Chemical Dependency Treatment
Initial Pre-Certification Review Request Form
Please complete all sections of this form and fax it to (651) 662-0718. You will be notified of the review outcome
within one business day. If you have any questions, please contact provider services Admissions Intake Team at
1-866-938-9741.
Patient Information
Last name: ___________________________ First name: ______________________ Middle initial: _____
Date of birth: ___________
Member ID: ___________________
Admission date: ___________
Number of days requested: ______
Level of care requested (High, Medium, Low Intensity Residential): High Intensity Residential
Assessment Overview
What are this patient’s drugs of choice? Patterns of use?
Does this patient have an increase in tolerance? Do they experience withdrawal symptoms? If so
what are their symptoms?
What is this patient’s drug history? (First use and last use)
What is the patient’s treatment history? (If this patient received previous treatments, what is longest
period of abstinence?)
Continue to next page
X18558R02(02/14)
Family history of chemical dependency/mental health?
What is the impact of this patient’s chemical use? Is there legal, financial, family, social, physical, mental
health impact?
Please provide Intake Dimension Ratings and a brief summary supporting each rating. Please be specific in how
ratings are determined for this patient, where patient struggles, and what goals or recommendations are being
made to aid this patient in this area. Do not use blanket statements, as each patient has unique needs and
struggles.
Dimension 1Dimension 2Dimension 3Dimension 4Dimension 5Dimension 6Person completing form: ____________________________________________
Facility name: ______________________________________________________
Phone number: _________________________
Fax number: _________________________
Concurrent review guidelines:
We will review chemical dependency stays regularly for medical necessity:
• Inpatient stays are reviewed every 2 weeks from the date of admission
• Extended Care stays are reviewed every 3 weeks from date of admission
• Halfway house placements are reviewed every 30 days from date of admission
There may be some exceptions to these timelines based on the patient’s needs/progress.
Please note: A new pre-certification request must be submitted for patients who are transitioning from one
level of care to another prior to the transition.