Requesting Authorization for Mental Health Services

Level of Care Calculated (View only)

• This field displays the LOC calculated by CMBHS based on the information entered into the Assessment by the clinician.
• This field will display the LOC based on the answers entered into the Assessment.
• If the Assessment has not been completed at the time that the authorization is requested, the Level of Care Calculated will default to Pre admission.

One of these MH Service Packages will display:

• Adult Mental Health Service Package 0
• Adult Mental Health Service Package 1
• Adult Mental Health Service Package 2
• Adult Mental Health Service Package 3
• Adult Mental Health Service Package 4
• Adult Mental Health Service Package 5

Level Of Care Recommended (Required for mental health services)

• If the client has not been admitted to the business entity, the Level of Care Requested will default to 'None Selected' because there are no services types associated with pre-admission (the default) that require authorization.
• Pre-admission will not be a selectable service package in Level of Care Requested or Level of Care Approved.

Select one of these MH Service Packages :

• Adult Mental Health Service Package 0
• Adult Mental Health Service Package 1
• Adult Mental Health Service Package 2
• Adult Mental Health Service Package 3
• Adult Mental Health Service Package 4
• Adult Mental Health Service Package 5

Service Package Length (Required for mental health services)

• This field reflects the length of time the service package will last.

Reason For Deviation (Required for mental health services)

• If the LOC-R is different from the LOC-C, then a reason for the deviation must be documented.
• One of the following answer choices must be selected.

Answer Choices:

• Client Need
• Client Choice
• Continuity of Care per UM Guidelines
• Resource Limitations

• If there is a reason other than the answer choices above for the deviation between the calculated and a recommended service package, it is documented here. (Required for mental health services)

Begin Date (Required for mental health services)

• Enter the begin date for the services for which you requesting authorization.
• You must enter eight numbers that represent the date and CMBHS will put them into the correct format date format mm/dd/yyyy.

End Date (Required for mental health services)

• The end date cannot be edited past the maximum time allowed for that service package. A service will be unauthorized if the date the service was delivered on a date that is past the new authorization end date.
• You must enter eight numbers that represent the date and CMBHS will put them into the correct format date format mm/dd/yyyy.

Example 1:
The authorization date range cannot be more than 7 days for crisis services.
The end date may not be changed to a date that causes already delivered services to be unauthorized.

Authorization Narrative (This field is optional for mental health services)

• The authorization requester may document any relevant information related to the justification for the request, the client’s special needs or the provider’s circumstances in this text box.
• You may enter unlimited data characters in to this field.