Service Request Application (SRA) for:

INTENSIVEINHOME(IIH) SERVICES

INITIALREQUEST

ALL ITEMS ARE REQUIRED

After response is entered, use the Tab key to advance to next item.

MEMBER INFORMATION / PROVIDER INFORMATION
Member First Name / ProviderName
Member Last Name / ClinicalContactName
Medicaid Number / Provider MIS#
Member Date of Birth / Provider Tax ID#
Provider NPI
Sex / Male Female / Provider Phone / Ext:
Member Phone / Provider Email
Member Address
City, State & Zip Code / Service Address
City, State & Zip Code
CLINICAL INFORMATION
Procedure Code / H2012
Primary Diagnosis
Secondary Diagnosis
Requested Units
Requested Start Date / Retro Review Request? Yes No
Requested End Date
Is this an EPSDT request? / Yes No (Has member received this service for over 6 months with any IIHS provider since beginning of most recent fiscal year(July 1))

Intake:

  1. What was the date of the Intensive In-Home Intake for this individual?
  1. Wasthe Intensive In-Home Intake completed by an LMHP type? Yes No
  1. Has the individual expressed suicidal ideation in the last 30 days?Yes No
  2. If yes, what is the safety plan?

Service Coordination:

  1. Have Health,Safety andWelfareissuesbeenidentifiedwith thisIndividual? Yes No
  2. If yes, has a Child Protective Services (CPS) referral been made?Yes No
  3. If no, whatintervention(s) havebeentakentoaddressthisconcern?
  1. Has the local CSB been contacted to determine if Mental Health Case Management services are being provided? Yes No
  2. Date of Contact:
  3. Name of CSB:
  1. Is the individual receiving Mental Health Case Management? Yes No
  2. If yes, what is the name of the Mental Health Case Manager?
  3. If no, was a referral made to the CSB for Mental Health Case Management with the consent of the parent or guardian? Yes No –If yes, date of referral: If no, why not?
  1. Does the individual have a primary care physician (PCP)? Yes No
  2. If yes, has there been communication with the PCP to provide updates regarding treatment and service coordination? Yes No
  3. If yes, name of Physician:
  4. If no, have there been efforts to connect the individual with a PCP? Yes No
  1. List any physical health conditions which require treatment:
  1. List all medications(forphysical andbehavioral healthconditions) that individualistaking:

Clinical:

  1. Date this individual was admitted to Intensive In-Home Services:
  1. Have you submitted an SRA for this service and this individual in the last 30 days which was not approved? Yes No
  2. If yes, describe what changes have occurred to indicate this service is now necessary:
  1. Does the individual demonstrate a clinical necessity arising from a condition due to mental, behavioral, or emotional illness that results in significant functional impairments in major life activities?Yes No
  1. Is at least oneparentor responsibleadult withwhomtheindividualislivingwillingtoparticipatein intensivein-homeservices,with thegoal of keepingindividualwith thefamily?Yes No
  2. If yes, describe how the family member will be involved in the service:

Individual must meetat least twoof thefollowing threecriteria (14-16)onacontinuingor intermittent basis:

  1. Does theindividualhavedifficulty inestablishingor maintainingnormalinterpersonal relationships tosuchadegreethat theyareat riskofhospitalizationorout-of-homeplacement becauseofconflictswithfamilyorcommunity?Yes No If yes, please explain using specific behaviors and settings in which these occurred including frequency and intensity of these behaviors, and avoiding vague words such as ‘aggressive’:
  1. Does individual exhibit such inappropriate behavior that repeated interventions (documented) by the mental health, social services or judicial system are or have been necessary resulting in being at risk for out of home placement?Yes No If yes, explain the interventions being required by the community systems:
  1. Does the individual exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior to such a degree that they are at risk for out of home placement? Yes No If yes, please explain using specific behaviors and settings in which these occurred including frequency and intensity of these behaviors, and avoiding vague words such as ‘aggressive’:
  1. List initial treatment goals identified at intake for the individual and parent/guardian related to the behaviors above. If immediate physical threat to self or others is indicated in the intake, include safety goals included in the ISP:
  1. Identify how services provided in the child’s residence are more likely to be successful than a clinic:
  1. What is the discharge plan for this client including step down services and connection to community and other natural supports?

Revised 9/15/2016 ®Magellan Healthcare, Inc.Page 1 of 2