Mental Health Intensive Outpatient Program (IOP)
(All information requested on this form must be complete. Missing data may result in authorization delay.)
PLEASE CHECK IF INITIAL OR CONCURRENT
q Initial Authorization q Concurrent Authorization
•Submission of this information by fax or phone does not constitute authorization of services. Blue Cross of Idaho’s Medical Management department will notify you of
their decision by secure email, mail, phone or fax. Authorization period may not exceed three months without review of medical records. If medical necessity justifies
special handling, please include an explanation.
•Please fax this completed form, along with the medical records documenting the clinical indications or medical necessity to the appropriate fax number listed below.
For questions regarding this form, please call 208-331-7535 or 800-743-1871.
•Please submit all elective prior authorization requests at least 10 days prior to the scheduled date of service.
• If the request is URGENT please check here: q Reason for Urgent: ______________________________________________________
• Behavioral Health: Fax 208-387-6840
Requesting Facility
Facility ID
Date
Office Address
City
State
Contact Person
Phone
Fax
Patient Name
Enrollee ID
Date of Birth
Zip
# Days/ Week# Hours/Day
Submitting Staff Name/Credentials:
Phone #:
Attending MD Name:
Phone #:
Presenting Problem:
Diagnoses: (List by name with accompanying code, include mental and substance use disorders, personality disorders, intellectual disabilities and medical conditions)
Psychosocial and Environmental Stressors:
Risk Assessment
Suicide o YES o NO
Homicide o YES o NO
Self/Other Harm: o Passive
o Thoughts
o Plan
If YES, reported to whom?_____________________________________________________________________
o Intent
o Comments/Safeguards in place:
Current Symptoms
Mood: o Sad
o Elated
Anxiety: o Worry
o Hopeless
o Panic
Thought: o Delusions
o Low Energy
o Fearfulness
o Hallucinations
Behavior: o Aggressive
o Truant
o Poor Concentration
o Compulsive
o None
o Disorganized Speech
o Runaway
o Angry
o Obsessive
o Disorganized Behavior
o Distractible
o Compulsive
Sleep Problems, Describe:_________________________________________________
Eating Disorder: o Restrictive Eating
Substance Abuse: o Cravings
o Compulsive Exercise
o Weight Loss
o Obsessions w/Past Drug Use
o Appropriate
o No Problem
o Other:_________________________
o Other:_________________________
o No Problem
o Hyperactive
Appetite Problems, Describe:______________________________________________
o Binge Eating
o Glorification
o Other:_________________________
o Other:_________________________
o Purging
o Drug-Seeking Behavior
o Food Rituals
o Guilt
o Other:_________________________
o Impulsive
o Irritable
o Frustrated
o Other:_________________________
Functional/Role Impairments
o Leave of absence from work or school
o Loss of residence
o Loss of job
o Socially isolated/withdrawn
o Support system unavailable
o Unemployed and unable to seek work
o Persistent difficulty in work or school
o Unable to care for children or vulnerable adults
o Support system unable to manage symptoms
o Difficulties with ADLs/IADLs
o Support system questionable competent
o Legal problems:_________________________ o Other:_________________________
Current Support Systems
o Work
o Friends
o Community
o Church
o Home
Has a family/support session been completed? o YES
o NO
o Legal
o Other
o N/A
Outcome of session:________________________________________________________________________________________________________________________________
Is treatment mandated by a third party? o YES
o NO
If YES, by whom?__________________________________________________________________________________
OVER *
3000 E. Pine Ave. • Meridian, Idaho 83642 • (208) 345-4550 Mailing Address: P.O. Box 7408 • Boise, ID 83707-1408
Form No. 12-126 (11-14)
©2014 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association
Current Medications (Include dose, duration of Rx and response)
1.
2.
3.
4.
Compliance: __________>90%
__________50%-90%
__________<50%
Reasons for noncompliance:
Treatment History: (include outpatient and inpatient with dates, locations and lengths of stay)
Stage of Engagement (Please select the patient’s response to treatment since last review or start of treatment if this is first report)
o Pre-Contemplation (Client is not yet considering change)
o Contemplation (Client is ambivalently weighing the pros and cons of change)
o Determination/Preparation (Client makes a beginning commitment to the change process)
o Action (Client is taking specific steps towards accomplishing change)
o Maintenance (Client is maintaining the changes made)
o Relapse (Client temporarily returns to pre-change behaviors)
Outline plan to engage internal/external motivators to gain commitment to next stage of engagement________________________________________________________________
________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
Substance Usage
Substance:_______________
Substance:_______________
Length of Current Use:_______________
Length of Current Use:_______________
Quantity:_______________
Quantity:_______________
Frequency:_______________
Frequency:_______________
Date of Last Use:_______________
Date of Last Use:_______________
Goals of Treatment (STATE IN MEASURABLE TERMS)
1.
2.
Target Date
Target Date
3.
4.
Target Date
Target Date
Treatment Progress & Barriers:
Coordination of Care
If no coordination of care, please explain why:____________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
Have you recommended evaluation by psychiatrist/PCP for medication management? o YES
o NO
o No psychotropic medications at this time
Explain outcome: __________________________________________________________________________________________________________________________________
Have other providers been contacted? o YES
o NO
Please list other providers: ___________________________________________________________________________
Planned Discharge date: __________ Is member aware of discharge date?: __________
Was member involved in discharge planning? o YES
o NO
Service Request
Number of Sessions to date:__________
Date of 1st visit:__________
Number of Sessions this plan year:__________
Current Frequency:__________
Date of last visit:__________
If Child/Adolescent: Is family involved? o YES
o NO
If no please explain: ________________________________________________________________________________________________________________________________
Prior Treatment Episodes in past year?
__________MH: # of times: o Outpatient
Outcome: o AMA Discharge
__________SA: # of times:
Outcome: o AMA Discharge
o Inpatient
o Completed Treatment
o Outpatient
o Inpatient
o PHP
o PHP
o Completed Treatment still using
Number of IOP sessions requested:_______________
Requested start date of new auth: ________________
o IOP
o Unknown transferred to another provider
o Other_____________________________________________________
o IOP
o Completed treatment Sober
o Other_______________________________________________________