Applied Behavioral Analysis (ABA) Prior Authorization Request Form (Coordinated Care) Instructions
This form contains 56 fields organized into 16 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| ABA Treatment Goals Agreement | ||
| ABA Treatment Goals Agreement - Yes | Radiobutton |
Check this box if the parent or guardian agrees with the ABA treatment goals.
|
| ABA Treatment Goals Agreement - No | Radiobutton |
Check this box if the parent or guardian does not agree with the ABA treatment goals.
|
| ABA Treatment Review | ||
| ABA Treatment Reviewed by BH Provider: Yes | Radiobutton |
Check this box if the ABA treatment has been reviewed with a Behavioral Health (BH) provider.
|
| ABA Treatment Reviewed by BH Provider: No | Radiobutton |
Check this box if the ABA treatment has not been reviewed with a Behavioral Health (BH) provider.
|
| Behavioral Health Treatment Information | ||
| Current or Historical Behavioral Health Treatment Yes | Radiobutton |
Check this box if the individual has received current or historical behavioral health treatment.
|
| Current or Historical Behavioral Health Treatment No | Radiobutton |
Check this box if the individual has not received current or historical behavioral health treatment.
|
| Name of Treating Behavioral Health Provider | Text |
Provide the name of the Behavioral Health (BH) Provider who is treating the patient.
|
| Current Medications | ||
| Current Medication 1 | Text |
Enter the name and dosage for the first current medication.
|
| Current Medication 2 | Text |
Enter the name and dosage for the second current medication.
|
| Current Medication 3 | Text |
Enter the name and dosage for the third current medication.
|
| Current Medication 4 | Text |
Enter the name and dosage for the fourth current medication.
|
| Current Medication 5 | Text |
Enter the name and dosage for the fifth current medication.
|
| Current Medication 6 | Text |
Enter the name and dosage for the sixth current medication.
|
| Date | ||
| Date | Date |
Enter the date.
|
| First Service Requested | ||
| First Service Requested Procedure Code | Text |
Enter the procedure code for the first service requested.
|
| First Service Requested Start Date | Date |
Provide the start date for the first service requested.
|
| First Service Requested End Date | Date |
Provide the end date for the first service requested.
|
| First Service Requested Units | Number |
Enter the number of units requested for the first service.
|
| ICD 10 Diagnosis Code(s) | ||
| Primary ICD 10 Diagnosis Code | Text |
Provide the primary ICD 10 diagnosis code.
|
| Secondary ICD 10 Diagnosis Code | Text |
Provide the secondary ICD 10 diagnosis code.
|
| Additional ICD 10 Diagnosis Code | Text |
Provide any additional ICD 10 diagnosis code.
|
| Initial ABA Attached Documents | ||
| Initial ABA Initial Evaluation | Checkbox |
Check this box if the Initial Evaluation document is attached for the Initial ABA authorization.
|
| Initial ABA Treatment Plan with Smart Goals | Checkbox |
Check this box if the Treatment Plan with Smart Goals document is attached for the Initial ABA authorization.
|
| Initial ABA Signed Prescription for ABA Therapy Services | Checkbox |
Check this box if a signed copy of the prescription for ABA Therapy Services is attached for the Initial ABA authorization.
|
| Initial ABA The DSM-5 Checklist | Checkbox |
Check this box if The DSM-5 checklist is attached for the Initial ABA authorization.
|
| Initial ABA Level of Support Requirements Form HCA 12-411 | Checkbox |
Check this box if the ABA Level of support Requirements form HCA 12-411 is attached for the Initial ABA authorization.
|
| Medical Conditions | ||
| Reported Medical Conditions | Text |
Please provide all medical conditions as reported by the parent or guardian.
|
| Patient Information | ||
| Patient Name | Text |
Please provide the patient's full name.
|
| Patient Date of Birth | Date |
Please provide the patient's date of birth.
|
| Patient Medicaid Number | Text |
Please enter the patient's Medicaid identification number.
|
| Patient Phone Number | Text |
Please provide the patient's phone number.
|
| PCP Coordination | ||
| PCP Coordination Yes | Radiobutton |
Check this box if coordination of care has occurred with the PCP.
|
| PCP Coordination No | Radiobutton |
Check this box if coordination of care has not occurred with the PCP.
|
| PCP Name | Text |
Enter the full name of the Primary Care Physician (PCP).
|
| Provider Information / Billing Facility | ||
| Provider Name | Text |
Enter the full name of the provider.
|
| Facility Name | Text |
Enter the full name of the billing facility.
|
| Individual/Facility NPI | Number |
Enter the National Provider Identifier (NPI) for the individual or facility.
|
| TIN Number | Number |
Enter the Taxpayer Identification Number (TIN).
|
| Authorized Contact Person | Text |
Enter the name of the authorized specific contact person for this request.
|
| Provider | Radiobutton |
Check this box if the claims will be submitted under the Provider.
|
| Facility | Radiobutton |
Check this box if the claims will be submitted under the Facility.
|
| Fax Number | Text |
Enter the fax number for the provider or facility.
|
| Psychiatrist Coordination | ||
| Psychiatrist Coordination - Yes | Radiobutton |
Check this box if coordination of care has occurred with a psychiatrist.
|
| Psychiatrist Coordination - No | Radiobutton |
Check this box if coordination of care has not occurred with a psychiatrist.
|
| Psychiatrist Name | Text |
Provide the full name of the psychiatrist involved in the coordination of care.
|
| Recertification of ABA Services Attached Documents | ||
| Recertification Current Evaluation/Assessment | Checkbox |
Check this box if a current evaluation or assessment is attached for recertification of ABA services.
|
| Recertification Current Treatment Plan with Smart Goals | Checkbox |
Check this box if a current treatment plan with smart goals is attached for recertification of ABA services.
|
| Recertification Current Level of Support | Checkbox |
Check this box if a current level of support document is attached for recertification of ABA services.
|
| Second Service Requested | ||
| Second Procedure Code | Text |
Enter the procedure code for the second service requested.
|
| Second Start Date | Date |
Enter the start date for the second service requested.
|
| Second End Date | Date |
Enter the end date for the second service requested.
|
| Second Units Requested | Number |
Enter the number of units requested for the second service.
|
| Third Service Requested | ||
| Third Service Procedure Code | Text |
Enter the procedure code for the third requested service.
|
| Third Service Start Date | Date |
Enter the start date for the third requested service.
|
| Third Service End Date | Date |
Enter the end date for the third requested service.
|
| Third Service Units Requested | Text |
Enter the number of units requested for the third service.
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