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Autism Spectrum Disorder
Progress Report and Continued Services Authorization Request
PBHCS - ASD Services 1 of 4 Progress Report and Services Request Form 2016
PROVIDERS PLEASE SUBMIT TO PBHCS TO REQUEST AUTHORIZATIONS THIRTY (30) DAYS BEFORE EXPIRATION OF CURRENT SERVICES Please complete all parts as clearly and as specifically as possible. Omissions, generalities, and illegibility will result in the form being returned for completion or clarification. All services require preauthorization Provider(s) Information Referring Pediatrician/Specialist __________________________________________ Phone # ____________ Fax # ____________ Name and Credentials of Provider(s) delivering Services
1) _____________________________________ 2) _____________________________________
Phone # ____________ Phone # ____________
Fax # ____________ Fax # ____________ Group __________________________________________ Contact ________________________________ INN OON NPI# __________________ TAX ID # __________________ Address __________________________________________ City _____________________________________ State ________ Zip ________ Phone # ____________ Fax # ____________ Patient Information PBHCS ID # ___________________________________ UPHS UPenn Name ___________________________________ DOB ____________ Age ________ Address ___________________________________________________________________________________ City ___________________________________ State ____ Zip ________ Guardian ____________________ Relationship to patient _________________ Phone # ____________ Time in Treatment from Initial PBHCS Treatment Plan 6 Months 1 Year
Other ________ Date of Initial PBHCS Treatment Plan ____________
Autism Spectrum Disorder
Progress Report and Continued Services Authorization Request
PBHCS - ASD Services 2 of 4 Progress Report and Services Request Form 2016
PROGRESS REPORT Please complete the Progress Report below as clearly and as specifically as possible to receive authorization for ongoing services. Omissions, generalities, and illegibility will result in delays, as the form will be returned for completion or clarification. If you submit your own document, please include all information as outlined below. Part 1: Bio-psychosocial update DSM 5 Diagnosis _______________________________________ _______________________________________ _______________________________________ _______________________________________ If applicable, describe changes related to the life and functioning of the child, family structure, and school placement
Part 2: Progress of Target Behaviors that are the Focus of Treatment Below, list Progress in all areas of functioning and for each goal identified in the PBHCS Treatment Plan
List mastered programs/targets and ongoing targets Explain reason for not working on any goals set in the initial PBHCS treatment plan, or that the parents are
concerned about (i.e. the child was not ready to work on this yet, or the behavior was no longer a concern) Submit graphical display of progress
1) First Area of Concern (e.g., functional communication, social skills, self-help skills, etc.)
Treatment Goals Progress
2) Second Area of Concern (e.g., functional communication, social skills, self-help skills, etc.)
Treatment Goals Progress
Autism Spectrum Disorder
Progress Report and Continued Services Authorization Request
PBHCS - ASD Services 3 of 4 Progress Report and Services Request Form 2016
3) Third Area of Concern (e.g., functional communication, social skills, self-help skills, etc.) Treatment Goals Progress
4) Fourth Area of Concern (e.g., functional communication, social skills, self-help skills, etc.)
Treatment Goals Progress
5) List additional goals/target areas as needed
Target Behaviors Treatment Goals
Part 3: Approach to Intervention Treatment Modality (e.g., Discrete Trial, Pivotal Response Therapy, Verbal behavior Therapy, Early Start Denver Model, Floortime)
Intervention Setting(s) Parent Training Discharge Criterion
Autism Spectrum Disorder Progress Report and Continued Services Authorization Request
PBHCS - ASD Services 4 of 4 Progress Report and Services Request Form 2016
Part 4: Request for Continued Services
1. Supervision must be delivered to each paraprofessional or BCaBA® level staff a minimum of sixty (60) minutes per month, not to exceedeight (8) hours per month at a ratio of one (1) hour per every ten (10) hours of direct service
2. Treatment Planning is required a minimum of sixty (60) minutes per month, not to exceed eight (8) hours per month at a ratio of one (1)hour per every ten (10) hours of direct service
3. Authorizations can cover a period up to six (6) months and cannot go beyond the benefit year-end date of 6/30; if end date of servicesfalls after 6/30 the remainder of the units will be authorized after 7/1
4. Modifiers 03 School; 12 Home; 14 Group Home; 99 Intermediate Care for the Disables
Increase Services Decrease Services Same Services
If applicable, explain evidence to support changes in treatment hours and type of services
Provider Service Code Service Description Location
Modifier Hours per week
Treatment Dates
Start-End
# of weeks
Total # of 15 minute units
H0031 Functional Behavioral Assessment (FBA) x4 =
H0031 Treatment planning by BCBA/LBS x4 =
H0031 Consultation by BCBA/LBS with _________________ x4 =
H0032 Direct supervision by BCBA/LBS x4 =
H0032 Caregiver Training by BCBA x4 =
H0032 Direct Services by BCBA/LBS x4 =
H2019 Direct services by ABA supervised by a BCBA x4 =
H2014 Social Skills Group x4 = H2021 Therapeutic Support Staff x4 = 90837 Mobile Therapy x4 =
x4 =
Treatment Plan completed by _____________________________________ Submit Roster of Providers
Treating Provider Signature _____________________________________
Date ____________ Phone # ____________ Fax # ____________
Claims payment is subject to eligibility and benefits on the date of service, coordination of benefits, authorization, utilization management guidelines when applicable, and adherence to plan policies, plan procedures, and claims editing logic.
Penn Behavioral Health Corporate Services 3440 Market Street, Suite 450
Philadelphia, PA 19104 Phone: 1-888-321-5533
Fax: 215-746-7454
For Internal Use only PBHCS received on ____________ PBHCS Authorization sent on ____________ CM _______________