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Level 1 Family Type (H0046) Initial: In Network Providers are eligible for Notification Authorization of up to 180 days. Out of Network providers are not eligible for Notification Authorization and are required to submit the following:
Service Authorization Request (SAR)
Person Centered Plan (PCP) with Service Order
Comprehensive Clinical Assessment (CCA)
Concurrent:
Service Authorization Request (SAR)
Updated Person Centered Plan (PCP)
Level 2 Group Home (H2020) Initial: In Network Providers are eligible for Notification Authorization of 120 days. Out of Network providers are not eligible for Notification Authorization and are required to submit the following:
Service Authorization Request (SAR)
Person Centered Plan (PCP) with Service Order
Comprehensive Clinical Assessment (CCA)
Concurrent:
Service Authorization Request (SAR)
Updated Person Centered Plan (PCP)
Comprehensive Clinical Assessment (CCA) within prior 60 days for continued stay beyond 12 months
Level 3 and Level 4 Group Home (H0019 with modifiers)
Mandatory referral to Care Management
Initial: In Network Providers are eligible for Notification Authorization of 120 days for Level 3 and 60 days for Level 4. For Level 4, members must be age 14+ to be eligible for Notificaiton Authorization. Out of Network providers are not eligible for Notification Authorization and are required to submit the following:
Service Authorization Request (SAR)
Person Centered Plan (PCP) with Service Order
Comprehensive Clinical Assessment (CCA) completed within 30 calendar days from the requested initial authorization start date
Transition/Discharge Plan (Federally Required)
Concurrent:
Service Authorization Request (SAR)
Updated Person Centered Plan (PCP)
Transition/Discharge Plan (Federally Required)
For length of stay beyond 180 days: Independent updated Psychiatric or Psychological Evaluation. If provider is a CABHA agency, this is not required to be an independent evaluation
Level 3 SAY Program (H0019 TJ HE)
Mandatory referral to Care Management
Initial: In Network Providers are eligible for Notification Authorization of 120 days. Out of Network providers are not eligible for Notification Authorization and are required to submit the following:
Service Authorization Request (SAR)
Person Centered Plan (PCP) with Service Order
Comprehensive Clinical Assessment (CCA) or CCA addendum completed within 30 days prior to admission
Transition/Discharge Plan (Federally Required)
A current specific evaluation that addresses sexual harm behaviors (within last 3-6 months)
If psychological w/in last 30 days that addresses both MH and the sexualized behaviors, this can be accepted without CCA
Concurrent:
Service Authorization Request (SAR)
Updated Person Centered Plan (PCP)
Transition/Discharge Plan (Federally Required)
For length of stay beyond 180 days: Independent updated Psychiatric or Psychological Evaluation
If provider is a CABHA agency, this is not required to be an independent evaluation
Service Definition Authorization Parameters
Level 1 Family Type (H0046)
Concurrent: up to 180 days
Level 2 Group Home (H2020)
Concurrent: up to 90 days
Level 3, Level 3 SAY Program and Level 4 Group Home (H0019 with modifiers)
H0019 HQ 22- Enhanced Residential for Complex Needs
H0019 22 US HE - Res L3 >5 Specialized Prog
H0019 HK - HRI Res Level IV 4 beds or less
H0019 HQ - HRI Res Level III, 4 beds or less
H0019 TJ - HRI Res Level III, 5 beds or more
H0019 UR HRI Res Level IV, 5 beds or more
H0046 - HRI Residential level I
H2020 - HRI Residential Level II Group Home
H0019 TJ HE- HRI Res Level III 5 beds or more
Full Service Definition
Alliance Statement of Work
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