Get La Amerihealth Caritas Applied Behavioral Analysis (aba) Treatment Request For A Functional 2017

Navigating the LA AmeriHealth Caritas Applied Behavioral Analysis (ABA) Treatment Request For A Functional form can be straightforward with the right guidance. This comprehensive guide provides step-by-step instructions to help you accurately complete the form online.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the member information. Clearly print the patient’s name, legal guardian’s name, date of birth, and Medicaid or health plan number.
3. Next, provide the provider information, which includes the group or agency name, whether in-network, out-of-network, or in the credentialing process. Enter the provider name and credential type (MD, PhD, LMHP, LBA, SCABA, Tech) as applicable.
4. List the physical address, phone number, Medicaid or provider/NPI number, contact name, and fax number of the provider.
5. Detail the DSM diagnosis, including primary diagnosis, secondary diagnosis, and any medical diagnosis as required.
6. Include all required clinical documentation. This section emphasizes that the responsibility to obtain comprehensive diagnostic evaluations rests with the referring or requesting provider.
7. For the treatment request, specify ABA services needed, behavior identification assessment, number of units required, CPT code (0359T), and desired time frame (weekly or monthly). Keep in mind the limitation reminders of four units per authorization and one-hour units.
8. Provide any additional comments or information that may be relevant to the request.
9. Finally, include the provider signature confirming that any paraprofessional under supervision holds the appropriate education, training, and certifications if applicable. Also, record the date of the signature.
10. Review the completed form for accuracy. After confirming all information is correct, you can save changes, download, print, or share the form as necessary.

Complete your document online today to ensure timely processing!