record the legal guardian’s relationship to client.
Current Residence = Check all that apply, and fill in applicable blanks.
Level of Request = Mark only one based on current CAR scores or special criteria.
Admit Date to Current Facility = Note the most recent date the client was admitted to the facility.
Treatment History = Document all that apply to this client, including Hospitalizations, PCP/Day TX, Outpatient
TX, and or School Based Behavioral Health Service. Provide information regarding
facility name, reason for treatment, and admit/discharge dates.
DSM Diagnoses = Complete all five axes, following DSM-IV or DSM-IV-TR guidelines. (refer to DSM as
needed).
Axis I: Clinical Disorders/Other Conditions That May Be a Focus of Clinical Attention
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Record the principle diagnosis code and corresponding title first. Other disorders are then listed in order
focus of attention and treatment. V codes and 900 codes are accepted only on
Level 1. A Deferred diagnosis (799.9) or a provisional diagnosis is not acceptable.
of
Axis II: Personality Disorders/Mental Retardation (MR)
Record the diagnosis code and corresponding title. If the diagnosis is MR, the client’s IQ must also be
documented. To diagnose a Personality Disorder in children less than 18 years of age, features must have been
apparent for a minimum of one year. However, Antisocial Personality Disorder cannot be diagnosed under the
age of 18.
Axis III: General Medical Conditions
Record the client’s current medical conditions that are potentially relevant to understanding or managing the
client’s mental disorder. It is generally not necessary to list minor problems or historical problems that are
resolved.
Axis IV: Psychosocial and Environmental Problems
Check all psychosocial and environmental stressors that are applicable and note any additional
problems that may affect the diagnosis, treatment, and prognosis of the mental disorders listed on
Axes II and I.
Axis V: Global Assessment of Functioning (GAF)
Record the clinician’s judgment of the client’s Current overall level of functioning at time of assessment and the
Highest Level of Functioning in the past year (may be an estimate).
D. Historical Information
Document historical data that is relevant to the current diagnosis and treatment of the client and family history
should be recorded.
E. Client Assessment Record (CAR)
The date at the top of the page should accurately reflect the date of the face-to-face interview/assessment of the
client, not the date it was typed/written.
Record the Past and Current CAR scores for each domain. Do not span the numbers (e.g., 20-29). Document
one specific number for Past score and one for Current score (e.g., 23 and 20). Current CAR scores are based
solely on client functioning at the present time, not historical functioning. Check applicable problem areas and
cite specific details of problem areas in the narrative portion of the domain. The descriptors supporting each
score must be client-specific, age-appropriate, and developmentally appropriate. Documentation should contain
descriptive detail to adequately reflect behavioral symptoms and rationale supporting the CAR scores. Frequency,
duration and intensity should be noted for identified symptoms/behaviors.
Both the Low Complexity and Moderate Complexity Mental Health Service Plans require a CAR evaluation.
The CAR must reflect current information and a completely new/updated CAR must be submitted with each
request.
F. Interpretive Summary/Additional Information
Initial Requests should include an overall summary of the client’s current level of functioning, history of
previous treatment, any current stressors not previously documented in the request and prognosis for treatment.
Data should not be a duplicate of the information already documented in the CAR assessment. Document
whether other family members are or will be receiving services from your agency.
Extension Requests should include a summary of overall treatment, compliance or noncompliance with
treatment and prognosis for continued treatment. If family psychotherapy is provided, the family participation
and progress in treatment should be described.
Any additional information that is relevant to the client’s treatment would also be noted.
G. Mental Health Service Plan
Low Complexity or Moderate Complexity = Mark only one.
Problem = Record the behavior/situation that is problematic to the client. The symptom pattern must be
associated with the diagnostic criteria, but must not be the diagnosis.
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Goal = Record the client’s expected positive outcome.
Current Objectives = Record the specific primary objectives that the client is presently working on in treatment in
behaviorally measurable terms.)
Date Initiated = Record the date each objective began, i.e. the date it first appeared on the treatment plan.
Target Date = Record the date (Month/Year) each objective is to be achieved.
Type of Service = Record each treatment service corresponding to the stated objective to be received by the
client.
Progress on Current/Previous Goal Since Last Authorization = On extension request, record the client’s progress
in treatment towards accomplishing goals and objectives. Reasons for lack of progress or regression should also
be documented. This can be done by listing the progress on the specific objectives or in more general terms that
relate to the client’s overall progress toward the treatment goal.
Signature Page
Client Signatures = A valid treatment plan must be signed and dated by the client (age 14 and over), the
parent/guardian (if under age 18, or age 18 and over if an client has a legal guardian), and must include a
statement by the client and /or guardian regarding their involvement, understanding and comments on the plan. If
the client does not complete the statement of involvement, the clinician must make a statement regarding the
client’s involvement. If a client is unable to sign or make a witnessed mark, on his/her treatment plan, document
the reason(s).
Parent/Guardian Signature = If the client is in custody of the Oklahoma Department of Human Services (DHS),
then the signature of either the DHS Case Worker or the Foster Parent is required. Providers are required to
obtain a release of information on client’s records to DHS, for the client’s file.
Treatment Team Signatures = The dated signature and complete credentials of the responsible MHP, physician,
and all other clinician’s providing direct client service. These signatures are required on the initial Mental Health
Service Plan in order for it to be considered a valid service plan. If the physician’s signature is not required on the
service plan for extension requests, mark the designated box indicating it is not required. Treatment team
signatures must include all applicable credentials (degree, licensure, under supervision for licensure). Clinical
staff should sign on the designated line indicating the type of service(s) they will be providing.
Note: All signatures must be dated at the time they are signed, by the person signing the official state
document.
Type of Service and Frequency = The type of service is listed on the signature page. The frequency of the service
should be noted beside each service type being requested. Frequency should be listed as hours/minutes per
week/month or units per week/month if the service is individual or interactive psychotherapy.
H. RVU Request Page
Recipient ID # = Record the client’s current Recipient ID #. If the client’s eligibility has not been confirmed
and an ID # has not been issued, write “Pending” in the space.
Provider ID# = Record the Provider ID number and the letter indicating the location site and case management
reference.
Psychotherapy = Record the number of psychotherapy sessions by selecting the unit (time frame for individual)
and the equivalent RVU’s per month for each service being requested. Total the number of psychotherapy
RVU’s.
Psychosocial Rehabilitation and Case Management = Record the number of rehabilitation and case
management sessions and the equivalent RVU’s per month for each service being requested. Total the number
of rehabilitation and case management RVU’s.
Combined Total RVU’s = Record the total RVU’s requested per month.
Requested Authorization Dates = Record the date (Month/Day/Year) you would like the authorization
period to begin and mark whether a three or six month authorization period is requested.
Additional/Optional Services = Record these services as needed, with supporting documentation in the request
packet. No RVU calculation is required for these services.
Note: Additional documentation may be required based upon the level of care requested. Please carefully review the
medical necessity criteria for each level of care. RC’s may request additional information and/or documentation to
assist them in making a decision regarding the medical necessity of services.
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Relative Value Unit
Each billing unit has a relative value associated with it to equalize the different services that are
available to clients based on the pay rate for these different units. For example, two different level III
clients could each have 42 RVU’s. One client could have all the RVU’s authorized in the form of group
psychosocial rehabilitation and the other client could have 42 RVU’s from a combination of psychotherapy
and psychosocial rehabilitation, but the total payment for each client’s services would be approximately the
same.
The RVU Page of the request form converts the units into RVU’s for the different services that are
requested by the provider. This is done to obtain the total RVU’s for one month of service. This one-month
total corresponds to the criteria pages to ensure that the total RVU’s per month do not exceed the
maximum allowed for the level of care. The number of units to be provided during a one-month period is
entered in the first blank for the type of service (____# of sessions per month). Multiple the number of
units requested times the relative value unit (RVU). The result is the number of RVU’s per month. This
calculation is completed for each service requested. The RVU’s for the different services are totaled to
determine the Combined Total RVU’s. The services listed below the Combined Total RVU’s are not
counted toward the maximum RVU’s allowed for the level. These services include, Medication Training
and Support and Psychological Testing.
Enter the Start Date for the Requested Authorization Date and indicate whether a 3 or 6-month
authorization period is being requested. The start date requested might be adjusted by OFMQ for several
reasons, which are explained elsewhere in the Provider Manual outlining the types of decisions. The level
of service may dictate whether a 3 or 6-month authorization is available.
There are three new billing codes for Individual Psychotherapy. Each one has a specific timeframe
associated with it. The first one is a 20 – 30 minute session, the second a 45 – 50 minute session and the
third a 75 – 80 minute session. There are also three new codes for Interactive Psychotherapy with the same
timeframes. The RVU values have been calculated for each of the new codes and are listed under the
different timeframes for Individual Psychotherapy and Interactive Psychotherapy. The provider is required
to request the specific timeframe (unit) being requested for Individual or Interactive Psychotherapy. More
than one timeframe for these services can be requested during the same authorization period. Remember
that the provider can only bill one individual therapy unit per day. Selecting the right unit of service is
important in the preauthorization system.
COMPUTING RVU’s
To compute the number of RVU’s needed for a request; determine the total number of sessions to be provided per
month for each treatment service. Multiply the number of sessions per month by the RVU. For example, 8 sessions
of family psychotherapy X 2.30 RVU’s = 18.4 RVU’s. Add the combined total number of RVU’s for each treatment
service to determine the total RVU’s per month.
ADDENDUM
Completion of this page is not required for preauthorization of services and does not need to be submitted to OFMQ
for review. The items noted on this page, however, may be required documentation for SURS reviews, CARF
certification and /or JCHO certification.
Outpatient Behavioral Health Rehabilitative
Services Provider Manual
Revised 1/2004 - 62
TERMINOLOGY CHANGES
Previous Term
Treatment Plan Development
Treatment Plan Review
Individual Counseling
Group Counseling
Family Counseling
Group Rehab Treatment
Individual Rehab Treatment
Medication Review
Outpatient Behavioral Health Rehabilitative
Services Provider Manual
Current Term
Mental Health Service Plan Development
Moderate Complexity
Mental Health Service Plan
Low Complexity
Individual Psychotherapy or
Interactive Psychotherapy
Group Psychotherapy
Family Psychotherapy
Psychosocial Rehabilitation
Psychosocial Rehabilitation
Medication Training and Support
Revised 1/2004 - 63
OKLAHOMA FOUNDATION FOR MEDICAL QUALITY
BEHAVIORAL HEALTH DEPARTMENT
Outpatient Behavioral Health Program
14000 Quail Springs Pkwy Suite 400, Oklahoma City, OK 73134
Phone (405) 858-9090 Fax (405) 858-9098
STATUS REQUEST
FAX DATE:
TIME:
ATTENTION CLERICAL STAFF
FAX NUMBER: (405) 858-9098
FROM FACILITY/AGENCY:
CONTACT NAME:
FAX NUMBER:
(
PROVIDER #:
)
PHONE NUMBER:(
)
WE ARE REQUESTING STATUS ON:
(Mark only ONE of the following)
INITIAL REQUEST
IMPORTANT NOTICE RESPONSE
EXTENSION REQUEST
MODIFICATION REQUEST
CORRECTION REQUEST
RECONSIDERATION/APPEAL REQUEST
FOR THE FOLLOWING CLIENT
CLIENT NAME:
First
MI
Last
Designation
(Sr., Jr., III, etc.)
Medicaid#:
THIS DOCUMENTATION WAS ORIGINALLY SENT ON
Date
If the Request needs to be resubmitted it should be received by OFMQ within 2 business days from the date Status
Request Response was sent to your agency. If the Request is received at OFMQ within 2 business days, the Request
will be backdated 3 business days from the ‘fax received’ date of this Status Request.
STATUS REQUEST RESPONSE FROM OFMQ CLERICAL STAFF
CONFIDENTIALITY
The documents included in this transaction may contain confidential information from the Oklahoma Foundation for Medical
Quality, Inc. The information is intended for the use of the person or entity name on this transmittal sheet. If you are not the intended
recipient, be aware that any disclosure, copying, distribution or use of the contents of this transmission is prohibited. If you have
received this transmission in error, please immediately telephone the Oklahoma Foundation for Medical Quality, Inc. so that we can
arrange for the disposition of the transmitted documents.
Outpatient Behavioral Health Rehabilitative
Services Provider Manual
Revised 5/2004
Oklahoma Foundation for Medical Quality, Inc.
14000 Quail Springs Parkway Suite 400 Oklahoma City, OK 73134-2600
Phone (405) 858-9090 Fax (405) 858-9098
FAX DATE: ___________________________ TIME: __________________
TYPE OF FAX: (Mark only ONE of the following)
____INITIAL REQUEST
____IMPORTANT NOTICE RESPONSE
(Attention: Reviewer)
____EXTENSION REQUEST
____PENDING ELIGIBILITY RESPONSE
(Attention: Reviewer)
____MODIFICATION REQUEST
(Attention: Reviewer)
____PROVIDER CHANGE OF DEMOGRAPHIC
INFORMATION (Attention: Clerical Staff)
____CORRECTION REQUEST
(Attention: Reviewer)
____RECONSIDERATION REQUEST
(Attention: Appeals Committee)
____OTHER ___________________________________________________________________________________
TO: OFMQ – Medicaid Outpatient Preauthorization Unit
FAX NUMBER: (405) 858-9098
ATTENTION: ____________________________________
(Reviewer)
FROM: FACILITY/AGENCY: ___________________________________________________________________
CONTACT NAME: _____________________________________________________________________________
PROVIDER ID #: __ __ __ __ __ __ __ __ __ - __
CASE MGMT ID #: __ __ __ __ __ __ __ __ __ - __
FACILITY ADDRESS: _____________________________________________________________________________
Street
City
State
Zip
FAX NUMBER: (
___)_____________________ PHONE NUMBER: (
)___________________
RE: CLIENT NAME: ______________________________________________________________________________
First
MI
Last
Designation (Sr., Jr., III, etc.)
RECIPIENT ID #: __ __ __ __ __ __ __ __ __
PA #: __ __ __ __ __ __ __ __ __ __
(If Applicable)
NUMBER OF PAGES INCLUDING THIS PAGE: _________
COMMENTS: (NO clinical information) ____________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
CONFIDENTIALITY
The documents included in this transaction may contain confidential information from the Oklahoma Foundation for Medical Quality, Inc. The information is
intended for the use of the person or entity name on this transmittal sheet. If you are not the intended recipient, be aware that any disclosure, copying, distribution
or use of the contents of this transmission is prohibited. If you have received this transmission in error, please immediately telephone the Oklahoma Foundation for
Medical Quality, Inc. so that we can arrange for the disposition of the transmitted documents.
Page 1 of _____
Revised 5/2004
OUTPATIENT REQUEST FOR PRIOR AUTHORIZATION
Date Completed: _________________________
Client Name:_________________________________________________________________________________________________
First
MI
Last
Designation (Sr. , Jr., III, etc.)
Social Security # __ __ __ - __ __ - __ __ __ __
Legal Guardian Name: __________________________________________
Relationship to Client: ________________________________
Date of Birth: ____________ Age: ____ Sex: ____
MM/DD/YY
Current Residence: (Check ALL that apply) ___Systems of Care
___Individual Home ___Residential Care Facility ___Group Home (Level_____) ___Nursing Home ___Shelter
___ICF/MR (Admit Date:_____________) ___ DHS/OJA/IH Custody (Worker:________________ Phone#_____________)
___Foster Care (Placement Date:_________________)
___TFC
Multiple placements in past 2 years (#________)
LEVEL: ___ 1 ___2 ___3 ___4 ___Exceptional Case ___0-36 months ___ICF/MR ___RBMS
ADMIT DATE TO CURRENT FACILITY: _____________________
TREATMENT HISTORY: (Admit / Discharge dates, facility, IP or OP, reason for treatment)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
DSM DIAGNOSES: (Complete ALL five axes)
Principal Axis I (code): __________
Title:________________________________________________________________________
__________
________________________________________________________________________
Second Axis I (code):
__________
________________________________________________________________________
Axis II (code):
_________
________________________________________________________________________
_________
________________________________________________________________________
Axis III: __________________________________________________________________________________________________
___________________________________________________________________________________________________
Axis IV: Problems related to: ___Primary support group ___ Social environment ___Education ___Housing ___Economic
___ Occupation ___ Access to health care services ___ Interaction with legal system/crime ___ Other ________________
Axis V: Current GAF:____________ Highest Level in the Past Year:_________
HISTORICAL INFORMATION (relevant to current diagnosis and treatment): _______________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Page 2 of _____
Revised 5/2004
Client Name: _______________________________________ Date Completed: ________________________
CLIENT ASSESSMENT RECORD
Past
Current
1. FEELINGS/MOOD/AFFECT
Problem areas: ___Mood lability ___ Coping skills ___Suicidal/homicidal ideation/plan ___Depression SCORE ______
_______
___Anger ___Anxiety ___Euphoria ___Change in appetite/sleep patterns
Evidenced by (specific examples, symptom frequency, duration and intensity, impact on daily functioning):_______________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
__________________________________________________________________________________________
2. THINKING/MENTAL PROCESS
SCORE ______
_______
Oriented x _________ MMSE score (if administered) _________ IQ Score (if MR diagnosis) _________
Problem areas: ___Memory ___Cognitive process ___Concentration ___Judgment ___Obsessions
___Delusions/hallucinations ___Belief system ___Learning disabilities ___Impulse Control
Evidenced by (specific examples, symptom frequency, duration and intensity, impact on daily functioning):_______________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
__________________________________________________________________________________________
3. SUBSTANCE USE:
SCORE ______
_______
Drug of Choice
Amount Used
Frequency of Use
First Used
Last used
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Functional impact of current use, give examples of level of dependency:__________________________________________________
____________________________________________________________________________________________________________
__________________________________________________________________________________________
4. MEDICAL/PHYSICAL
SCORE ______
_______
Current medical/physical conditions:______________________________________________________________________________
____________________________________________________________________________________________________________
Impact/limitations on day-to-day functioning:________________________________________________________________________
____________________________________________________________________________________________________________
MEDICATIONS
Name of Rx
Dosage/Frequency
Reason for Rx
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
5. FAMILY
SCORE ______
_______
Currently resides with ___biological family ___adoptive family ___foster family ___Alone ___Other_________________
Problem areas: ___ Parenting ___Conflict ___Abuse/violence ___Communication ___Marital ___Sibling ___Parent/child
Evidenced by (specific examples, frequency, duration and intensity, impact on daily functioning):______________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Page 3 of _____
Revised 5/2004
Client Name: __________________________________
Date Completed: ___________________________
Past
Current
6. INTERPERSONAL
SCORE ______
_______
Problem areas: ___Peers/friends ___Social interaction ___ Withdrawal ___Make/keep friends ___Conflict
Evidenced by (specific examples, frequency, duration, intensity, impact on daily functioning):_________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
__________________________________________________________________________________________
7. ROLE PERFORMANCE
SCORE ______
Functional role: ___Employment/Volunteer ___School/daycare ___ Home management ___Other _______
Effectiveness of functioning in identified role _________________________________________________
_______
____________________________________________________________________________________________________________
Evidenced by (specific examples, frequency, duration and intensity, impact on daily functioning):_______________________________
____________________________________________________________________________________________________________
_________________________________________________________________________________________
8. SOCIO-LEGAL
SCORE ______
_______
Problem areas: ___Ability to follow rules/laws ___Authority issues ___Legal issues ___Aggression
___Probation/parole ___Abides by personal ethical/moral value system ___Antisocial behaviors
Evidenced by (specific examples, frequency, duration and intensity, impact on daily functioning): ______________________________
____________________________________________________________________________________________________________
_________________________________________________________________________________________
9. SELF-CARE/BASIC NEEDS
SCORE ______
_______
Problem areas: ___Hygiene ___Food ___Clothing ___Shelter ___Medical/dental needs ___Transportation
Evidenced by (specific examples, frequency, duration and intensity, impact on daily functioning): _______________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
COMMUNICATION (required for ICF/MR level of care) ___ESL ___Hearing impaired ___Non-verbal
___Uses interpreter ___Signs ___Uses mechanical device ___Speech impaired ___Fluency
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
INTERPRETIVE SUMMARY/ADDITIONAL INFORMATION: _____________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Page 4 of _____
Revised 5/2004
Client Name: __________________________________________
Date Completed: ______________________
MENTAL HEALTH SERVICE PLAN
___Low Complexity
___Moderate Complexity
PROBLEM 1: _______________________________________________________________________________________________
GOAL 1: ___________________________________________________________________________________________________
CURRENT OBJECTIVES: (Must be behaviorally measurable)
1a: ________________________________________________________________________________________________________
1b: ________________________________________________________________________________________________________
1c: ________________________________________________________________________________________________________
1d: ________________________________________________________________________________________________________
1e: ________________________________________________________________________________________________________
1f: ________________________________________________________________________________________________________
TYPE OF SERVICE
DATE INITIATED
TARGET DATE
1a: ________________________________________________________________________________________________________
1b: ________________________________________________________________________________________________________
1c: ________________________________________________________________________________________________________
1d: ________________________________________________________________________________________________________
1e: ________________________________________________________________________________________________________
1f: _________________________________________________________________________________________________________
PROGRESS ON CURRENT/PREVIOUS GOAL SINCE LAST AUTHORIZATION:
(Extension Requests Only)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Page 5 of _____
Revised 5/2004
Client Name: ______________________________________________
Date Completed: __________________________
PROBLEM _____: __________________________________________________________________________________________
GOAL _____: ______________________________________________________________________________________________
CURRENT OBJECTIVES: (Must be behaviorally measurable)
_____a: ___________________________________________________________________________________________________
_____b: ___________________________________________________________________________________________________
_____c: ___________________________________________________________________________________________________
_____d: ___________________________________________________________________________________________________
_____e: ___________________________________________________________________________________________________
_____f: ___________________________________________________________________________________________________
TYPE OF SERVICE
DATE INITIATED
TARGET DATE
_____a: ___________________________________________________________________________________________________
_____b: _______________________________________________________________________________________________ ___
_____c: ___________________________________________________________________________________________________
_____d: ___________________________________________________________________________________________________
_____e: ___________________________________________________________________________________________________
_____f: ___________________________________________________________________________________________________
PROGRESS ON CURRENT/PREVIOUS GOAL SINCE LAST AUTHORIZATION:
(Extension Requests Only)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Page _____ of _____
Client Name:
Date Completed:
Revised 5/2004
MENTAL HEALTH SERVICE PLAN
PROBLEM:
GOAL:
CURRENT OBJECTIVES: (Must be behaviorally measurable)
a:
a – Intervention:
b:
b - Intervention:
c:
c - Intervention:
d:
d - Intervention:
e:
e - Intervention:
TYPE OF SERVICES
DATE INITIATED
TARGET DATE
a:
b:
c:
d:
e:
Progress on current/previous goal since last authorization (extension requests only)
Page___ of___
Revised 5/2004
Client Name: ____________________________________________
Date Completed: ______________________
I/We (client/guardian) have actively participated in the development of this service plan and understand the treatment goals and objectives
listed. I have the following comments/response:
____________________________________________________________________________________________________________
I/We (___Agree) (___Disagree) with this service plan.
______________________________________________
Client Signature, 14 or older
Date
_______________________________________________
Parent/Guardian Signature
Date
Witness: _______________________________________
Relationship to client: ______________________________
Date
If unable to sign, document reason:_______________________________________________________________________________
TREATMENT TEAM:
__________________________________________________
Responsible MHP Signature, Degree/License
Date
Type of
Service
Frequency
(per week or month)
Staff/Credentials
(print)
___________________________________________________
Physician, Credentials
Date
____Physician signature not required
Signature
Date
Ind Psy ________Sessions per___________________________________________________________________________________
Int Psy ________ Sessions per___________________________________________________________________________________
Fam Psy _______Hour(s) per____________________________________________________________________________________
Grp Psy _______ Hour(s) per____________________________________________________________________________________
P/S Reh-G ______Hour(s) per____________________________________________________________________________________
P/S Reh-I _______Hour(s) per____________________________________________________________________________________
Psy Test ________Hour(s)_______________________________________________________________________________________
Med T/ S _______ Hour(s) per____________________________________________________________________________________
C/M ___________ Hour(s) per____________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
________________________________________________________________________________________________________
Page _____ of _____
Revised 5/2004
Client Name: _________________________________________
Date Completed: _______________
Recipient ID #: ________________
Provider #: ______________________
Location: ____
Case Mgmt: _____
Psychotherapy:
_____# of 20-30 min sessions per month=
(1 unit= .92 RVU’s)
_____RVU’s per month
_____# of 45-50 min sessions per month=
(1 unit = 1.76 RVU’s)
_____RVU’s per month
_____# of 75-80 min sessions per month=
(1 unit = 2.86 RVU’s)
_____RVU’s per month
_____# of 20-30 min sessions per month=
(1unit = 0.96 RVU’s)
_____# of 45-50 min sessions per month=
(1 unit = 1.85 RVU’s)
_____RVU’s per month
_____# of 75-80 min sessions per month=
(1 unit = 3.00 RVU’s)
_____RVU’s per month
Family Psychotherapy:
_____# of 60 min sessions per month=
(60 min = 2.30 RVU’s)
_____RVU’s per month
Group Psychotherapy:
_____# of 60 min sessions per month=
(60 min = 1.10 RVU’s)
_____RVU’s per month
Individual Psychotherapy:
Interactive Psychotherapy:
_____RVU’s per month
Total Psychotherapy RVU’s per month= ______________
Psychosocial Rehabilitation and Case Management:
Children Group Rehab:
_____# of 60 min sessions per month=
(60 min = 0.68 RVU’s)
_____RVU’s per month
Adult Group Rehab:
_____# of 60 min sessions per month=
(60 min = 0.52 RVU’s)
_____RVU’s per month
Individual Rehab:
_____# of 60 min sessions per month=
(60 min = 1.80 RVU’s)
_____RVU’s per month
Case Management:
_____# of 60 min sessions per month=
(60 min = 1.96 RVU’s)
_____RVU’s per month
Total Psychosocial Rehabilitation/Case Management per month =______________
Combined Total RVU’s =____________
Requested Authorization Dates:
Start Date: ___________________
___3 month ___6 month authorization period
(check one) ___ Extended level of care
Additional / Optional Services:
Medication Training and Support:
_____# of additional sessions per month
Psychological Testing:
_____# of hours
Page _____ of _____
Revised 5/2004
Client Name: ______________________________________
Date Completed: _________________
ADDENDUM
Completion of this page of the request packet is optional for the provider and is not required for the preauthorization process at OFMQ.
The items listed on this page, however, may be required documentation for SURS reviews, CARF certification and/or JCAHO
certification. Please do not submit this form to OFMQ as part of the request packet unless instructed to do so on a specific request by an
OFMQ review coordinator.
COMMUNITY INTEGRATION: ______________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
CAREGIVER RESOURCES (for clients under the age of 21): ______________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
CLIENT’S STRENGTHS/ABILITIES (in client’s own words): _____________________________________________________
____________________________________________________________________________________________________________
CLIENT’S LIABILITIES/NEEDS (in client’s own words): _________________________________________________________
____________________________________________________________________________________________________________
THEORETICAL APPROACH BEING UTILIZED WITH INDIVIDUAL PSYCHOTHERAPY:
____________________________________________________________________________________________________________
COLLABORATION WITH SCHOOL SYSTEM (school age children only): __________________________________________
____________________________________________________________________________________________________________
REFERRALS TO OTHER COMMUNITY SERVICES: ___________________________________________________________
____________________________________________________________________________________________________________
DISCHARGE PLAN:
a. CRITERIA (client-specific behaviors): ________________________________________________________________________
____________________________________________________________________________________________________________
b. ESTIMATED DATE OF DISCHARGE (M/Y): _________________________________________________________________
c. AFTERCARE PLAN: ______________________________________________________________________________________
____________________________________________________________________________________________________________
Client Name:
Date Completed:
INTERPRETIVE SUMMARY/ADDITIONAL INFORMATION: (CONTINUED)
Revised 5/2004
(Page___ of___)