The purpose of this letter is to clarify procedure for obtaining pre-authorization for ABA treatment from Midwest Behavioral Health Network (MBHN).

Transcription

1 Dear ABA Prvider: The purpse f this letter is t clarify prcedure fr btaining pre-authrizatin fr ABA treatment frm Midwest Behaviral Health Netwrk (MBHN). Prir t beginning new services, please instruct families t call MBHN t initiate ABA services, prir t setting up treatment. MBHN will wrk with the family t btain a clear diagnsis, which may require additinal testing. All infrmatin needed by MBHN must be cllected prir t the issuance f an authrizatin fr ABA evaluatin/treatment. A preliminary authrizatin fr 8 hurs (32 units) f will be issued after MBHN has cmmunicated directly with parent. This 8 hurs is t be used t cllect baseline infrmatin necessary t cmplete the MBHN Request fr ABA Treatment frm fr nging treatment, which must be submitted prir t rendering additinal treatment. The MBHN Request fr ABA Treatment frm fr must be submitted t request authrizatin fr nging treatment. This frm must be typewritten, with every sectin cmplete. All data supplied must be quantifiable and measureable (gals, baseline data, and any prgress). ONE frm shuld be submitted per treatment perid, which includes all past and present gals. Requests submitted n any ther frm will nt be reviewed. If any part f the frm is incmplete, it will be returned t yu unprcessed. The MBHN Request fr ABA Treatment frm is a Wrd Dcument int which data shuld be typed. Please add as many rws as necessary t list all gals, and FAX this frm t The MBHN Request fr ABA Treatment frm includes: 1. Administrative Infrmatin. Include prvider infrmatin, member infrmatin, units per CPT cde that are being requested per week, start and end date, and where treatment will ccur. 2. Ten narrative questins. Answers shuld be succinct and patient specific. 3. Clinical Data. All data (fr Gals, Baseline, and Prgress) must be Quantifiable & Measurable. Include ALL gals (past, current and new) n this frm. A Quantifiable & Measurable Gal might be: Will independently engage in parallel play near peer child fr a minimum f 2 minutes, in 30 minute bservatins, acrss 5 sessins. Targeting will be either Nt Yet Targeted, r a date indicating when targeting began. Quantifiable & Measurable Baseline is the member s level f functining PRIOR t initiatin f treatment. A baseline measure fr the abve gal might be: 0 minutes/2 minutes. Initial baseline can be taken per parent reprt. Prgress at Date f Request is a quantifiable measure f member s CURRENT functining.

2 Prgress fr abve gal might be: Imprvement during last treatment perid: 45 secnds/2 minutes in 3/5 sessins. If the gal has been met prvide the date it was met. The number f gals submitted must supprt the number f units per week yu are requesting. Gals shuld nt be academic in nature, as this is a behaviral health benefit nly. Subsequent Request fr ABA Treatment frms will include ALL gals, including all gals previusly met in treatment. In additin, new gals will be added t the same frm. Parental participatin with a BCBA is expected fr all treatment received in the hme. Fr facility based treatment, parents are expected t participate a minimum f 1 hur fr every 20 hurs f treatment. MBHN supprts ABA that ccurs in the natural envirnment (hme and schl), as this will mre quickly prmte generalizatin f skills. Upn receipt f the MBHN Request fr ABA Treatment frm, the infrmatin will be reviewed. If any infrmatin is missing, the frm will be returned t the prvider, unprcessed. After a cmpleted request is received, it will be reviewed, a letter will be sent t the member s physician prvider, and a decisin rendered. At any pint in this prcess additinal infrmatin may be requested. After all necessary infrmatin is submitted, it culd ptentially take 2-3 weeks fr review and creatin f authrizatin. Please plan accrdingly by submitting yur request with cmplete infrmatin 3-4 weeks befre yur current authrizatin expires. Authrizatins will generally be issued fr 6 mnths f treatment. Hwever, if prgress is less than expected, an authrizatin may be issued fr a shrter perid f time. Please frward this infrmatin t any BCBA at yur facility wh may be requesting pre-authrizatin frm MBHN fr ABA services. If yu have any questins abut prcedure, please cntact me. Sincerely, April Walker, MSW, LCSW Supervisr f Clinical Services Midwest Behaviral Health Netwrk Ph: , ext 1812

3 Develpmental Disability-Children s Glbal Assessment Scale Review the subject s perfrmance acrss the main dmains f functining [a) self care, eating, dressing, sleeping; b) cmmunicatin; c) scial behavir; and d) academic perfrmance] and settings [hme, schl, and cmmunity]. Scre verall level f functining by selecting the heading that describes functining relative t typically develping child f the same age. Use intermediary levels (e.g., 35, 58, 62), as needed. Scres shuld indicate actual level f functining, regardless f treatment r prgnsis. Fcus n functinal interference f psychpathlgy rather than symptms per se. The descriptrs prvided belw are nly illustrative and are nt required fr a particular rating Superir functining. Superir functining within family, schl, with peers. Superir accmplishments relative t age peers (e.g., high achievement in Scuts). Schl-age child ding well academically. Independently perfrms daily activities and self -care apprpriate fr age Adequate functining in all areas: hme, schl, and peers; brief disturbances f behavir r emtinal distress in respnse t life stresses (e.g., unanticipated changes in daily rutine r physical envirnment), but n interference with functining. Adaptive skills at age level in all dmains Slight impairment in functining. Mst daily living activities at age level, but may need prmpts and structure t accmplish. Minr changes in daily rutine r envirnment may cause transient decrease in functining. Scial interactins may be ne-sided and activity-based rather than intimacy-based. May appear immature, but nt deviant. Language generally age-apprpriate but cnversatins may be ne-sided and/r fcused n preccupatins Slight impairment in functining and mderate impairment in at least ne dmain. Scial deficits apparent in mst situatins. Learns apprpriate scial skills, but inflexibly and unable t generalize. Adaptive/self-help skills immature in mst areas. Behavir nticeably unusual in sme situatins (e.g., scial grups, unstructured settings) affecting scial acceptance, and may restrict participatin in agenrmative activities in ne r tw dmains r in a specific setting Mderate impairment in functining in mst dmains. Needs cnsiderable structure and supervisin fr daily rutines. Daily living/adaptive skills are belw age level. Cmmunicates needs, respnds t basic requests (verbally r nnverbally). Verbal language, if present, is inflexible and delayed. Scial deficits and/r unusual behavirs are apparent in mst settings and cntribute t functining belw age expectatin Mderate impairment in functining in mst dmains and severe impairment in at least ne dmain (e.g., daily living r cmmunicatin). Scial vertures and/r respnses are markedly absent r inapprpriate. Daily living skills significantly delayed (e.g., dressing, bathing, eating). Steretypic and/r ther persistent unusual behavirs are nticeable t a casual bserver and impede functining Severe impairment in functining in sme dmains. Rudimentary instrumental (nt scial) cmmunicatin skills. Repetitive behavirs that interfere with adaptive functining. Marked scial withdrawal in mst situatins. Adaptive behavir significantly impaired. Significant envirnmental accmmdatins are needed in sme dmains. Very immature adaptive and self-care skills in at least tw dmains Severe impairment in all dmains and settings, (e.g., hme and schl). Markedly withdrawn and islated behavir. Requires extensive envirnmental accmmdatins (e.g., 1:1 supervisin fr behavir, lcking cabinets, remving breakable bjects frm bedrm). Dependent in all aspects f daily living (e.g., dressing, bathing, tileting) beynd age expectatin. May exhibit disturbance f basic regulatry prcess (e.g., sleeping, feeding) Extreme impairment in at least ne dmain. Needs cnstant supervisin; r extensive envirnmental accmmdatins fr safety r fr basic care (e.g., feeding, tileting). May need residential placement. Des nt cmmunicate basic needs. Des nt interact with thers. Marked disturbance f basic regulatry prcesses (e.g., sleeping, feeding) Extreme and pervasive impairment. Pses danger t self r thers. Needs intensive cnstant supervisin (e.g., 24-hr care utside f the hme) fr safety r ttal dependence in basic self-help skills. Marked disturbance f basic regulatry prcesses. Needs specialized care (e.g., behavir management r medical care) beynd what can be prvided at hme and by utpatient supprt services.

4 Instructins fr Raters Areas t be cnsidered in ratings include: Overall functining in majr adaptive dmains: Self care: eating, dressing, sleeping Cmmunicatin Scial behavir Academic perfrmance and setting Cnsistency r incnsistency f functining acrss settings: hme, schl, cmmunity Level f envirnmental adaptatin needed Level f supervisin needed 1. Use the table belw t rganize yur judgment f impairment acrss the fur dmains f functin. 2. Chse the header/categry that best describes general functining (ex: mderate impairment in functining in mst areas ). The descriptr shuld be a gd descriptin f the general functining f the child, regardless f whether the surce f impairment is cgnitive, behaviral r ther. Yu are cmparing the descriptin f adaptive functining t what wuld be expected f a typically develping child, regardless f whether the impairment is due t develpmental disability, behaviral disturbance, envirnmental factrs, r ther. Be wary f placing t much emphasis n standard scres; variability in functining may get averaged ut in the standard scre. Instead, place mre emphasis n descriptins f functining. 3. Check details f that categry t cnfirm that this is a general descriptin, but nte that mst children will nt fit perfectly int any particular categry. Yu are lking fr the best fit. 4. When yu think yu have fund the best fit, lk at the tw adjacent categries, t see if the child has sme characteristics that fit int the next higher r lwer categry. This will help yu adjust yur scre. Fr example, if the child fits best int Mderate impairment in functining in mst areas but has sme similarity t 41-50, yu wuld scre in the lwer half f the range (51-55). Cnversely, if the child fits best in but has sme strengths that are cnsistent with the next higher categry, yu wuld scre in the tp half f the categry (55 60). DOMAIN Self Care Cmmunicatin Scial Behavir Schl/Academic LEVEL OF IMPAIRMENT Nne Slight Mderate Severe Extreme The DD-CGAS was adapted frm the Children s Glbal Assessment Scale (CGAS; Shaffer et al, 1983) and the Glbal Assessment Scale (GAS; Endictt et al, 1976). Suggested reference: Wagner A, Lecavalier L, Arnld LE, Aman MG, Scahill L, Stigler KA, Jhnsn CR, McDugle CJ, Vitiell B. Develpmental disabilities mdificatin f the Children s Glbal Assessment Scale. Bil Psychiatry 61: Nte. Readers are permitted t make free cpies, as required. Electrnic cpies f the DD-CGAS can be btained by writing t the authrs.

5 NEW AVENUES / MBHN: Request fr ABA Treatment Midwest Behaviral Health Netwrk P.O. Bx 360, Suth Bend, IN Phne: (866) Fax: (574) Facility/Cmpany: Prviding BCBA and Licensure: Site Address: Fax: Phne: Date Span f Requested Auth: Prvider Signature: Date Signed: Member Name: DOB: Parent/Primary Guardian Name: Parent Phne: Health Plan: Member ID: Diagnsis: Diagnsing Prvider: Treatment Plan: Observatin Assessment 1 st Review 3 Mnth Review 6 Mnth Review Prcedure Cde Prcedure Descriptin Units Requested per week BCBA: Initial assessment (15 min unit) units/wk BCBA: Reassessment (15 min unit) units/wk BCBA: Behavir Assessment (15 min unit) units/wk BCBA: Grup (15 min unit) units/wk BCBA: Health & Behavir Family with patient present (15 min unit) units/wk BCBA: Health & Behavir Family w/ patient present (15 min unit) units/wk Direct Care: Therapeutic activities (15 min unit) units/wk Direct Care: Develpment f cgnitive skills,1:1 (15 min unit) units/wk Direct Care: Sensry Integrative Techniques (15 min unit) units/wk Direct Care: Self care/hme management skills ADLs (15 min unit) units/wk Start Date End Date Place f Service: Facility, Hme, Schl Services Listed Belw Must Be Pre-Authrized Thrugh Medical Netwrk 97001/02 Physical Therapy (1hr unit) 97003/04 Occupatinal Therapy (1hr unit) 92506/07/08 Speech Therapy (1hr unit) IS PROVIDED DATA QUANTIFIABLE AND MEASURABLE? THIS REQUEST WILL NOT BE PROCESSED IF DATA IS NOT QUANITIFIABLE/MEASURABLE

6 1. Summary paragraph f member s treatment/prgress fr last authrized treatment perid: 2. Prgress during last authrized treatment perid: a. Number f Gals Imprved: b. Number f Gals Regressed: c. Number f Gals w/ N Prgress d. Number f Gals On Hld e. Number f Gals NYT 3. Develpmental Disability Children s Glbal Assessment Scale Scres (See frm fllwing instructin letter): a. Self Care: b. Cmmunicatin: c. Scial Behavir: d. Schl/Academic: 4. Family Invlvement with BCBA, A minimum f 50% f all parental invlvement must be face-t-face. Hme-based - parent r guardian has been present at all times. Schl-Based, Full-Time - parent r guardian has participated 1 hur per week. Schl-Based, Full-Time - parent r guardian has participated 2 hurs per week. Facility-Based, Part-Time - parent r guardian has participated 1 hur per week. Facility-Based, Full-Time - parent r guardian has participated 2 hurs per week. 5. Describe any medical/health c-existing cnditins present? And are they being treated? 6. What medicatins are prescribed? Wh is the prescribing physician? 7. Describe any cgnitive/intellectual delays present? 8. Describe any scial envirnmental barriers r stressrs affecting prgress? 9. Has attendance been steady as recmmended? If nt, please explain: 10. Hw is treatment addressing schl transitin r adaptatin issues? IS PROVIDED DATA QUANTIFIABLE AND MEASURABLE? THIS REQUEST WILL NOT BE PROCESSED IF DATA IS NOT QUANITIFIABLE/MEASURABLE

7 INFORMATION MUST BE TYPEWRITTEN, ADD ROWS AS NECESSARY TO LIST ALL GOALS. REFER TO DIRECTION LETTER AS NECESSARY. QUANTIFIABLE & MEASURABLE GOAL TARGETING QUANTIFIABLE & MEASURABLE BASELINE PROGRESS AT DATE OF REQUEST Example: Will hld eye cntact, 90% f the time when being spken t, ver 3 cnsecutive days. Nt Yet Targeted 02/03/13 Nt Yet Targeted Nt Yet Targeted Nt Yet Targeted Nt Yet Targeted As f 01/01/14, hlds eye cntact 0% f the time. Imprvement, during last treatment perid: 25% ver 3 days. Regressin, as evidenced N Prgress On Hld as f: Gal Met as f: Imprvement, during last treatment perid: Regressin, as evidenced N Prgress On Hld as f: Gal Met as f: Imprvement, during last treatment perid: Regressin, as evidenced N Prgress On Hld as f: Gal Met as f: Imprvement, during last treatment perid: Regressin, as evidenced N Prgress On Hld as f: Gal Met as f: Imprvement, during last treatment perid: Regressin, as evidenced N Prgress IS PROVIDED DATA QUANTIFIABLE AND MEASURABLE? THIS REQUEST WILL NOT BE PROCESSED IF DATA IS NOT QUANITIFIABLE/MEASURABLE

8 On Hld as f: Gal Met as f: Nt Yet Targeted Nt Yet Targeted Nt Yet Targeted Nt Yet Targeted Imprvement, during last treatment perid: Regressin, as evidenced N Prgress On Hld as f: Gal Met as f: Imprvement, during last treatment perid: Regressin, as evidenced N Prgress On Hld as f: Gal Met as f: Imprvement, during last treatment perid: Regressin, as evidenced N Prgress On Hld as f: Gal Met as f: Imprvement, during last treatment perid: Regressin, as evidenced N Prgress On Hld as f: Gal Met as f: IS PROVIDED DATA QUANTIFIABLE AND MEASURABLE? THIS REQUEST WILL NOT BE PROCESSED IF DATA IS NOT QUANITIFIABLE/MEASURABLE