Prior Authorization Resources

Required Documents for Utilization Management Prior Authorization:

PA (KF-005):

  • Mental/Behavioral Health Assessment signed by QMHP within 1 year of service start date.
  • Mental Health treatment plan (ISSP) signed by QMHP or higher for new provider, signed by Licensed Medical Provider for yearly updates. Must be within 1 year of service start date.

POC (KF-007):

  • Mental/Behavioral Health Assessment signed by QMHP within 1 year of service start date.
  • LOCUS signed by QMHA or higher qualification. Within 1 year (used to be 6 months) of service start date.
  • LSI must be completed by within 1 year (used to be 1 month) of service start date (before or after) by a QMHA or higher.
  • Residential care plan (not MH treatment plan). Must be within 1 year of service start date.

 

Checklist for Applied Behavioral Analysis (ABA) Requests:

The Following Five Items are Required:

  1. A diagnosis of autism spectrum disorder or stereotypy with self-harming behavior from a physician.
  2. An order for ABA treatment from a physician (or appropriately qualified Clinical Psychologist).
  3. An Assessment and Treatment Plan formulated by a licensed ABA therapist
  4. Form KF-004
  5. Form KF-005

Note: The first two bullets are usually the same document.

(An assessment that refers to a doctor that gave a child a diagnosis of autism is not enough. There must be a documented diagnosis and order from the physician.)