Applied Behavioral Analysis (ABA) Prior Authorization Request Form (Health Net Behavioral Health Autism Center) Instructions
This form contains 55 fields organized into 19 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Case Supervisor Information | ||
| Case Supervisor Name and Credentials | Text |
Enter the full name and any relevant credentials of the case supervisor.
|
| Case Supervisor National Provider Identifier (NPI) | Text |
Provide the case supervisor's National Provider Identifier (NPI).
|
| Case Supervisor Phone Number | Text |
Enter the contact phone number for the case supervisor.
|
| Case Supervisor Email | Text |
Provide the email address for the case supervisor.
|
| Case Supervisor Availability for Callback | Text |
Indicate the days and times when the case supervisor is available for a callback.
|
| Sessions per_Week | CheckBox | |
| Sessions per_Month | CheckBox | |
| Hours per auth period 5_Week | CheckBox | |
| Hours per auth period 5_Month | CheckBox | |
| Hours per auth period 6_Week | CheckBox | |
| CPT Code 0362T | ||
| CPT Code 0362T Hours | Number |
Enter the total hours for CPT Code 0362T per authorization period.
|
| CPT Code 0373T | ||
| CPT Code 0373T Hours | Number |
Enter the number of hours for CPT Code 0373T.
|
| CPT Code 97151 | ||
| CPT Code 97151 Hours Per Auth Period | Number |
Enter the total number of hours requested for CPT Code 97151 per authorization period.
|
| CPT Code 97152 | ||
| CPT Code 97152 Hours per Authorization Period | Number |
Enter the total number of hours requested per authorization period for CPT code 97152.
|
| CPT Code 97153 | ||
| CPT Code 97153 Hours | Number |
Enter the total hours per week for CPT Code 97153.
|
| CPT Code 97154 | ||
| CPT Code 97154 Hours | Number |
Enter the total hours for CPT Code 97154.
|
| CPT Code 97155 | ||
| CPT Code 97155 Hours per | Number |
Enter the number of hours per week or month for CPT Code 97155.
|
| CPT Code 97156 | ||
| CPT Code 97156 Hours | Number |
Enter the number of hours requested for CPT Code 97156.
|
| CPT Code 97157 | ||
| CPT Code 97157 Hours per | Number |
Enter the number of hours per for CPT Code 97157.
|
| CPT Code 97158 | ||
| CPT Code 97158 Hours per Auth Period | Number |
Enter the number of hours for CPT Code 97158 per authorization period.
|
| HCPCS Code H0031 | ||
| HCPCS H0031 Hours per Auth Period | Number |
Enter the number of hours for HCPCS code H0031 per authorization period.
|
| Hours per auth period 10_Week | CheckBox | |
| HCPCS Code H0032 | ||
| HCPCS Code H0032 Hours | Number |
Provide the number of hours for HCPCS Code H0032.
|
| Hours per auth period 10_Month | CheckBox | |
| Hours per auth period 11_Week | CheckBox | |
| Hours per auth period 11_Month | CheckBox | |
| HCPCS Code H2014 | ||
| HCPCS H2014 Hours | Number |
Enter the number of hours for HCPCS code H2014.
|
| HCPCS Code H2019 | ||
| HCPCS Code H2019 Hours per | Number |
Enter the number of hours for HCPCS Code H2019.
|
| HCPCS Code S5111 | ||
| S5111 Sessions | Text |
Enter the total number of sessions for HCPCS Code S5111.
|
| Member Information | ||
| Member ID Number | Text |
Enter the member's identification number.
|
| Member Date of Birth | Date |
Enter the member's date of birth.
|
| Member First Name | Text |
Enter the member's first name.
|
| Member Last Name | Text |
Enter the member's last name.
|
| Member Address | Text |
Enter the member's full address.
|
| Hours per auth period 6_Month | CheckBox | |
| Hours per auth period 7_Week | CheckBox | |
| Hours per auth period 7_Month | CheckBox | |
| Hours per auth period 8_Week | CheckBox | |
| Hours per auth period 8_Month | CheckBox | |
| Proposed Authorization Dates | ||
| Proposed Authorization Start Date | Date |
Enter the proposed start date for the authorization.
|
| Proposed Authorization End Date | Date |
Enter the proposed end date for the authorization.
|
| Week | Checkbox |
Check this box if the authorization for CPT code 97157 is proposed per week.
|
| Month | Checkbox |
Check this box if the authorization for CPT code 97157 is proposed per month.
|
| Provider Information | ||
| Provider Facility/Group Name | Text |
Enter the name of the provider facility or group.
|
| Provider Taxpayer Identification Number (TIN) | Text |
Enter the provider's taxpayer identification number (TIN).
|
| Provider Address | Text |
Enter the street address of the provider.
|
| Provider City, State, Zip | Text |
Enter the provider's city, state abbreviation, and zip code.
|
| Provider Phone Number | Text |
Enter the provider's phone number.
|
| Provider Fax Number | Text |
Enter the provider's fax number.
|
| H0032 Hours per Week | Checkbox |
Check this box to indicate that H0032 services will be reported or authorized on a weekly basis.
|
| H0032 Hours per Month | Checkbox |
Check this box to indicate that H0032 services will be reported or authorized on a monthly basis.
|
| H2014 Hours per Week | Checkbox |
Check this box to indicate that H2014 services will be reported or authorized on a weekly basis.
|
| H2014 Hours per Month | Checkbox |
Check this box to indicate that H2014 services will be reported or authorized on a monthly basis.
|
| H2019 Hours per Week | Checkbox |
Check this box to indicate that H2019 services will be reported or authorized on a weekly basis.
|
| H2019 Hours per Month | Checkbox |
Check this box to indicate that H2019 services will be reported or authorized on a monthly basis.
|