The Cigna Behavioral Health Substance Abuse Intensive Outpatient Program Review Form serves as a critical component in the administration and management of treatment services for individuals facing substance abuse challenges. Revised in February 2009, this comprehensive document requests detailed information essential for the initial approval and concurrent review processes, emphasizing the requirement for complete data submission to avoid delays or denials in authorization. It outlines specific sections for client identification, including name, date of birth, and identification number, alongside facility details to ensure accurate processing. The form meticulously captures the treatment's current status—distinguishing between initial requests and continued authorization needs—and delves into diagnostic codes, treatment phases, session frequencies, and the client’s engagement level in their recovery journey. Additionally, it addresses the client's medication, the presence of a support system, and the integration of external motivators into the treatment plan. Crucial to its purpose, the document also highlights the requirement for a clear articulation of the client’s progress, functional impairments, treatment goals, and the criteria for discharge to less intensive care. Accompanying this, the form mandates an outline for aftercare planning, underscoring Cigna’s commitment to a continuum of care even post-discharge, while candidly stating that form submission and authorization do not guarantee payment, which hinges on the client's benefit eligibility and coverage conditions. Furthermore, a separate section for the IOP Discharge Summary underscores the significance of evaluating treatment outcomes and planning subsequent care steps, reinforcing the overall objective of supporting individuals through their recovery journey with a well-structured and thorough review process.
| Question | Answer |
|---|---|
| Form Name | Cigna Review Form |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | cigna review form, cigna ash medical necessity review form, cigna iop authorization form, cigna mental healthintensive outpatientreview form |
REVISED 2/09 |
CIGNA Behavioral Health |
Substance Abuse Intensive Outpatient Program Review Form
INITIAL:
CONCURRENT:
All information requested on this form must be complete; missing data may result in delay of authorization. There is
no authorization guarantee for retrospective authorization requests.
Today’s Date: _________________________ Client’s Name: ___________________________________
Date of Birth: ________________ SS #/ID # of card holder: ___________________________
Facility/Program Name: _________________________________________________________________
Facility Tax ID #: _______________ State: ____ Zip Code: __________ Fax #: _________________
Submitting Staff
Name/Credentials: ____________________________________ Phone #: _________________________
Attending MD Name: __________________________________ Phone #: ________________________
Continued Authorization Request:
Level of Care (**Please Check One**): IOP: Phase
Low Intensity OP:
# Sessions attended to date: ______ |
Additional sessions requested: ______ |
|
Requested start date of new auth: _________ # Sessions per week: _______ |
# Hours per session: ______ |
|
Diagnosis with DSM IV codes: (**Include any changes**)
Axis I: _______________________________________________________________________________________
Axis II: ______________________________________________________________________________________
Axis III: _____________________________________________________________________________________
Axis IV: _____________________________________________________________________________________
Axis V: Current_________ Baseline _________
MH assessment completed: ____ Outline plan to address any MH issues: ______________________________
_____________________________________________________________________________________________
Client’s current medication (**Include all changes**):
1._________________________ 2. _______________________ 3. _________________________
The client’s current Stage of Engagement in substance abuse treatment (Place “X” on Correct Line):
_____ (Client is not yet considering change) |
|
Contemplation: |
_____ (Client is ambivalently weighing the pros and cons of change) |
Determination/Preparation: _____ (Client makes a beginning commitment to the change process)
Action: |
_____ (Client is taking specific steps toward accomplishing change) |
Maintenance: |
_____ (Client is maintaining the changes made) |
Relapse: |
_____ (Client temporarily returns to |
Client’s current status (“Y” or “N”):
____ Is the client attending a 12 step program?
____ Is the client connected with a 12 step “sponsor”?
____ Have external motivators (work, church, legal, family, friends) been involved in treatment?
If “No”, when are you planning for them to be? ______________________
____ Have relapse triggers been identified?
____ Is the client actively working on 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?
If the answer to any of the above questions is “No”, please explain: ____________________________________
REVISED 2/09 |
CIGNA Behavioral Health |
Date of client’s last use: _______________ |
|
The client currently finds support from: |
|
Work _____ Friends _____ Community _____ |
Home ___ Church ___ Legal _____ None _____ |
Date of last family/support session: __________ Outcome: _____________________________________
____________________________________________________________________________________________
If no family/support session, when is one planned? ____________________
Describe the current functional impairment (describe what responsibilities or activities are currently impaired and what role the current symptoms have on the impairment):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
How does the client verbalize his/her goals of treatment?
1.___________________________________________________________________________________________
2.___________________________________________________________________________________________
3.___________________________________________________________________________________________
Client’s progress toward his/her treatment goals (If no progress, identify barriers):
1.___________________________________________________________________________________________
2.___________________________________________________________________________________________
3.___________________________________________________________________________________________
What are the specific behavioral changes that must occur in order for the client to be appropriate for discharge to routine outpatient treatment? (discharge criteria):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Planned discharge date: __________ If discharge date has changed, please explain:_______________________
_____________________________________________________________________________________________
Client aware of planned discharge date: _______ Client involved in discharge planning: _______
Aftercare Plan (**Provider Name, Number, Credentials, Appointment Date, and Time**):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Will you need assistance with aftercare planning? _______
**Submission of this form and any subsequent authorization of visits by CIGNA Behavioral Health do not guarantee claims payment. Payment for services rendered is contingent upon the participant’s current health benefit eligibility status, co payments, and available mental health/substance abuse benefits. Please note that benefit and/or coverage changes can occur on an account’s anniversary date, which is often at the end of the calendar year. If you have any questions regarding your participant’s eligibility, please contact CIGNA Behavioral Health at the
number on the back of the participant’s identification card.**
Please fax this form to CIGNA Behavioral Health: (860)
REVISED 2/09 |
CIGNA Behavioral Health |
IOP Discharge Summary
**Please complete only after client has concluded IOP**
CLIENT’S NAME: _________________________________
SS #/ID # OF
CLIENT’S DOB: ______________ LAST AUTHORIZATION # RECEIVED: _______________
UTILIZATION REVIEW PERSON/COUNSELOR/CARE MANAGER NAME & PHONE #:
__________________________________________________________________________
FACILITY’S NAME/CIGNA BEHAVIORAL HEALTH PROVIDER#:
__________________________________________________________________________
WAS THIS:
MH IOP
CD IOP
FIVE AXIS DX AT DISCHARGE:
AXIS I ______________________________________
AXIS II ______________________________________
AXIS III _____________________________________
AXIS IV _____________________________________
AXIS V _____________________________________
# OF IOP SESSIONS ATTENDED: _____ DATE OF DISCHARGE: ________
THE REASON FOR THE DISCHARGE IS:
____ SUCCESSFULLY COMPLETED TREATMENT
____ BENEFITS EXHAUSTED
____ DROPPED OUT OR NO SHOWED MORE THAN ONCE
____ TRANSITIONING TO ALTERNATIVE LEVEL OF CARE (______________________)
MEDS AT D/C: __________________________________________________________
PROGNOSIS: __ EXCELLENT __ GOOD __ FAIR __ POOR
THE FOLLOW UP APPOINTMENTS ARE AS FOLLOWS:
__ MD APPT WITH DR.________________________ ON ________ FOR MEDICATION MGT.
__ THERAPIST APPT WITH ______________ ________ ON ________ FOR THERAPY
ANY OTHER RECOMMENDATIONS FOR
_______________________________________________________________________
PLEASE FAX THIS FORM TO CIGNA BEHAVIORAL HEALTH: (860)