Magellan Behavioral Health Of Pennsylvania, Inc. Intensive .

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Magellan Behavioral Health of Pennsylvania, Inc.Intensive Behavioral Health Services (IBHS) Written Order LetterCover PageThis cover page must accompany Part A (Initial Written Order) or Part B (Written Order for Continued IBHS Treatment) tocomplete the Written Order.Member’s Name:Date of Birth:Medical Assistance ID #:Date of Written Order:County of Residence: Select OneParent/Guardian’s Name(s):School (If Applicable):Other Agency Involvement (If Applicable):Following my recent face-to-face appointment and/or evaluation onwithless intrusive levels of care such as, I am making the following Written Order:It is medically necessary thatServices (IBHS)., and after considering less restrictive,receive a comprehensive face-to-face assessment for Intensive Behavioral HealthAlong with this Written Order, I have included clinical documentation to support the medical necessity of the servicesordered, including a behavioral health disorder diagnosis (listed in the most recent edition of the DSM or ICD), andmeasurable improvements in the identified therapeutic needs that indicate when services may be reduced, changed, orterminated, as per regulations.Current Behavioral Health Diagnosis:A behavioral health diagnosis is necessary to initiate IBHS. In addition, please include other behavioral health and/or physicalhealth diagnoses, or issues of concern as applicable (Reference Mixed Services Protocol List ary Behavioral Health Diagnosis:Additional Behavioral Health Diagnosis:Additional Behavioral Health Diagnosis:Additional Behavioral Health Diagnosis:Medical Conditions/Physical Health Diagnosis:Medical Conditions/Physical Health Diagnosis:Medical Conditions/Physical Health Diagnosis:List Measurable Goals and Objectives to be met with IBHS:1.2.3.4.5.6.7.8.Magellan Behavioral Health of Pennsylvania, Inc. (Magellan) is an affiliate of Magellan Healthcare, Inc. 2004-2020 Magellan Health, Inc. This document is the proprietary information of Magellan.Rev: 1/30/2020Page 1 of 7

Magellan Behavioral Health of Pennsylvania, Inc.Intensive Behavioral Health Services (IBHS) Written Order LetterCover PageList Clinical Information that supports the Medical Necessity of the Order:1.2.3.4.5.6.7.8.List Measurable Improvements that would indicate when services may be Reduced, Changed or Terminated:1.2.3.4.5.6.7.8.Magellan Behavioral Health of Pennsylvania, Inc. (Magellan) is an affiliate of Magellan Healthcare, Inc. 2004-2020 Magellan Health, Inc. This document is the proprietary information of Magellan.Rev: 1/30/2020Page 2 of 7

Magellan Behavioral Health of Pennsylvania, Inc.Intensive Behavioral Health Services (IBHS) Written Order LetterPart A: Initial Written Order for Initial Assessment, Stabilization andTreatment InitiationA comprehensive, face-to-face assessment is recommended to be completed by an IBHS clinician to further define how therecommendations in this order will be used and to inform and complete an Individualized Treatment Plan (ITP). IBHSTreatment Services may also be delivered during the assessment period for stabilization and treatment initiation provideda treatment plan has been developed for the provision of these services. Please select the assessment type and treatmentservices necessary for stabilization that you are recommending based on the symptom(s), behavior(s) of concern and thesettings/domains in which they are occurring. All sections within one row must be completed for a service to beappropriately authorized.Service TypeAssessment Type/Clinician TypeIBHS Assessment forIndividual, Group or Evidencebased Services NOTE:Assessment must occur within15 days of service initiationIBHS ABA Assessment for ABAservices (for ABA DesignatedProviders with an IBHSLicense) NOTE: Assessmentmust occur within 30 days ofservice initiationBHRS Assessment for BHRSServices NOTE: Assessmentmust occur within 15 days ofservice initiationBHRS Assessment for ABAServices (For ABA DesignatedProviders without an IBHSLicense) NOTE: Assessmentmust occur within 30 days ofservice initiationIBHS Individual Services/Evidence-Based BHRSException ServicesIBHS Clinical Assessment by aMT, BC, or Graduate LevelProfessional (when MST, FFT,PCIT, CRR HH or an IBHSGroup Service)ABA Assessment by a BCBA orBC-ABAIBHS Group Services/BHRSExceptionsEarly Childhood TreatmentSocial Skills TreatmentSummer Therapeutic Program(STAP)Therapeutic After SchoolProgramMaximum Number of Hoursper Month (hpm)(IBHS agency may provide less,as clinically indicated)Settings in which Service isNecessaryEpisode Start date, specify:HomeSchool, specify:Community, specify:Episode Start date, specify:HomeSchool, specify:Community, specify:BHRS Clinical Assessment byan MT or BSCEpisode Start date, specify:HomeSchool, specify:Community, specify:ABA Clinical Assessment by anBSC or BCBAEpisode Start date, specify:HomeSchool, specify:Community, specify:Multi-systemic Therapy (MST)Functional Family Therapy(FFT)Mobile Therapist (MT)Behavior Consultant (BC)Behavior Health Technician(BHT)EpisodeEpisodeHomeSchool, specify:Community, specify:Other, specify:Up toUp toUp tohpmhpmhpmStart date, specify:Up tohpmUp tohpmUp tohpmUp tohpmGroup Service SiteIf applicable, specify setting(s)other than the group servicesite:Start date, specify:Magellan Behavioral Health of Pennsylvania, Inc. (Magellan) is an affiliate of Magellan Healthcare, Inc. 2004-2020 Magellan Health, Inc. This document is the proprietary information of Magellan.Rev: 1/30/2020Page 3 of 7

Magellan Behavioral Health of Pennsylvania, Inc.Intensive Behavioral Health Services (IBHS) Written Order LetterPart A: Initial Written Order for Initial Assessment, Stabilization andTreatment InitiationService TypeIBHS ABA Services (for ABADesignated Providers with anIBHS License)BHRSBHRS ABA (For ABADesignated Providers withoutan IBHS License)Other IBHS TreatmentAssessment Type/Clinician TypeBehavior Analytic Services(BCBA)Behavior Consultant (BC-ABA)Assistant Behavior Consultant(Assistant BC-ABA)Behavioral Health Technician(BHT-ABA)Mobile Therapist (MT)Behavior Specialist Consultant(BSC)Therapeutic Support StaffSchoolTherapeutic Support StaffNon-SchoolABA-Behavior SpecialistConsultation (ABA-BSC)ABA-Therapeutic SupportStaff-School (ABA-TSS-S)ABA-Therapeutic SupportStaff-Non-School (ABA-TSSNS)Community ResidentialRehabilitation (CRR) HostHomeOther, specify:Maximum Number of Hoursper Month (hpm)(IBHS agency may provide less,as clinically indicated)Up tohpmUp toUp tohpmhpmUp tohpmStart date, specify:Up tohpmUp tohpmUp tohpmUp tohpmhpmUp tohpmHomeSchool, specify:Community, specify:HomeSchool, specify:Community, specify:Start date, specify:Up tohpmUp toSettings in which Service isNecessarySchool, specify:Community, specify:Start date, specify:Start date, specify:HomeCommunity, specify:Collaboration and Confirmation:Prescriber:I confirm that following my recent face-to-face appointment and/or evaluation of this child, and after considering lessrestrictive levels of care, as well as the prioritization of available evidence-based treatments, I am making therecommendations as per the above Written Order.Prescriber’s Name:License Type:Degree:NPI #:Prescriber’s Signature:PROMISE ID #:Date:Parent/Guardian:I confirm that I have participated in the face-to-face appointment and/or evaluation (of my child) and understand the aboverecommendations for further assessment and, if applicable, treatment initiation for stabilization under IBHS. I understandthat the treatment hours listed above describe the maximum amount to be received per month and that IBHS treatmenthours may vary, based on clinical need and ongoing assessment.Parent/Guardian’s Name:Magellan Behavioral Health of Pennsylvania, Inc. (Magellan) is an affiliate of Magellan Healthcare, Inc. 2004-2020 Magellan Health, Inc. This document is the proprietary information of Magellan.Rev: 1/30/2020Page 4 of 7

Magellan Behavioral Health of Pennsylvania, Inc.Intensive Behavioral Health Services (IBHS) Written Order LetterPart A: Initial Written Order for Initial Assessment, Stabilization andTreatment InitiationParent/Guardian’s Signature:Date:Youth’s Name if 14 or Older:Youth’s Signature if 14 or Older:Date:If you need to be connected to an IBHS provider in the Magellan network, please contact Magellan Member Services at:Bucks/Montgomery County Provider Line:877-769-9779Cambria County Provider Line:800-424-3711Delaware County Provider Line:800-686-1356Lehigh/Northampton County Provider Line:866-780-3368Magellan Behavioral Health of Pennsylvania, Inc. (Magellan) is an affiliate of Magellan Healthcare, Inc. 2004-2020 Magellan Health, Inc. This document is the proprietary information of Magellan.Rev: 1/30/2020Page 5 of 7

Magellan Behavioral Health of Pennsylvania, Inc.Intensive Behavioral Health Services (IBHS) Written Order LetterPart B: Written Order for Intensive Behavioral Health ServicesA comprehensive, face-to-face assessment (attached) has been completed by this prescriber and/or an IBHS clinician tofurther define how the recommendations in this written order will be used. An Individualized Treatment Plan (attached)has also been completed, based on the result of the assessment. Please select which one of the following service types youare recommending, based on the symptom(s) and/or behavior(s) of concern and the settings/domains in which they areoccurring. All sections within one row must be completed for a service to be appropriately authorized.Service TypeAssessment Type/Clinician TypeIBHS Individual Services/Evidence Based BHRSException ServicesMulti-systemic Therapy (MST)Functional Family Therapy(FFT)Mobile Therapist (MT)Behavior Consultant (BC)Behavior Health Technician(BHT)IBHS Group Services/BHRSExceptionsEarly Childhood TreatmentSocial Skills TreatmentSummer Therapeutic Program(STAP)Therapeutic After SchoolProgramOther, specify:ABA ServicesBHRSBHRS ABA (For ABADesignated Providers withoutan IBHS License)Other IBHS TreatmentBehavior Analytic Services(BCBA)Behavior Consultant (BC-ABA)Assistant Behavior Consultant(Assistant BC-ABA)Behavioral Health Technician(BHT-ABA)Mobile Therapist (MT)Behavior Consultant (BC)Therapeutic Support StaffSchoolTherapeutic Support StaffNon-SchoolABA-Behavior SpecialistConsultation (ABA-BSC)ABA-Therapeutic SupportStaff-School (ABA-TSS-S)ABA-Therapeutic SupportStaff-Non-School (ABA-TSSNS)CRR Host HomeOther, specify:Maximum Number of Hoursper Month (hpm)(IBHS agency may provide less,as clinically indicated)EpisodeEpisodeUp toUp toUp tohpmhpmhpmStart date, specify:Up tohpmUp tohpmUp tohpmUp toHomeSchool, specify:Community, specify:Group Service SiteIf applicable, specify setting(s)other than the group service site:hpmStart date, specify:Up tohpmUp toUp tohpmhpmUp tohpmStart date, specify:Up tohpmUp tohpmUp tohpmUp toSettings in which Service isNecessaryHomeSchool, specify:Community, specify:HomeSchool, specify:Community, specify:hpmStart date, specify:Up tohpmUp tohpmUp tohpmStart date, specify:Start date, specify:Magellan Behavioral Health of Pennsylvania, Inc. (Magellan) is an affiliate of Magellan Healthcare, Inc. 2004-2020 Magellan Health, Inc. This document is the proprietary information of Magellan.School, specify:Community, specify:HomeCommunity, specify:Rev: 1/30/2020Page 6 of 7

Magellan Behavioral Health of Pennsylvania, Inc.Intensive Behavioral Health Services (IBHS) Written Order LetterPart B: Written Order for Intensive Behavioral Health ServicesCollaboration and Confirmation:Prescriber:I confirm that following my recent face-to-face appointment and/or evaluation of this child, and after considering lessrestrictive levels of care, as well as the prioritization of available evidence-based treatments, I am making therecommendations as per the above Written Order.Prescriber’s Name:Degree:License Type:NPI #:PROMISE ID #:Prescriber’s Signature:Date:Parent/Guardian:I confirm that I have participated in the face-to-face appointment and/or evaluation (of my child) and understand the aboverecommendations for further assessment and, if applicable, treatment initiation for stabilization under IBHS. I understandthat the treatment hours listed above describe the maximum amount to be received per month and that IBHS treatmenthours may vary, based on clinical need and ongoing assessment.Parent/Guardian’s Name:Parent/Guardian’s Signature:Date:Youth’s Name if 14 or Older:Youth’s Signature if 14 or Older:Date:If you need to be connected to an IBHS provider in the Magellan network, please contact Magellan Member Services at:Bucks/Montgomery County Provider Line:877-769-9779Cambria County Provider Line:800-424-3711Delaware County Provider Line:800-686-1356Lehigh/Northampton County Provider Line:866-780-3368Magellan Behavioral Health of Pennsylvania, Inc. (Magellan) is an affiliate of Magellan Healthcare, Inc. 2004-2020 Magellan Health, Inc. This document is the proprietary information of Magellan.Rev: 1/30/2020Page 7 of 7

Magellan Behavioral Health of Pennsylvania, Inc. Intensive Behavioral Health Services (IBHS) Written Order Letter Cover Page Magellan Behavioral Health of Pennsylvania, Inc. (Magellan) is an affiliate of Magellan Healthcare, Inc. Rev: 1/30/2020

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