Progress Report and Continued Services Authorization Request

Autism Spectrum Disorder

Progress Report and Continued Services Authorization Request

PBHCS - ASD Services 1 of 4 Progress Report and Services Request Form 2016

PROVIDERS PLEASE SUBMIT TO PBHCS TO REQUEST AUTHORIZATIONS THIRTY (30) DAYS BEFORE EXPIRATION OF CURRENT SERVICES Please complete all parts as clearly and as specifically as possible. Omissions, generalities, and illegibility will result in the form being returned for completion or clarification. All services require preauthorization Provider(s) Information Referring Pediatrician/Specialist __________________________________________ Phone # ____________ Fax # ____________ Name and Credentials of Provider(s) delivering Services

1) _____________________________________ 2) _____________________________________

Phone # ____________ Phone # ____________

Fax # ____________ Fax # ____________ Group __________________________________________ Contact ________________________________ INN OON NPI# __________________ TAX ID # __________________ Address __________________________________________ City _____________________________________ State ________ Zip ________ Phone # ____________ Fax # ____________ Patient Information PBHCS ID # ___________________________________ UPHS UPenn Name ___________________________________ DOB ____________ Age ________ Address ___________________________________________________________________________________ City ___________________________________ State ____ Zip ________ Guardian ____________________ Relationship to patient _________________ Phone # ____________ Time in Treatment from Initial PBHCS Treatment Plan 6 Months 1 Year

Other ________ Date of Initial PBHCS Treatment Plan ____________




PROGRESS REPORT Please complete the Progress Report below as clearly and as specifically as possible to receive authorization for ongoing services. Omissions, generalities, and illegibility will result in delays, as the form will be returned for completion or clarification. If you submit your own document, please include all information as outlined below. Part 1: Bio-psychosocial update DSM 5 Diagnosis _______________________________________ _______________________________________ _______________________________________ _______________________________________ If applicable, describe changes related to the life and functioning of the child, family structure, and school placement

Part 2: Progress of Target Behaviors that are the Focus of Treatment Below, list Progress in all areas of functioning and for each goal identified in the PBHCS Treatment Plan

List mastered programs/targets and ongoing targets Explain reason for not working on any goals set in the initial PBHCS treatment plan, or that the parents are

concerned about (i.e. the child was not ready to work on this yet, or the behavior was no longer a concern) Submit graphical display of progress

1) First Area of Concern (e.g., functional communication, social skills, self-help skills, etc.)

Treatment Goals Progress

2) Second Area of Concern (e.g., functional communication, social skills, self-help skills, etc.)





3) Third Area of Concern (e.g., functional communication, social skills, self-help skills, etc.) Treatment Goals Progress

4) Fourth Area of Concern (e.g., functional communication, social skills, self-help skills, etc.)


5) List additional goals/target areas as needed

Target Behaviors Treatment Goals

Part 3: Approach to Intervention Treatment Modality (e.g., Discrete Trial, Pivotal Response Therapy, Verbal behavior Therapy, Early Start Denver Model, Floortime)

Intervention Setting(s) Parent Training Discharge Criterion

Autism Spectrum Disorder Progress Report and Continued Services Authorization Request


Part 4: Request for Continued Services

1. Supervision must be delivered to each paraprofessional or BCaBA® level staff a minimum of sixty (60) minutes per month, not to exceedeight (8) hours per month at a ratio of one (1) hour per every ten (10) hours of direct service

2. Treatment Planning is required a minimum of sixty (60) minutes per month, not to exceed eight (8) hours per month at a ratio of one (1)hour per every ten (10) hours of direct service

3. Authorizations can cover a period up to six (6) months and cannot go beyond the benefit year-end date of 6/30; if end date of servicesfalls after 6/30 the remainder of the units will be authorized after 7/1

4. Modifiers 03 School; 12 Home; 14 Group Home; 99 Intermediate Care for the Disables

Increase Services Decrease Services Same Services

If applicable, explain evidence to support changes in treatment hours and type of services

Provider Service Code Service Description Location

Modifier Hours per week

Treatment Dates

Start-End

# of weeks

Total # of 15 minute units

H0031 Functional Behavioral Assessment (FBA) x4 =

H0031 Treatment planning by BCBA/LBS x4 =

H0031 Consultation by BCBA/LBS with _________________ x4 =

H0032 Direct supervision by BCBA/LBS x4 =

H0032 Caregiver Training by BCBA x4 =

H0032 Direct Services by BCBA/LBS x4 =

H2019 Direct services by ABA supervised by a BCBA x4 =

H2014 Social Skills Group x4 = H2021 Therapeutic Support Staff x4 = 90837 Mobile Therapy x4 =

x4 =

Treatment Plan completed by _____________________________________ Submit Roster of Providers

Treating Provider Signature _____________________________________

Date ____________ Phone # ____________ Fax # ____________

Claims payment is subject to eligibility and benefits on the date of service, coordination of benefits, authorization, utilization management guidelines when applicable, and adherence to plan policies, plan procedures, and claims editing logic.

Penn Behavioral Health Corporate Services 3440 Market Street, Suite 450

Philadelphia, PA 19104 Phone: 1-888-321-5533

Fax: 215-746-7454

For Internal Use only PBHCS received on ____________ PBHCS Authorization sent on ____________ CM _______________

Documents

Progress Report and Continued Services Authorization Request