Prior Authorization Form

This is the Maine Behavioral Health ASO KEPRO CareConnection® Authorization Request Form. This form is to be used by providers to submit request for Initial Registration for MaineCare members and other consumers as appropriate.

Fields with a (*) next to them are required. Please submit this information via KEPRO CareConnection® whenever possible. If necessary, you may complete and fax this form to KEPRO at 1-866-325-4752. Please call KEPRO Provider Relations with any questions, as 1-866-527-0027, Option 1.

*Member Information

*Member MaineCare ID:

*Member First Name: *Member Last Name:

*Member SSN:	*Date of Birth:

*Gender: Female Male Unknown	Phone Number (with area code):

*Address of Record:

*City:	*State:	*Zip Code:

*AMHI Consent Decree Class Member: YES NO

*Race:	White	Black or African American	Alaskan Native

Native Hawaiian	American Indian	Hispanic

Asian	Other Pacific Islander	Other Race

Unknown

Guardian/Power of Attorney

Guardian Organization (if applicable): Child Welfare Elder Services Office of Cognitive Disabilities

Guardian First & Last Name: Phone Number:

Guardian Address:

City: State: Zip Code:

Relationship to Member:	Family Member Friend Agency Spouse Other

Additional Information:

*Administrative Data

*Authorization Type:

*Organization:

* Submission Date: *Requested Start Date of Service:

* Review Type:

*Category of Service: CHOOSE ALL THAT APPLY

Adult Mental Health	Children’s Services

Community Integration	Targeted Case Management

Intensive Case Management	Inpatient Services

Assertive Community Treatment	Day Treatment

Daily Living Support Services	Crisis Support Services

Skills Development	Infant Mental Health

Day Supports	Children’s Outpatient

Specialized Group Services	Family PsychoEducational

Crisis Supports Services	Child Assertive Community Treatment

Hospital Services – Acute	Medication Services

Home Based	Child & Family Behavioral Health Treatment

Group Psychotherapy	Community Based Treatment without Permanency

Medication Management	Private Non-Medical Crisis Unit

Psychotherapy	Treatment Foster Care

PNMI	Children’s PNMI Services

Psychological Services	Multidimensional Treatment Foster Care

Family PsychoEducational	Baxter Fund Services

Community Rehabilitation Services	Provided by an Educational System

Long-Term Supported Employment	Rehab and Community Support Services – Section 28

Baxter Fund Services	Partial Hospitalization

Dorothea Dix/Riverview	Intensive Outpatient Program

Partial Hospitalization	Behavioral Health Homes

Intensive Outpatient Program

Home and Community Benefits for Adults	Substance Abuse Services

Behavioral Health Homes	Inpatient Substance Abuse

Clubhouse	Outpatient Substance Abuse

ITRT Referral	Intensive Outpatient Program

Grant-Funded Adult Services	Psychological Services

Community Integration	Psychological Services

Assertive Community Treatment

Daily Living Support Services

Community Rehabilitation Services

Location (for PNMI, Crisis Units, & Hospitals):

Referral date:	Location at Time of Referral: Hospital Community

Date Case Worker Assigned: / / Date Seen Face to Face: / /

*Requesting Agency/Facility

* Requesting Facility/Agency Name:

* Requesting Staff First & Last Name:

*Requesting Staff Phone (with Area Code):

UM/Supervisor Name/Phone:

*Diagnostic Assessment

*Date of Diagnostic Assessment:

*Primary Diagnosis: Diagnosis: Diagnosis:

Diagnosis: Diagnosis:

Other Medical Conditions:

*Procedure Request

*Procedure Request

*Service Code:

*Frequency:	*Units:

*Start Date: *NPI Number:

*Service length and end date will automatically populate based on the type of service. The units for most services will also auto-populate.

Symptoms/Behavior Summary (Required for Section 17 Services Only)

Has member become homeless or at risk of losing his/her current residence?	YES NO
Is member causing repeated disturbances in the community because of poor judgment or bizarre, intrusive, or ineffective behavior?	YES NO
Is member at great risk of arrest because of behavior which results from his or her psychiatric diagnosis, or is presently incarcerated because of such behavior?	YES NO
Does member present a clear risk of harming self or others without community supportive services?	YES NO
Does member manifest great difficulty in care for self, posing a threat to his/her life or limb without community support services?	YES NO
Would member deteriorate clinically to a point of needing immediate medical or psychiatric hospitalization in the absence of prompt community services?	YES NO

Assessment Tools (required as appropriate):

Date LOCUS Completed (Most Recent): Rater ID:

LOCUS Composite Score (1-35): Caregiver Questionnaire:

LOCUS Level of Care:	ASAM Level:

CAFAS/PECFAS (required as appropriate):

Date CAFAS/PECFAS Completed (Most Recent):

School/Work/Preschool:	0	10	20	30

Moods/Emotions:	0	10	20	30

Home:	0	10	20	30

Self-Harmful Behavior:	0	10	20	30

Community:	0	10	20	30

Substance Abuse (CAFAS Only)	0	10	20	30

Behavior Towards Others:	0	10	20	30

Thinking/Communication:	0	10	20	30

Agency Involvement (check all that apply):	Family/Social Involvement (check all that apply):

DHHS Adult Mental Health	Family

DHHS Child Welfare	Spouse/Partner

DHHS Elder Services	Friends

Corrections (Court, JCCO, etc.)	Religious Group

EAP	Community Resources

Special ED/505	AA/NA or Self-Help Group

None	None

Other:	Other:

Rate Overall Level of Family Involvement in Treatment Goals:

Rate Overall Level of Natural Supports Involvement with the

Client/Family:

*Psychiatric Medications

*Is the member prescribed medication?	YES NO
If yes, does member take prescriptions as prescribed?	YES NO
Did you notify the member’s PCP of this medication?	YES NO
Is the member’s PCP prescribing psychiatric medications to the member?	YES NO

Please list all currently prescribed psychiatric medications:

Clinical Indicators Justifying Service Request

Select the time period that describes the individual’s most recent occurrence for each indicator that applies.

Risk/Danger to Self/Others

Name of Symptom	Indicate Current Severity	Indicate History of Severity
Aggressive:
Fire Setting:
Assaultive:
Homicidal Attempt:
Homicidal Ideation:
Self-Care Deficit:
Self-Injurious Behavior:
Sexually Inappropriate Behavior:
Suicide Attempt:
Suicidal Ideation:
Use of Weapons:
Harm to Animals:

Symptoms and Behaviors

Name of Symptom	Indicate Current Severity	Indicate History of Severity
Anxiety/Panic:
Attachment Problems:
Depressed mood:
Dissociative Symptoms:
Grandiose/Hyper-Religious:
Hopeless/Helpless:
Hyperactive:
Hyper-vigilance:
Impulsive:
Insomnia:
Irritable:
Lying/Manipulative:
Obsessions/Compulsions:

Oppositional Behavior:
Phobias:
Property Destruction:
Psychomotor Retardation:
Racing Thoughts:
Running Away:
Sexually Inappropriate Behavior:
Separation problems:
Social Withdrawal:
Stealing:
Trauma-Related Symptoms:
Truancy:
Verbal Aggression:

Thought, Attention, and Cognition

Name of Symptom	Indicate Current Severity	Indicate History of Severity
Decreased Concentration:
Dementia:
Disorganized Thinking:
Distractible:
Hallucinations:
Paranoid:
Poor Judgment:
Thought Disorder:

Drugs and Alcohol

Name of Symptom	Indicate Current Severity	Indicate History of Severity
SA-Related Medical Problems:
Over-the-counter medications:
Alcohol Use/Abuse:
Illicit Drug Use/Abuse:
Prescription Drug Use/Abuse:

Treatment and Service History

Select the tool(s) used to screen for co-occurring mental health and substance abuse disorders using the check boxes. Next to each selected tool, indicate if there were one or more YES responses. If the AC-OK is used, answer for all 3 domains. If the MHSK III is used, CRAFFT or UNCOPE must also be used

AC-OK MH Issues Domain YES NO	UNCOPE YES NO
AC-OK MH Trauma Issues Domain YES NO	CRAFFT YES NO
AC-OK Sub. Abuse Issues Domain YES NO	MSHF III YES NO

Date of Assessment for Co-Occurring Disorders: / /

Have you communicated with the Member’s PCP to coordinate mental health and physical health care?	NO YES N/A
Is member receiving integrated MH/SA Services?	NO YES
How long has member been receiving this service?
Number of Inpatient Admission in the last 12 months:	0 1-2 3-4 5 or more
Number of ER or other crisis episodes in the last 12 months:	0 1-2 3-4 5 or more
Number of years of active mental health treatment:	0 1-2 3-4 5 or more
Number of lifetime homeless episodes:	0 1-2 3-4 5 or more
Number of lifetime jail/prison terms:	0 1-2 3-4 5 or more
Currently on probation/parole or conditional release?	NO YES
For youth in school, number of suspensions in the last 12 months:	0 1-2 3-4 5 or more
For youth under age 18, number of times run away for over a 24hr. period:	0 1-2 3-4 5 or more

RDS (Required for Section 17, CI, ACT, CRS and Adult BHH Services)

RDS (Required for Section 17 CI, ICI, ICM, and ACT Services) *ISP Status: Initial ISP 90-Day Review of ISP Annual Review of ISP Person w/ISP left CSS Program

Needed Resources (check all that apply)	Date Identified	Date Satisfied	No Longer
Mental Health Services
Assertive Community Treatment (ACT)
Community Integration Services
Dialectical Behavioral Therapy
Family Psycho-Educational Treatment Services
Group Counseling
Individual Counseling
Inpatient Psychiatric Facility
Intensive Case Management Services
Intensive Community Integration Services
Psychiatric Medication Management
Other Mental Health Services
Mental Health Crisis Planning Services
Development of Mental Health Crisis Plan
Development of Mental Health Advance Directives
Other Mental Health Crisis Planning
Peer Recovery and Support Resources
Peer Recovery Center
Recovery Workbook Workgroup
Social Club
Peer-Run Trauma Recovery and Empowerment Group
Wellness Recovery and Action Planning
Family Support
Other Peer Recovery and Support
Substance Abuse Services
Outpatient Substance Abuse Services
Residential Treatment Substance Abuse Services
Needed Resources (check all that apply)	Date Identified	Date Satisfied	No Longer
Other Substance Abuse Services
Housing Resources
Supported apartment
Community Residential Facility
Residential Treatment Facility
Assisted Living Facility
Nursing Home
Residential Crisis Unit
Rent Subsidy
Other Housing Resources
Health Care Resources
Dental Services
Eye Care Services
Hearing Services
Physical Therapy
Physician Medical Services
Other Health Care Resources
Legal Resources
Advocates
Guardian (Private)
Guardian (Public)
Other Legal Resources
Financial Security Resources
Assistance w/ Managing Money
Assistance w/ Securing Public Benefits (e.g. SSI, TANF, Food Stamps, MaineCare)
Representative Payee
Other Financial Security Resources
Education Resources
Adult Education (Other than GED)
GED
Literacy Assistance
Post High School Education (Incl. 2 & 4 yr. courses of study)
Tuition Reimbursement related to Employment Goals
Other Education Resources
Vocational/Employment Resources
Benefits Counseling Related to Employment
Club House/Transitional and/or Peer Vocational Support
Competitive Employment (No supports)
Supported Employment
Vocational Rehabilitation
Other Vocational/Employment Resources
Living Skills Resources
Daily Living Support Services
Day Support Services
Occupational Therapy
Skills Development Services
Other Living Skills Resources
Transportation Resources
Transportation to ISP – Identified Svs.
Transportation to other ISP – Identified Activities
After Hours Transportation (Evenings and Weekends)
Other Transportation Resources
Personal Growth/Community Participation Resources
Avocational Activities
Recreation Activities
Social Activities
Spiritual Activities
Other Personal Growth/Comm. Participation Resources
Other Resources
Other Resources

*Individual Treatment Plan

*Describe member’s strengths and skills (Check all that apply):

Positive family network

Interest in work/volunteer activity

Good problem-solving skills/able to seek help when needed

Natural supports

Stable home setting

Good self-awareness/self-understanding

Consumer’s strengths are incorporated into the treatment plan

Positive peer support

Realistic, positive, expectations and goals for future

Spiritual/Cultural involvement

Good physical health/self-care

Involvement in positive activities/interests

Other:

Additional Required Reporting Data (as applicable)

Current Living Situation:

Homeless Shelter or on the streets	Own apartment or home

Temporarily staying with others	Supported apartment

Community Residential Facility	Nursing Home

Residential Treatment Facility (Group Home Arrangement)	Residential Crisis Unit

Riverview Psychiatric Center	Dorothea Dix Psychiatric Center

Other Psychiatric Inpatient Unit or Facility	Hospitalized for Medical Reasons

Incarcerated in a State Prison or County Jail	Foster Care

Other:

Does the member receive a Rent Subsidy?	YES	NO

Current Vocational/Employment Status:

Volunteer

Sheltered/Enclave Worker

Self-Employed

Currently receiving Vocational Rehabilitation Service

Competitively Employed Full Time (32 or more hours per week)

Competitively Employed Part Time (Less than 32 hours per week)

Working with Supports Full-Time (32 or more hours per week)

Working with Supports Part Time (Less than 32 hours per week)

Not employed – Not looking for work

Not employed – Looking for work

Other:

Does the member receive Vocational Rehabilitation Services?	YES	NO

Was the member involved with the legal system/police within the last 6 months?	YES	NO

Since the last authorization period, has the member missed a significant number

of days of school?	YES	NO	UNKNOWN

Transition Discharge Plan – Check all that apply

*Is Discharge anticipated during the Authorization Period?	YES	NO

Projected Date of Transition/Discharge:

Anticipated Step Down Services:

Natural Supports	Respite	AA/NA

Peer Support	Outpatient	Groups

Psychiatric/Medication Management	Case Management/CI	Section24

Day Treatment	ACT/CI	Corrections

65M&N	Adult Home-Based Services	DLSS

Substance Abuse Treatment	Crisis Services	Crisis Unit

Foster Care/Child Welfare	Adult Protective	Supported Nursing Facility

Medical Hospitalization	Residential Treatment

Other:

Plan for Transition/Discharge:

Additional Information

*Additional Information

*Provider Name:

*Provider Electronic Signature:

*Date: