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
Patient name:
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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
Patient name:
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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
Patient name:
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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
Patient name:
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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
Patient name:
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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.