Great Rivers BH-ASO Non-Medicaid Request Form

Great Rivers BH-ASO Non-Medicaid Request Form
Disclaimer

Authorization is not a guarantee of payment. An individual must meet all criteria necessary to be eligible at the time services are rendered.

Before an authorization is approved, Great Rivers BH-ASO must verify available funding and medical necessity for requested services. Call the voluntary authorization line at 800.218.5006 if you have questions related to the Non-Medicaid Request Form.

Please note: The ASO expects providers to look into all financial resources for the individual to pay for the services being rendered before completing a Non-Medicaid Request Form.
Mental Health Documentation Requirements

If you are submitting a Mental Health pre-authorization or concurrent submission and you do not yet have completed medical documentation please call the voluntary authorization line at 800.218.5006 and we will send you a secure link.
Response Notification Timeliness

For standard authorization requests you will receive a decision or request for additional information within five (5) days of receipt of written request.

For pre-authorization mental health voluntary inpatient hospitalizations (LOC 6) you will receive a decision or request for additional information within twelve (12) hours of receipt of the written request.

Please know that incomplete forms will result in a denial if required information is not provided within authorization timelines.

GR BH ASO Clinical Policy 6000 Utilization Management Requirements
FAQs
1. What if I don’t have all of the clinical documentation at the time of making the non-Medicaid authorization request?

A provider can still request a “pre-authorization” without all the completed clinical documentation, though the status of the auth request would be considered “incomplete”, while “pending authorization review”, until all required documents are received and the ASO has reviewed and made a final determination.

2. What if I don’t know the individual’s income and our agency cannot obtain that information?

The ASO has limited resources. The ASO has income eligibility requirements for certain funding sources to pay for voluntary services being requested. Please check your agencies policy and procedures, desk references, or protocols on how individual eligibility verification takes place and what steps are taken when the agency cannot obtain information to verify income. Additionally, please refer to the ASO 6019 Medicaid Eligibility Verification and 6033 Non-Medicaid Services, General Fund State, & Federal Block Grant policy and procedures on our website, grbhaso.org, for more information. Therefore, the ASO does need the agencies to perform this step for us to determine if the services being requested can be paid for. It is acceptable for the agency to include as part of the income verification process after the agency exhausted all attempts (these attempts should be documented) to receive a written client statement about their income situation. This would be considered as a self-report.

3. Can any agency fill out the non-Medicaid request form?

Any behavioral health provider in the State of Washington can fill out the request to authorize behavioral health treatment services.

4. Who should be filling out the non-Medicaid request form?

The agency/provider that is providing the treatment services directly to the individual is the one that should be filling out the request.

5. Is there a limit to how many times someone can request authorization from Great Rivers BH-ASO?

No, there is no limit to how many times someone can request authorization from Great Rivers BH-ASO, but it is expected that the provider would collaborate with the ASO regarding possible over-utilization and provide adequate care coordination for individuals.

6. How long does it take to get notice of an approval or denial?

Please reference the ASOs Policy No. 6000 Utilization Management Requirements, in the “Timeframes for Authorization Decisions”, section, 3.10.

7. What if the individual would “likely” qualify for Medicaid, but they refuse to sign up for Medicaid?

The ASO has limited resources. The ASO has income eligibility requirements for certain funding sources to pay for voluntary services being requested. Please check your agencies policy and procedures, desk references, or protocols on how individual eligibility verification takes place and what steps agencies take to assist the individual in obtaining certain public health insurance coverage such as Medicaid, Medicare, Veterans, etc. Additionally, please refer to the ASO 6019 Medicaid Eligibility Verification and 6033 Non-Medicaid Services, General Fund State, & Federal Block Grant policy and procedures on our website, grbhaso.org, for more information. We encourage continued attempts as appropriate, as this funding is limited. The attempts should be a part of the process and documented when requested to ASO to pay for the services.

8. Does the request for authorization have to be for “recent” services?

For post-service or retrospective authorization reviews, the service dates must be during the current fiscal year which starts July 1st. Any requests for authorization prior to July 1st will be denied as current funding cannot pay for previous fiscal year.
Response Details
Type of Request*

Mental Health (MH)Substance Use Disorder (SUD)
Authorization type being requested*

Pre-auth requestConcurrent ReviewRetro Review
Date of authorization request submission*

MonthDayYear
Date
Name of Provider/Agency*
Provider Address*

Street Address

Street Address Line 2

CityState

Zip Code
Requestor's Name*

First NameLast Name
Requestor's Email*
example@example.com
Approving Supervisor's Name*

First NameLast Name
Approving Supervisor's Email*
example@example.com
Client Information
The individual seeking treatment MUST be a resident of the Great Rivers Region.
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Do you have a permanent address for the client on file?*

YesNo
Please explain why you do not have a permanent address for the client.*
Client Permanent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please select the county of individual's residence*

CowlitzWahkiakumPacificGrays HarborLewisOther
Verify the county of residence in ProviderOne*

The county of residence in ProviderOne matches their current residenceThe county of residence does not match ProviderOne
Please explain why the county of residence doesn't match ProviderOne*
ProviderOne Inquiry Start Date*

MonthDayYear
Date
Financial
Please reference our provider billing guidelines below for any questions.

HCA Provider Billing Guides and Fee Schedules
Reason for Request
Reason for Request: Check all that apply*

Individual is uninsured and is unable to pay for the requested serviceIndividual has insurance but is unable to pay the co-pay or the deductible for servicesYouth is requesting treatment without guardian consentIndividual's payor does not cover appropriate treatment services within the regionIndividual is using excessive Crisis Services due to inability to access non-crisis behavioral health servicesIndividual has more than five (5) visits over six (6) months to the emergency department, withdrawal management facility, or sobering center due to SUDIndividual has a Medicaid spend-down, but is unable to pay it
What is the amount of the individual's Medicaid spend-down?*
Payer of Last Resort*

The individual qualifies for Medicaid coverageThe individual qualifies for Medicare coverageThe individual qualifies for Veterans coverageThe individual qualifies for AEM coverageThe individual DOES NOT qualify for any coverage listed above
What is the individual's Medicaid plan?*

WellpointUnited HealthcareMolinaCoordinated CareCommunity Health Plan of Washington (CHPW)
Is this client covered under alien emergency medical*

YesNoUnknown
Please describe why you are requesting non-Medicaid funds if the client qualifies for the coverage you indicated.*
Do you understand that we expect our service providers to assist the individual with obtaining the insurance coverage listed above? This will help the individual, service providers, and payers in the long run to help the success of the individual in their behavioral health needs.*

I understand and agree to complete my due diligence.
Income
Individuals who do not qualify for Medicaid, and have income up to two hundred twenty percent (220%) of the federal poverty level (FPL) meet the financial eligibility for GFS services.

Individuals who do not qualify for Medicaid, is a Medicaid recipient requesting services not allowed under Medicaid, and/or has income greater than 220% of the federal poverty level meet the financial eligibility for Mental Health Block Grant (MHBG) or Substance Abuse Block Grant (SABG) services.
Monthly Income (Network Provider to verify)*
Number of members in the household?*
What documentation is on file to support monthly income?*

PaystubIRS Tax ReturnProvider Developed DocumentOther
Does the individual meet the income eligibility of 220% of the FPL, see chart below?*

YesNo
Clinical

Requested Service and Duration
Please reference our Level of Care Guidelines below for any questions you may have.

Great Rivers BH ASO Level of Care Guidelines
For Retro-Reviews. Please enter the actual dates of treatment and services.
Date of request for service from individual*

MonthDayYear
Date
Available treatment start date*

MonthDayYear
Date
Anticipated start date of services*

MonthDayYear
Date
Anticipated end date of services*

MonthDayYear
Date
Additional Information of Service and Duration
Program Type*

FACT/PACTAOTNo Program
SUD: Service type and anticipated length of treatment supported by non-Medicaid funds*

SUD Residential TreatmentWithdrawal ManagementIntensive outpatient treatment (not to exceed 3 months without review)Outpatient treatment (not to exceed 6 months without review)
MH: Service type and anticipated length of treatment supported by non-Medicaid funds

Intensive outpatient treatment (not to exceed 3 months without review)Outpatient treatment (not to exceed 6 months without review)Voluntary mental health inpatient treatment (3 days depending on clinical presentation)Crisis Stabilization Unit (up to 14 days)
Pre-intake services*

AssessmentIntake EvaluationBrief InterventionEngagement/ReferalOpiate Dependency/HIV Outreach
Post-intake based on LOCUS/CALOCUS/CANS/ASAM*

Psychological AssessSpecial Population EvalBrief OutpatientMental Health OPHigh Intensity TxDay SupportEBP/WraparoundFamily TreatmentMed ManagementMed MonitoringPeer SupportGroup TherapyIndividual TherapyRehabilitation Case ManagementTherapeutic PsychoeducationIntensive Outpatient-SUDInterim ServicesMAT/OTPCase ManagementTB Counseling, Screen, Test & ReferralTB Screening/Skin TestUrinalysis/Screening Test
Inpatient - Substance Use Disorder*

Intensive Inpatient Residential-SUDLong-Term Care Residential-SUDRecovery House-SUDWithdrawal Management-AcuteWithdrawal Management-Sub AcuteNot applicableSUD Residential Co-Ocurring TreatmentOther
Inpatient - Mental Health*

Voluntary InpatientMH ResidentialPsychiatric ServicesCrisis Stabilization UnitNot applicable
For mental health voluntary inpatient hospitalizations (LOC 6) you will receive a decision or request for additional information within twelve (12) hours of receipt of the written request.
Medical Necessity
Do you have LOCUS, CALOCUS, or CANS Level of Care documentation*

LOCUSCALOCUSCANSNone
Please note, this request is not complete until we receive a completed LOCUS, CALOCUS, or CANS. Please reach out to the Utilization Team and call the voluntary authorization line at 800.218.5006 to send us the completed LOCUS, CALOCUS, or CANS.
Upload LOCUS

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Upload CALOCUS

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Upload CANS

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MH inpatient voluntary - please upload complete assessments and psych evaluation to justify the level of care for the inpatient stay*

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Do you have a completed ASAM?*

YesNo
Please note, this request is not complete until we receive a completed ASAM. Please reach out to the Utilization Team and call the voluntary authorization line at 800.218.5006 to send us the completed ASAM.
What is the completion date of the ASAM

MonthDayYear
Date
SUD - Please upload ASAM level of care documentation

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List covered behavioral health diagnosis(es) starting with primary*
Please enter ICD-10 F Code*
Priority Populations
SABG Funds are prioritized based on these specific populations. Check all that apply.

Woman who is pregnant and injecting drugsWoman who is pregnant with a substance use disorderWoman with dependent childrenIndividual who is injecting drugsPostpartum (up to one year, regardless of pregnancy outcome)Individual transitioning from residential care to outpatient careYouthIndividual who is an offenderN/A
If providing SUD Interim Services. Check all that apply

Referral for prenatal care and counseling on the effects of alcohol and drug use on the fetusBrief screeningDevelopment of a service planIndividual and/or group contacts to assist the individual directly or by way of referral in meeting their basic needsUpdates to advise them of their treatment availability, and information to prepare the individual for treatmentCounselingEducation; and,Referral regarding Human Immunodeficiency Virus (HIV) and tuberculosis (TB) education, if necessary a referral to treatment for HIV and TBN/A
Start date of SUD Interim Services, if applicable

MonthDayYear
Date
High Risk Individual. Check all that apply.*

Utilized crisis/emergency system(s) multiple times within a one (1) month periodAre at risk of imminent inpatient admission (outpatient only)Are recently (within the last 30 days) discharged from a 24-hour facility. This includes: E&Ts, WSH, City or County Jails, Department of CorrectionsAre recently discharged from a 24-hour facility and are on a LRA or CRHave a history of multiple crisis or inpatient servicesHomeless/transientN/A
Justification for consideration of non-Medicaid funds for services. Include information regarding planned services and discharge.*
Provider Checklist
Clinical documentation MUST be provided for the request to be considered complete. Please provide the supplemental documents with this request
Please upload all clinical documents, treatment plans, and discharge plans that justify the level of care being requested for payment.

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Please note - Great Rivers BH-ASO should be included in any discharge planning for pre-authorization or concurrent requests
Please verify that you are human*
Should be Empty:

Great Rivers BH-ASO Non-Medicaid Request Form

FAQs

Response Details

Client Information

Financial

Reason for Request

Income

Clinical

Additional Information of Service and Duration

Medical Necessity

Priority Populations

Provider Checklist