Retroactive Authorization Request Form

Mental Health Case Management Retroactive Authorization Request Form

To be used for retro request prior to 12/1/2013 Retro Review service authorization for mental health case management service (MHCM) (H0023) for services delivered prior to December 1, 2013 for an individual who did not have Medicaid at the time the services were delivered.

Submission steps: 1. Complete the Mental Health Case Management Retroactive Authorization Request Form 2. Fax the form to Magellan of Virginia at 1-888-656-2168 3. Magellan will forward the form to DMAS for review.

4. DMAS will enter the results in VAMMIS.

5. If approved, VAMMIS will generate an approval letter.

6. If denied, you will receive a letter from DMAS.

7. DMAS will alert Magellan of the results to input into their system.

8. Providers may email [email protected] if you have questions about Mental Health Case Management service authorization requests with retroactive Medicaid eligibility faxed to Magellan.

Required information for requests for Mental Health Case Management delivered prior to 12/1/13. 1. Provider Contact Name: 2. Provider Contact Number: 3. Provider email address:

4. Provider MIS #:

5. Provider NPI#:

6. Member Name:

7. Member Medicaid Number:

8. Member date of birth:

9. DSM diagnostic codes:

10. Admission Date:

Revised 2/24/2014 11. Requested start date:

12. Requested end date:

13. Requested number of units:

For Adults 18 and older:

14. Does the individual meet at least two of the following criteria on a continuing or intermittent basis:

1) Is unemployed; is employed in a sheltered setting or supportive work situation; has markedly limited or reduced employment skills; or has a poor employment history. Yes No

2) Requires public financial assistance to remain in the community and may be unable to procure such assistance without help. Yes No

3) Has difficulty establishing or maintaining a personal social support system. Yes No

4) Requires assistance in basic living skills such as personal hygiene, food preparation, or money management. Yes No

5) Exhibits inappropriate behavior that often results in intervention by the mental health or judicial system. Yes No

15. The individual is expected to require services of an extended duration, or the individual’s treatment history meets at least one of the following criteria:

1) The individual has undergone psychiatric treatment more intensive than outpatient care more than once in his or her lifetime (e.g., crisis response services, alternative home care, partial hospitalization, and inpatient hospitalization). Yes No

2) The individual has experienced an episode of continuous, supportive residential care, other than hospitalization, for a period long enough to have significantly disrupted the normal living situation. Yes No

16. Does the individual have a co-occuring mental health and substance use disorder? Yes No

16a. If yes, are the activities of the case manager related to substance abuse treatment intended to positively impact the mental health condition? Yes No

17. Is the individual expected to require services of an extended duration? Yes No

For individuals aged birth to 17:

Revised 2/24/2014 18. Does the child/adolescent exhibit all of the following: -Problems in personality development and social functioning that have been exhibited over at least one year’s time Yes No

-Problems that are significantly disabling based upon the social functioning of most children that age Yes No

-Problems that have become more disabling over time Yes No -Service needs that require significant intervention by more than one agency Yes No

Children diagnosed with Serious Emotional Disturbance and a co-occurring substance abuse or intellectual disability (mental retardation) diagnoses may also be eligible for Case Management for Serious Emotional Disturbance.

For individuals aged birth to 7:

19. Does the child meet at least one of the following: -The child exhibits behavior or maturity that is significantly different from most children of that age and which is not primarily the result of developmental disabilities or mental retardation Yes No -Parents, or persons responsible for the child’s care, have predisposing factors themselves that could result in the child developing serious emotional or behavioral problems (e.g., inadequate parenting skills, substance abuse, mental illness, or other emotional difficulties, etc.) Yes No

-The child has experienced physical or psychological stressors that have put him or her at risk for serious emotional or behavioral problems (e.g., living in poverty, parental neglect, physical or emotional abuse, etc.) Yes No

Revised 2/24/2014