Autism Spectrum Disorder

Treatment Plan Provider Recommendations Form

PBHCS - ASD Services 1 of 5 Treatment Plan Form 2016

PROVIDERS COMPLETE AFTER H0031 AND SUBMIT TO PBHCS TO REQUEST AUTHORIZATIONS BEFORE RENDERING ASD 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 Initial Treatment Plan – Providers complete this from only once before beginning treatment with a new patient Revised Treatment Plan – For Penn Medicine Autism Clinic Use only 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 # ____________

Autism Spectrum Disorder

Treatment Plan Provider Recommendations Form

PBHCS - ASD Services 2 of 5 Treatment Plan Form 2016

Family Information Parent/Guardian #1 Parent/Guardian #2 ___________________________________ ___________________________________ Relationship to patient Relationship to patient Mother Father Guardian Mother Father Guardian Other _______________________ Other _______________________ Home Phone # ____________ Home Phone # ____________ Work Phone # ____________ Work Phone # ____________ Cell Phone # ____________ Cell Phone # ____________ Address, same as patient Address, same as patient Other Address Other Address _______________________________________ _______________________________________

Part 1: Summary of Bio-psychosocial Information A Comprehensive Bio-psychosocial Evaluation should accompany this plan. If you choose to submit your own document, please make sure to include all information as outlined below DSM 5 Diagnosis _______________________________________ _______________________________________ _______________________________________ _______________________________________ Strengths of the child Family structure

Autism Spectrum Disorder

Treatment Plan Provider Recommendations Form

PBHCS - ASD Services 3 of 5 Treatment Plan Form 2016

School placement (including homeschool instruction) Time in school per week (including days per week and hours per day) Specify recent major life changes Summary of Cognitive/Developmental Level and Language Functioning Part 2: Target Behaviors that are the Focus of Treatment Please include baseline level for the behavior or skill, target dates and mastery criteria for the treatment goals, and if they are short term or long term.

1) First Area of Concern (e.g., functional communication, social skills, self-help skills, etc.) Target Behaviors Treatment Goals

2) Second Area of Concern (e.g., functional communication, social skills, self-help skills, etc.)

Target Behaviors Treatment Goals

3) Third Area of Concern (e.g., functional communication, social skills, self-help skills, etc.)

Target Behaviors Treatment Goals

Autism Spectrum Disorder Treatment Plan Provider Recommendations Form

PBHCS - ASD Services 4 of 5 Treatment Plan Form 2016

4) Fourth Area of Concern (e.g., functional communication, social skills, self-help skills, etc.)Target Behaviors Treatment Goals

5) List additional target areas as neededTarget 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)

Plan for Parent Training

Discharge Criterion

Autism Spectrum Disorder Treatment Plan Provider Recommendations Form

PBHCS - ASD Services 5 of 5 Treatment Plan Form 2016

Part 4: Request for 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

Initial Services Request - Providers check this box only once before beginning treatment with a new patient

Revised Services Request - For Penn Medicine Autism Clinic Use only

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 _______________