Medical necessity criteria

Below is a general outline that our care managers will follow when reviewing; however depending on the specifics, the care manager may ask for additional information. Please note, if the plan requires authorization for this level of care, an Intensive Outpatient Program Request Form will need to be submitted.

DSM Diagnosis Information

• Include any Clinical Disorders, Personality Disorders, Intellectual Disability, or General Medical Conditions

Current Medications:

• Medications: Name, dosage, frequency, start date/ end date and who prescribed
• Primary Care Physician and care coordination between practitioners.

Current Stage of Treatment Engagement

• Pre-Contemplation: Patient is not yet considering change
• Contemplation: Patient is ambivalently weighing the pros and cons of change
• Determination/Preparation: Patient begins commitment to the change process
• Action: Patient is taking specific steps toward accomplishing change
• Maintenance: Patient is maintaining the changes made
• Relapse: Patient temporarily returns to pre-change behaviors
• Outline plan to engage internal/external motivators to gain commitment to next SAE

Treatment Intervention/Planning

• Is the client attending a 12-Step Program?
• Is the client connected with a 12-Step Sponsor?
• External motivators (work, church, legal, family, friends) been involved in treatment?
• If no, when are you planning for them to be?
• Have the relapse triggers been identified?
• Is the client actively working a relapse prevention plan?
• Are outreach attempts made to assess and engage the client when there is a “no show”?
• Is the program utilizing urine drug screens?
• Has the client remained clean/sober?
• Identify the client’s reasons for wanting sobriety?

Discharge/Aftercare Planning

• Provider(s): Name, phone number, credential level, and appointment date and time.
• Identify utilization of community resources.
• Will you need assistance with aftercare planning?