substance use disorder withdrawal management …... wapec-1683-18 october 2018 substance use...

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https://providers.amerigroup.com WAPEC-1683-18 October 2018 Substance Use Disorder Withdrawal Management Prior Authorization and Continued Care Request (Use for American Society of Addiction Medicine [ASAM] withdrawal management levels of care) To avoid delays in processing, please fill this form out completely and fax to Amerigroup Washington, Inc. at 1-877-434-7578. If you have any questions, please contact Provider Services at 1-800-454-3730. Member information Name: Amerigroup ID: Date of birth: Address: City: State: ZIP code: Provider information Facility name: Facility NPI/TIN: Facility address: Office contact: Phone: Fax: Provider name: Provider NPI: ASAM level of care: 1-WM 2-WM 3.2-WM 3.7-WM 4-WM Admit date: DSM-V diagnoses: Please list all diagnoses (psychiatric, chemical dependency and medical) Current risk factors Suicide None Ideation Intent without means Intent with means Contracted not to harm self Homicide None Ideation Intent without means Intent with means Contracted not to harm others Physical or sexual abuse or child/elder neglect: Yes No If yes, patient is: Victim Perpetrator Both Neither, but abuse exists in family

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Page 1: Substance Use Disorder Withdrawal Management …... WAPEC-1683-18 October 2018 Substance Use Disorder Withdrawal Management Prior Authorization and Continued Care Request (Use for

https://providers.amerigroup.com

WAPEC-1683-18 October 2018

Substance Use Disorder Withdrawal Management Prior Authorization and Continued Care Request

(Use for American Society of Addiction Medicine [ASAM] withdrawal management levels of care)

To avoid delays in processing, please fill this form out completely and fax to Amerigroup Washington, Inc. at 1-877-434-7578. If you have any questions, please contact Provider Services at 1-800-454-3730.

Member information

Name:

Amerigroup ID: Date of birth:

Address:

City: State: ZIP code:

Provider information

Facility name: Facility NPI/TIN:

Facility address:

Office contact: Phone: Fax:

Provider name: Provider NPI:

ASAM level of care:

☐ 1-WM ☐ 2-WM ☐ 3.2-WM ☐ 3.7-WM ☐ 4-WM

Admit date:

DSM-V diagnoses: Please list all diagnoses (psychiatric, chemical dependency and medical)

Current risk factors

Suicide

☐ None ☐ Ideation ☐ Intent without means ☐ Intent with means ☐ Contracted not to harm self

Homicide

☐ None ☐ Ideation ☐ Intent without means ☐ Intent with means ☐ Contracted not to harm others

Physical or sexual abuse or child/elder neglect: ☐ Yes ☐ No

If yes, patient is: ☐ Victim ☐ Perpetrator ☐ Both ☐ Neither, but abuse exists in family

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Patient name:

Page 2 of 6

Abuse has been legally reported: ☐ Yes ☐ No

Abuse or neglect involving a child or elder: ☐ Yes ☐ No

Risk history

Current risk factors

Explain any significant history of suicidal, homicidal, impulse control or other behavior that may impact the patient’s level of functioning:

Job/school

Housing

Legal issues

Family history of mental illness or substance abuse

Page 3: Substance Use Disorder Withdrawal Management …... WAPEC-1683-18 October 2018 Substance Use Disorder Withdrawal Management Prior Authorization and Continued Care Request (Use for

Patient name:

Page 3 of 6

Vital signs

Date Time BP Respiration Pulse Temp

ASAM dimensions

I: Intoxication/withdrawal potential

Alcohol withdrawal

CIWA score:

☐ BAL ☐ Breathalyzer results

Withdrawing from other substances? If yes, provide all currently used substances:

☐ Yes ☐ No

History of blackouts? If yes, provide details:

☐ Yes ☐ No

History of seizures? If yes, provide details:

☐ Yes ☐ No

History of DTs? If yes, provide details:

☐ Yes ☐ No

Current withdrawal symptoms

☐ Tremor (shakes) ☐ Agitation ☐ Sweating ☐ Tachycardia

☐ Craving for alcohol ☐ Irritability ☐ Disorientation ☐ Hypertension

☐ Anxiety ☐ Loss of appetite ☐ Visual hallucinations ☐ Fever

☐ Insomnia ☐ Vomiting ☐ Auditory hallucinations ☐ Seizure

☐ Vivid dreams ☐ Headache ☐ Tactile hallucinations

Opioid withdrawal (select the category which best describes the current symptoms)

COWS score:

☐ Occasional yawning, slight pupillary dilation, rhinorrhea, chills, mild anxiety

☐ Frequent yawning, piloerection, abdominal cramps, nausea, loose stools, body aches, mild elevation of BP or pulse, mod sweating, anxiety, tremulousness, restlessness, irritability

☐ Vomiting, diarrhea, observable tremor, mild fever, mod elevation in BP or pulse, significant anxiety, sweating, restlessness, body aches, pupillary dilation, piloerection

☐ Debilitating vomiting and diarrhea, agitation, gross tremor, fever, severe elevation of BP or pulse

II. Significant active co-occurring physical health conditions? If yes, provide details:

☐ Yes ☐ No

II. Significant active co-occurring behavioral health conditions? If yes, provide details:

☐ Yes ☐ No

Page 4: Substance Use Disorder Withdrawal Management …... WAPEC-1683-18 October 2018 Substance Use Disorder Withdrawal Management Prior Authorization and Continued Care Request (Use for

Patient name:

Page 4 of 6

ASAM dimensions

III. Comprehension Please provide details:

☐ Awake ☐ Alert ☐ Knows name

☐ Knows location ☐ Knows date

III. Ability to understand and follow treatment recommendations? Please provide details:

☐ Good

☐ Fair

☐ Poor

IV. Level of cooperation? Please provide details:

☐ Cooperative

☐ Sometimes cooperative

☐ Uncooperative

IV. Commitment to WD management process? Please provide details:

☐ Committed

☐ Questionable

☐ Low commitment

V. Imminent risk of relapse? If yes, provide details:

☐ Yes ☐ No

VI. Support from family/friends/community? Please provide details:

☐ Strong support

☐ Moderate support

☐ Poor support

Medications (optional for nonphysicians):

Current medications Dosage Frequency

Patient’s treatment history, including all levels of care:

Mental health level of care

Number of distinct episodes/ sessions

Date of last episode/session

Substance Use Disorder (SUD) level of care

Number of distinct episodes/sessions

Date of last episode/ session

Inpatient — mental health

Inpatient/RTC — SUD

Page 5: Substance Use Disorder Withdrawal Management …... WAPEC-1683-18 October 2018 Substance Use Disorder Withdrawal Management Prior Authorization and Continued Care Request (Use for

Patient name:

Page 5 of 6

Patient’s treatment history, including all levels of care:

PHP — mental health

PHP — SUD

IOP — mental health

IOP — SUD

Outpatient —mental health

Outpatient — SUD

Withdrawal management/detox

Treatment goals

1.

2.

3.

Objective outcome criteria by which goal achievement is measured

1.

2.

3.

Discharge plan (SUD, BH, PCP appointments, housing, community supports)

Expected outcome and prognosis

☐ Return to normal functioning

☐ Expect improvement, anticipate less than normal functioning

☐ Relieve acute symptoms, return to baseline functioning

☐ Maintain current status, prevent deterioration

Page 6: Substance Use Disorder Withdrawal Management …... WAPEC-1683-18 October 2018 Substance Use Disorder Withdrawal Management Prior Authorization and Continued Care Request (Use for

Patient name:

Page 6 of 6

Number of days:

Estimated discharge date:

Provider signature:

Date:

Phone: Fax:

Disclaimer: Authorization indicates that Amerigroup determined medical necessity has been met for the requested service(s) but does not guarantee payment. Payment is contingent upon the eligibility and benefit limitations at the time services are rendered.