initial prior authorization request (cm-01) · pdf fileinitial prior authorization request...
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Case Management for Children and Pregnant Women
Initial Prior Authorization Request (CM-01)
Client Last NameWebber
Client First NameMaryiah
Medicaid Number530399619
Medicaid TypeTraditional Medicaid
Client Date of Birth2/8/2005
GenderF
Language PreferenceEnglish
Parent/GuardianTiffoney Jacobs
Home Phone(832) 523-4925
Alternate Phone
Mailing Address 11431 Ella Blvd
Mailing Address 2Apt 3911
CityHouston
Zip77014
PCPUnknown
Referral Date4/18/2018
Referral AgencyLegacy Community Health
Name of ContactDana Kober MD
Agency Phone Number(832) 548-0000
Health Condition, Health Risk or High-Risk Condition:Document health condition/s or describe specific health risk/s, symptom/s, developmental delay/sand/or behaviors. Additionally, describe how health condition, health risk, symptoms, developmentaldelays and/or behaviors impacts level of functioning. For a pregnant woman, describe high-riskcondition and describe how high-risk condition impacts level of functioning.Patient is 13 year old female with psychosis. She is in 6th grade at Bammel Middle School (Spring ISD). Mother reportedthat patient started being evaluated at school in January 2018. Mother had the ARD meeting on 4/16/18. Per mother, shefelt pressured and bullied at the ARD meeting. Mother reported that patient was placed in the most restrictive environment.Patient has psychosis and Dr. Kober recommends a less "chaotic environment." Also, mother reported that specialeducation services "should have started on 4/17" but have not. Also, mother reported that patient is not appropriatelysupervised. Mother reported that she has attempted to change the placement but has not been successful. Also, motherhas considered transferring patient to another school. Mother requested assistance with school advocacy resources andschool advocacy coaching. Mother can benefit from receiving school advocacy resources and education about her schoolrights.
Psychosocial Factor:If indicated, describe any specific high-risk psychosocial factors that are impacting the healthcondition, health risk, or high-risk condition.Mother unaware of her school rights and school advocacy resources.
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Case Management for Children and Pregnant Women
Initial Prior Authorization Request
Client Last NameWebber
Client First NameMaryiah
Medicaid Number530399619
For Pregnant Women - Expected date of delivery
The client is a:Child (age 0-20) with health condition or health risk
Pregnant woman (of any age) with a high-risk condition
Specific Needs related to the Health Condition/Health Risk/High-Risk Condition:In each box, describe one specific need and intervention. If indicated, list and describe any barriersor problems related to accessing the specific need. (Only document up to three specific needs).
School advocacy resources: SW will assist with school advocacy and will provide school advocacy resources.
By completing and submitting this request:
I attest that the client/parent/guardian has confirmed the documented needs, was informed of choice of case managementproviders and desires case management services.I confirm that the information is true and correct to the best of my knowledge.
I understand that Prior Authorization is a condition of reimbursement for services and not a guarantee of payment.
Name of Person Completing FormPriscila Leal LMSW
Date Intake Completed4/19/2018
Case Manager NamePriscila Leal LMSW
Case Manager TPI Number
Case Management ProviderLegacy Community Health
Provider TPI Number080462703
Group NPI1679524961
Case Manager NPI
Provider Phone Number(832) 548-5327
Provider Fax Number(832) 548-5284
Case Manager [email protected]