BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ...

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Inpatient Treatment Services Request Form Member Name: ____________________ Member ID:_____________ DOB: _____________ *Attach H&P and clinical information including medications and fax to: (715) 852-5755 Axis I: ___________________ Axis II: ___________________ Axis III:___________________ Axis IV:___________________ Chapter 51/Emergency Detention Mental Health Detox Inpatient AODA Axis V: ____________________ Date of Admission __/__/__ Estimated Length of Stay: _____ Actual D/C Date: __/__/__ Brief Summary of Current Clinical Status/Admission Information: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Provider Name:_______________________ Phone: _________________ Fax: ____________ Facility Name: ________________________Address: _________________________________ Tax ID: __________________________ I certify that I am the provider who will be delivering the services listed above and that the information contained herein is true and correct to the best of my knowledge. Provider Signature _________________________________________ Date_______________ The submission of supporting clinical documentation/plan of care is required with this form Fax completed form to: (715) 852-5755 Group Health Cooperative Health Management Phone: (800) 218-1745 Revised: 3/24/11 Health Management Fax: (715) 852-5755 GHC11022
Intensive In-Home Therapy Request Form Member Name: __________________________________Member ID:_____________DOB:___________ *Please attach clinical information/progress notes, current medications and therapeutic goals and fax to (715)‐852‐5755 Diagnosis Patient Participation: Poor Fair Good Axis I:______________________ Axis II:______________________ Estimated number of visits (total):___________ Estimated or Actual Discharge Date:__________ Axis III:_____________________ Mental Health AODA Dual Diagnosis Axis IV:_____________________ Axis V:______________________ Therapy CPT Code:_______ Frequency per Week:_________ Hours Per Week:_______ Travel CPT Code:_________ Auth Period to Begin:__________ Brief Summary of Clinical Status: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Criteria for Termination: _____________________________________________________________________________________ _____________________________________________________________________________________ *GHC does not require a psychiatric assessment to qualify for this service. Notes from an assessment with at least a Masters Level Provider indicating CURRENT symptoms/behaviors, severity of affected functioning and availability/competency of member’s support system is required. *Health Check screening documentation is required with this request. Members without a Health Check screen performed within the past 12 months will not be approved for this service. General follow up appointments with a Primary Care Provider DO NOT qualify as a Health Check. *At no time will GHC reimburse for more than two hours of travel time per visit. Revised: 6/15/11 Health Management Fax: (715) 852-5755 GHC11091 Page 1 of 2
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BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ...

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