№ lp_1_26004
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Character count: 3900
File size: 26 KB
The document outlines the procedure and requirements for submitting a prior authorization request and referral for Therapeutic Behavioral Services (TBS) for youth in need of mental health support.
Year:
Not specified
Region / City:
Not specified
Theme:
Mental health services, youth support
Document Type:
Form
Organization / Institution:
Optum
Author:
Not specified
Target Audience:
Health professionals, social workers, mental health providers
Effective Period:
Not specified
Approval Date:
Not specified
Date of Changes:
Not specified
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Note:
Year
Topic:
Behavioral Health Services
Document Type:
Assessment Tool
Target Audience:
Service providers, healthcare professionals
Document Type:
Prior Authorization Request and Referral Form
Program:
Therapeutic Behavioral Services (TBS)
Related Services:
Specialty Mental Health Services
Funding Program:
Medi-Cal
Submitting Entity:
Specialty Mental Health Provider (SMHP)
Reviewing Organization:
Optum
Target Population:
Youth under 21 years of age
Eligibility Criteria:
Full-scope Medi-Cal beneficiary status and receipt of specialty mental health services
Authorization Period:
Up to 6 months per cycle
Maximum Weekly Service Amount:
Up to 25 hours (unless otherwise authorized)
Clinical Requirements:
Diagnosis, documented impairment, medical necessity criteria
Involved Parties:
SMHP, TBS Provider, Parent/Caregiver, CWS/Probation (if applicable)
Determination Outcomes:
Authorized, Modified, Reduced, Denied, Terminated, or Suspended
Notification Timeline:
Determination within 5 business days of receipt
Year:
2021
Meeting:
3GPP TSG RAN WG1#105e E-meeting
Dates:
19–27 May 2021
Agenda Item:
8.9.3
Topic:
Support of 1736-bit DL TBS for eMTC
Document Type:
Feature Lead Summary
Organization:
3GPP TSG RAN WG1
Source:
Moderator (Sony)
Release:
LTE Release 17
Technology:
eMTC (LTE-M) / NB-IoT related discussion
Feature:
Maximum DL TBS of 1736 bits
UE Category:
HD-FDD Cat. M1 UEs in CE mode A
Configuration Method:
Unicast RRC configuration
Companies Providing Input:
ZTE, Ericsson, Nokia, Sony
Related Working Groups:
RAN1, RAN2
Referenced Documents:
R1-2104718, R1-2105891
Technical Aspects Discussed:
compatibility with other eMTC features, PUR configuration, multi-TB scheduling, multicast SC-MTCH, L2 buffer size considerations
Year:
2021
Event:
RAN1#105e E-meeting
Organization:
3GPP TSG RAN WG1
Authors:
Moderator (Sony), Ericsson, ZTE, Nokia NSB
Document type:
Technical summary
Scope:
eMTC, HD-FDD Cat. M1 UEs, CE mode A
Agenda item:
8.9.3
Proposals discussed:
DL TBS of 1736 bits in PUR, multi-TB scheduling, SC-MTCH/multicast
Conclusions:
1736-bit DL TBS assumed compatible with all other eMTC features
L2 buffer size recommendations:
24000 bytes for 1000-bit UL-SCH, 30000 bytes for 2984-bit UL-SCH
Date of meeting:
19–27 May 2021
References:
R1-2104718, R1-2105891
Document Type:
Prior Authorization Request and Referral Form
Program:
Therapeutic Behavioral Services (TBS)
Service System:
Specialty Mental Health Services (SMHS)
Related Program:
Medi-Cal
Institution / Organization:
Optum
Submitting Entity:
Specialty Mental Health Provider (SMHP) or TBS Provider
Target Population:
Youth under age 21 receiving Medi-Cal funded specialty mental health services
Eligibility Reference:
DMH Information Notice No. 08-38
Medical Necessity Standard:
BHIN 21-073
Associated Services:
Behavioral Health Assessment (BHA), Outpatient Authorization Request (OAR)
Authorization Period:
Up to 6 months of TBS intervention
Maximum Weekly Service Level:
Up to 25 hours of TBS intervention per week
Service Components:
Assessment (SC48), Plan Development (SC46), Intervention (SC47), Collateral (SC49)
Reviewing Authority:
Optum Clinician
Decision Outcomes:
Authorized, Modified, Reduced, Denied, Suspended, or Terminated
Beneficiary Program:
Medi-Cal Full-Scope Beneficiary
Submission Context:
Request for authorization of behavioral intervention services for eligible youth receiving specialty mental health treatment
Year:
2026
Region / City:
United States
Topic:
Federal procurement and contract management
Document Type:
Policy/Guidance
Agency / Institution:
GSA (General Services Administration)
Author:
GSA
Target Audience:
Contractors, Government Agencies
Period of Validity:
Ongoing
Approval Date:
N/A
Modification Date:
N/A
Year:
2026
Region / City:
N/A
Subject:
Prior authorization requirements for lower extremity endovascular procedures
Document type:
Checklist
Organization:
N/A
Author:
N/A
Target audience:
Healthcare providers
Period of validity:
N/A
Approval date:
N/A
Date of amendments:
N/A
Year:
2023
Region / City:
United Kingdom
Topic:
Accreditation of Prior Learning
Document Type:
Standard Operating Procedure
Institution:
Quality Assurance
Author:
Nicola Bell
Target Audience:
Academic staff, students
Period of Validity:
Until September 2025
Approval Date:
04/09/2023
Review Date:
September 2025
Date of Changes:
04/09/2023
Year:
Not specified
Region / City:
Not specified
Topic:
Prior Authorization Request
Document Type:
Letter
Organization / Institution:
Kyowa Kirin Inc.
Author:
Not specified
Target Audience:
Medical professionals, insurance providers
Period of Effectiveness:
Not specified
Approval Date:
Not specified
Date of Changes:
Not specified
Year:
2023
Region / City:
New York State
Theme:
Cultural Resource Management
Document Type:
Template for Historic Preservation Finding Document
Agency / Institution:
New York State Department of Transportation (NYSDOT)
Author:
Not specified
Target Audience:
Project managers, cultural resource coordinators, historical preservation professionals
Period of Validity:
Not specified
Approval Date:
Not specified
Date of Changes:
Not specified
Year:
2025
Topic:
Free, Prior and Informed Consent (FPIC)
Document type:
Protocol
Organization / institution:
Blue Action Fund
Author:
Blue Action Fund
Target audience:
NGOs, project developers, indigenous peoples, local communities
Period of validity:
Not specified
Approval date:
Not specified
Date of modifications:
Not specified
Organization:
Driscoll Health Plan
Document type:
Clinical policy and administrative guidelines
Revision date:
November 1, 2024
Geographic scope:
Texas
Programs referenced:
STAR, STAR Kids, CHIP
Subject area:
Therapy services prior authorization and medical necessity
Target audience:
Therapy providers and referring physicians
Authorization method:
Provider web portal and fax submission
Related forms:
Texas Standard Prior Authorization Request Form for Health Care Services (TARF), Therapy Referral Review by Ordering Physician Attestation Form
Effective policy elements:
Initial evaluations, re-evaluations, continuation of therapy, start of care rules
Coverage criteria:
Medical necessity based on clinical documentation
Source type:
Health plan policy guideline
Year:
2023
Region/City:
Illinois
Topic:
Youth support services, Therapeutic support services, Prior authorization process
Document Type:
Form
Organization:
Illinois Department of Healthcare and Family Services (HFS)
Author:
Unknown
Target Audience:
Providers of therapeutic and individual support services
Period of Action:
N/A
Approval Date:
N/A
Amendment Date:
N/A
Year:
Not specified
Region / jurisdiction:
South Carolina
Program:
Medicaid
Document type:
Administrative form
Purpose:
Prior authorization review for inpatient services
Submitting method:
Fax
Fax number:
1-855-300-0082
Responsible organizations:
KePRO; South Carolina Department of Health and Human Services
Provider identification:
National Provider Identifier (NPI); Medicaid ID
Mandatory provider location data:
9-digit ZIP code
Review types:
Initial; Recertification; Change; Cancel; Retrospective review
Service setting:
Inpatient; freestanding inpatient psychiatric
Population focus:
Medicaid members; psychiatric services for children under 21 and adults 65 and older
Eligibility window:
Up to 30 days prior to scheduled services
Clinical information required:
Diagnosis; severity of illness; intensity of services
Approval process:
Subject to medical necessity and eligibility verification
Year:
Not specified
Region / City:
Not specified
Theme:
Education, Articulation Agreements
Document Type:
Protocol
Organization / Institution:
University of Kent
Author:
Not specified
Target Audience:
Higher Education institutions, Admissions Officers, Boards of Studies
Effective Period:
Not specified
Approval Date:
Not specified
Amendment Date:
Not specified
Note:
Contextual Description
Year:
2022
Region / City:
United States
Topic:
Medical necessity, prior authorization, spinal cord stimulation
Document Type:
Template letter
Organization / Institution:
Abbott
Author:
Not specified
Target Audience:
Healthcare providers, insurance companies
Period of validity:
Not specified
Approval date:
Not specified
Amendment date:
Not specified
Year:
FY19
Region / City:
Massachusetts
Subject:
Higher Education, Program Proposal
Document Type:
Template
Institution / Organization:
Massachusetts Department of Higher Education
Author:
Massachusetts Department of Higher Education
Target Audience:
Higher education institutions, academic administrators
Effective Period:
Ongoing
Approval Date:
Not specified
Modification Date:
Not specified
Context:
This document is a template for the letter of intent required by institutions proposing new academic programs to be submitted for review and approval by the Massachusetts Board of Higher Education.
Year:
Not specified
Region / City:
Not specified
Topic:
Infliximab dose escalation in Crohn’s disease treatment
Document type:
Medical request letter
Institution / Organization:
Not specified
Author:
Not specified
Target audience:
Insurance company
Period of validity:
Not specified
Approval date:
Not specified
Date of modifications:
Not specified
Jurisdiction:
State of Wisconsin
Issuing body:
Wisconsin Department of Health Services
Division:
Division of Medicaid Services
Program:
ForwardHealth
Legal reference:
Wis. Admin. Code § DHS 107.10(2)
Form number:
F-01430
Form version date:
December 2021
Document type:
Prior authorization medical form
Subject matter:
Prescription authorization for Xyrem and Xywav
Medical conditions referenced:
Narcolepsy with cataplexy, narcolepsy without cataplexy, idiopathic hypersomnia
Intended users:
Prescribers and pharmacy providers
Required attachments:
Medical records, sleep study results, ESS, MWT, MSLT
Regulatory requirement:
Xyrem and Xywav REMS Program compliance
Signature requirement:
Prescriber signature and date