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EPSDT Sample Service Request
This may be used as a guideline for development of a request for services for a specific person. Please be sure to use details, behaviors and symptoms that are specific to each case. For each service, it is recommended that you use the MHP Provider Manual to help establish medical necessity for each specific service. To speed the referral process, please make a telephone referral first for the services you are requesting to Maryland Health Partners at 1-800-888-1965. Mr./Ms. _____________. Case Manager Director of Care Management Maryland Health Partners P.O. Box 3190 Columbia, Maryland 21045
Dear _____________: I am writing to request preauthorization for services under Medical Assistance for _____________, a _____________ year-old _____________ with a diagnosis of _____________, _____________, and _____________ who requires intensive supports and services designed to address her needs. _____________ has been admitted for in-patient treatment at __________________________ _____________ times within the past _____________ days/months. She was hospitalized from _____________ to _____________ and was rehospitalized on _____________. She was in the Adolescent Day Hospital at _____________ from _____________. She was rehospitalized from _____________ and was then in the Day Hospital from _____________ (Provide a summary of recent treatment here). _____________'s most recent in-patient admission, on _____________, was precipitated by _____________ _____________________________________________________________________. She is said to have ______________________________________________________________________________. _____________ reports that she has been __________________________. She has a significant history of _____________ behaviors. Diagnosis: Axis I: _______________________________________ Axis II: _______________________________________ Axis III: _______________________________________ Axis IV: _______________________________________ Axis V: Current GAF: _____________ The treatment team requests that the following medically necessary services be put into place: 1. To address needed behavioral changes, we request that MHP approve services and identify a provider who is a behavioral specialist (Master's or Ph.D. Psychologist) to provide _____________ with behavioral assessment and develop a behavior modification plan that can be implemented by a one-on-one aide in the home as set forth in paragraph 2. These services are medically necessary because _____________ is exhibiting maladaptive behaviors that include _____________. These behaviors interfere with her ability to interact effectively with peers and family and cause imminent risk of harm to self or others. An individualized behavior plan is necessary to reduce maladaptive behaviors and increase functional behaviors and skills. The goals of the services are: - To conduct a comprehensive behavioral assessment. - To develop, implement and evaluate a behavior modification plan to increase the frequency of adaptive behaviors such as __________________________ and decrease maladaptive behaviors such as __________________________. - To provide consultation and supervision to other mental health professionals including a one-on-one home behavioral aid whose primary function is to implement the plan. 2. Until target symptoms are ameliorated, we request that MHP approve services and identify a provider who is able to provide a one-to-one in-home behavioral aid to provide _____________ with intensive in-home support services Monday through Friday for __ hours per day and Saturday and Sundays for __ hours per day. The behavioral aid must have expertise in working with children who are dually diagnosed with psychiatric and developmental disabilities. One of the purposes of this aid is to implement a behavior modification plan that has been developed through services from the behavioral specialist (Master's or Ph.D. Psychologist) indicated in item 1. These services are medically necessary because _____________ demonstrates the following behaviors: _______________________________________ _______________________________________ _______________________________________ (examples of behaviors to include are frequent suicidal and self-harming or aggressive behaviors, an inability to interact effectively with peers and family, difficulty managing activities of daily living, difficulty attending school, is at risk of further hospitalization or RTC placement, is at risk during the transition from an RTC or hospital setting to a home or community setting and her family wishes for _____________ to maintain safety in their home). Additionally, this service will be medically necessary to ensure that the behavior plan developed through the service requested in item 1 is implemented in a manner that is clinically beneficial to _____________. The goals of the services are: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Examples of goals to include are: -To provide intensive daily assessment and differential diagnosis of maladaptive behaviors and identification of effective supports and interventions to reduce them. -To prevent suicidal behavior. -To reduce self-harming or aggressive behaviors and teach _____________ alternative skills such as the ability to express her emotional state, alternative stress reduction strategies and self-calming skills. -To teach _____________ communication and assertiveness skills. -To provide support to assist _____________ in creating behavior patterns and self-motivating skills to rise and prepare for her day each morning. -To provide crisis prevention services as necessary. 3. We request that MHP approve services and identify a provider who is able to provide _____________ with Mobile Treatment services. These services are medically necessary because _____________ is at risk of needing a higher, more restrictive level of care, demonstrates frequent suicidal and self-harming behaviors and her family wishes _____________ to maintain safety in their home. The goals of these services are: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Examples of goals to include are: -To provide ongoing assessment of _____________'s need for mental health treatment and the nature and intensity of the treatment that is needed. -To provide mobile outpatient planning and services to ameliorate psychiatric symptoms. 4. We request MHP approve services and identify a provider who is able to provide _____________ with Targeted Case Management services. These services are medically necessary because she has demonstrated functional impairments that interfere with her functioning in family and community activities; she is at risk of needing a higher, more restrictive level of care and has had _____________ hospitalizations within the past ______ days/months. The goals of these services are: -Ongoing assessment of _____________'s need for mental health services. -To assist _____________ and her family with ongoing linkage to medically necessary mental health services and other support services necessary for treatment of symptoms and ongoing support. -To provide _____________ and her family with access to crisis intervention services as necessary. _____________ is scheduled for discharge to her home on _____ OR was discharged to her home on _____. There is a need for these services to be put in place by (date) or there is an urgent need for these services to be put in place immediately. We request written approval or denial of this request for the above services under Medical Assistance; and written notification if you are unable to secure a provider for any or all of these services. Also, please send a copy of any notice to _____________'s parent, __________ at (address) . Please contact me if you need any further information. In the event you are unable to reach me, please contact the parent directly at (phone number) . Sincerely, __________________________, MD. ATTENDING AND CHIEF OF SERVICE _____________ OR _____________, ____. (Specify license such as Ph.D., LCSW, R.N., Professional Counselor or any other license by a professional of the healing arts.) |
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