Evaluation of Need for ICC

Evaluation of Need for ICC

<p> Evaluation of need for ICC Families with children under 21 in outpatient should be periodically reevaluated regarding their need for Intensive Care Coordination. In order to ensure that this occurs, all MCEs require documentation within 30 days of the first visit and every six months thereafter using this form if the youth has SED Member information Abbreviated medical necessity for ICC*: Name: ______Youth must meet criteria for SED, and must have MassHealth DOB: ______Standard or CommonHealth, and </p><p>{ a. need or receive MassHealth ID: ______multiple services other than ICC from the same or multiple Evaluation information provider(s)</p><p> or Date: ______b. need or receive Does youth meet MNC for ICC?  YES  NO* services from, state agencies, special education, or a *if youth doesn’t meet MNC no parental signature required combination thereof }</p><p> and If yes, has ICC been discussed CURRENTLY with family? c. need a care planning  YES  NO team to coordinate services the youth needs from multiple If NO to discussion, why not? providers or state agencies, special education, or a combination thereof.</p><p>If YES, what is the outcome of the discussion?  Referral made  Referral NOT made</p><p>Clinician name Clinician signature Date</p><p>Parent / guardian name Parent / guardian signature Date</p><p>* For full MNC, refer to: www.mass.gov/eohhs/gov/commissions-and-initiatives/cbhi/home-and-community-based-behavioral-health-srvcs.html</p><p>Version 2/17/16 * For full MNC, refer to: www.mass.gov/eohhs/gov/commissions-and-initiatives/cbhi/home-and-community-based-behavioral-health-srvcs.html</p><p>Version 2/17/16</p>

View Full Text

Details

  • File Type
    pdf
  • Upload Time
    -
  • Content Languages
    English
  • Upload User
    Anonymous/Not logged-in
  • File Pages
    2 Page
  • File Size
    -

Download

Channel Download Status
Express Download Enable

Copyright

We respect the copyrights and intellectual property rights of all users. All uploaded documents are either original works of the uploader or authorized works of the rightful owners.

  • Not to be reproduced or distributed without explicit permission.
  • Not used for commercial purposes outside of approved use cases.
  • Not used to infringe on the rights of the original creators.
  • If you believe any content infringes your copyright, please contact us immediately.

Support

For help with questions, suggestions, or problems, please contact us