Service Request Application (SRA) for:
COMMUNITY-BASED RESIDENTIAL SERVICES FOR CHILDREN AND ADOLESCENTS UNDER 21 (LEVEL A) AND THERAPEUTIC GROUP HOME (LEVEL B)
CONTINUED STAY REQUEST
ALL ITEMS ARE REQUIRED
After response is entered, use the Tab key to advance to next item.
MEMBER INFORMATION / PROVIDER INFORMATIONMember First Name / Provider Name
Member Last Name / Clinical Contact Name
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 / H2022 (Level A) H2020 (Level B)
Modifier / HW (CSA) If HW, Locality Code (required): HK (Non-CSA)
Primary Diagnosis
Secondary Diagnosis
Requested Units
Requested Start Date / Retro Review Request? Yes No
Requested End Date
Place of Service / 56-Psych Residential Treatment Ctr
Intake:
1. Was a service specific provider intake completed with this individual by an LMHP type? Yes No
2. Has an SRA been submitted for this individual for this service within the last 30 days which was not approved? Yes No
a. If yes, describe what changes have occurred to indicate that this service is now necessary:
3. Date of admission to this level of care:
4. Has an Individualized Service Plan (ISP) with all the required elements been completed, signed and dated throughout the entirety of individual’s stay: Yes No
a. Has this ISP been updated at least every 30 days during individual’s stay: Yes No
b. If yes, date of most recent ISP review/signature:
c. Please attach a copy of the most recent ISP with this SRA
5. Is member medically stable? Yes No
a. If no, please explain how member’s condition will be addressed:
6. If this is a dual diagnosis of mental health and substance use disorder, is the focus of treatment on the mental health problem? Yes No Not Applicable
FOR Comprehensive Services Act (CSA) ONLY
7. Has CPMT authorized continuation of services: Yes No
Clinical:
8. Did a QMHP reassess individual for medical necessity for this service after 6 consecutive months of receiving this service: Yes No N/A
a. If yes, was this reassessment signed by an LMHP: Yes No
9. Does individual’s family continue to demonstrate inability to care for individual’s needs such that individual continues to be at risk for higher level of care, OR continues to be at risk for harming self or others: Yes No
a. If yes, please identify individual’s specific current behaviors that put them at risk. Please use specific language and avoid vague words (such as aggressive):
10. Provide a narrative of the behaviors exhibited by the member that warrant the continuation of the requested level of care (please include frequency, intensity, and duration of behavior). Please use specific language and avoid vague words (such as aggressive) and describe behaviors over the past 30 days:
11. Has individual cooperated with rules and supervision provided, as well as treatment? Yes No
a. If no, please identify changes in intervention and/or treatment that have been made:
12. Has the desired outcome of level of functioning been restored or improved in the timeframe outlined in individual’s ISP: Yes No
a. If no, please identify how the ISP has been modified to allow individual to meet their goals in a timely manner:
13. Is the individual at risk for relapse based on history or the tenuous nature of the functional gains, and use of less intensive services will not achieve stabilization? Yes No
a. If yes, please explain:
14. Does the individual meet any of the following (one must be met for authorization of this service):
a. Individual has achieved initial ISP goals but additional goals are indicated that cannot be met at a lower level of care: Yes No
i. If yes, please identify additional goals, and why these can not be met at a lower level of care:
b. Individual has been making satisfactory progress toward meeting goals but has not attained ISP goals, and the goals cannot be addressed at a lower level of care: Yes No
i. If yes, please identify why these can not be met at a lower level of care:
c. Individual has not been making progress, and the ISP has been modified to identify more effective interventions: Yes No
i. If yes, please describe modifications to ISP and why they are likely to be effective:
d. Individual has shown current indications that he/she requires this level of treatment to maintain level of functioning as evidence by failure to achieve goals identified for therapeutic visits or stays in a non-treatment residential setting or in a lower level of residential treatment: Yes No
i. If yes, describe
15. Is weekly individual psychotherapy provided by an LMHP type: Yes No
16. Are seven (7) psychoeducational activities provided each week: Yes No
17. Please describe individual’s current discharge plan (The discharge plan should be comprehensive and should include aftercare services, how the individual will be able to access these services, how individual’s support system will aid in individual remaining in the community or how individual will develop such a support system, and the specific agencies to which the individual will be connected prior to leaving residential care. This plan should connect directly to individual’s treatment plan and account for reducing individual’s need for this level of care. Please avoid simply stating where individual will live upon discharge.):
Service Coordination
18. Have Health, Safety and Welfare issues been identified with this Individual? Yes No
a. If yes, has a Child Protective Services (CPS) referral been made? Yes No
b. If no, what intervention(s) have been taken to address this concern?
19. Does the individual have a primary care physician (PCP)? Yes No
a. If yes, has there been communication with the PCP to provide updates regarding treatment and service coordination? Yes No
b. If yes, name of Physician:
c. If no, have there been efforts to connect the individual with a PCP? Yes No
20. Has the individual expressed suicidal ideation in the last 30 days? Yes No
a. If yes, what is the safety plan?
Revised 4/21/2016 ®Magellan Healthcare, Inc. Page 3 of 3