The MN Health Authorization form is a crucial document utilized in Minnesota to authorize and outline mental health and chemical health treatment plans. It includes detailed information such as patient and provider data, diagnosis, treatment objectives, and consent for the release of information to involved parties. For individuals seeking to ensure their treatment plans are appropriately managed and shared with relevant health providers, completing this form meticulously is essential. Click the button below to start filling out your MN Health Authorization form.
Navigating the landscape of healthcare forms and authorizations can seem daunting, especially when it comes to mental health and chemical health services. Enter the Minnesota Health Authorization form, a crucial document designed to streamline the referral and authorization process for outpatient mental and chemical health services. This comprehensive form serves multiple purposes, including capturing essential patient information like the patient’s name, address, and health plan details, as well as detailed treatment-related information such as diagnosis, current symptoms, treatment goals, and the services requested. Providers are required to specify if the treatment is court-ordered and to indicate the number of sessions to date, along with the frequency of visits. Moreover, the form mandates the consent for the release of information to various parties, which is paramount for coordinating care among healthcare professionals. It also addresses prior treatment episodes, risk assessment, and the expected outcome and prognosis of the treatment, ensuring that each patient's care plan is thoroughly documented and communicated. This level of detail not only facilitates better coordinated care but also helps in complying with legal and insurance requirements, making the Minnesota Health Authorization form a vital tool in the delivery of mental and chemical health services.
Clinic Assigned Member Number
Please mark appropriate choice:
Referral Request
Authorization
Minnesota’s Universal Outpatient Mental Health/Chemical Health Authorization Form
PATIENT NAME:
Patient Address:
Subscriber Name:
Health Plan Name:
Health Plan/Group Number:
Member ID:
Patient DOB:
Is this treatment court-ordered?
No
Yes
(If yes, submit order and evaluation)
Number of Sessions to date:
Frequency
Date 1st Visit (present episode of care)
Date of most recent visit
Release of information for payer signed:
Release of information for PCP signed:
Release of Information for other treating professionals signed:
N/A
Tx Plan or Summary sent to patient’s PCP
Patient/Parent/Guardian refused consent for release to PCP
Patient states they have no PCP
PROVIDER NAME:
Degree/License Type: Clinic Name:
Mailing Address & Fax: (see instructions)
Provider ID:
Clinic ID (If
Applicable):
*Supervising Provider Name:
*Supervising Provider ID:
Provider Phone:
Provider Fax:
Prior Treatment- # Episodes in Past Year
MH:
Outpatient
Inpatient
PHP
IOP
CD:
Outcome: AMA discharge
Completed Treatment/still using
Completed Treatment/Sober
Active in CD Support Group
Current Symptoms:
Mood:
Sad
Elated
Hopeless
Low Energy
Poor Concentration
Angry
Appropriate
No Problem
Other
Anxiety:
Worry
Panic
Fearfulness
Compulsive
None
Thought:
Delusions
Hallucinations
Disorganized Speech
Obsessive
Distractible
No Problems
Behavior:
Aggressive
Truant
Runaway
Disorganized behavior
Hyperactive
Sleep Problems, Describe:
Appetite Problems, Describe:
Diagnosis: Tip: Use DSM-IV Codes; include all Axes.
Axis I Primary
Axis II
Secondary
Axis III
Risk Assessment:
Suicidality:
Homicidality
Hx Substance:
Abuse/ Dependence:
Axis IV
Economic problems Housing problems Occupational problems Other psychosocial problems
Axis V (GAF) Current
Target Problems/Symptoms
Problems accessing health services Problems related to interactions with legal/criminal system Problems related to social environment/school
Highest in last 12 months
Ideation
Plan
Intent w/o means
Intent with means
Ideation in past yr
Attempt in past yr
Family/peer history of completed suicide
If risk exists:
Client has contracted not to harm
Self
Others
Declined to Contract
Assessed Yes No
Problem? Yes No
If yes, drugs of choice:
Current abuse/dependence By family/significant other
Other Risk Factors:
Hx physical/sexual abuse Child/elder neglect Anorexia Bulimia
Goals: Expected Outcome & Prognosis:
Return to normal functioning
Expect improvement, anticipate less than normal functioning
Relieve acute symptoms, return to baseline functioning
Maintain current status/prevent deterioration
Treatment Objectives:
(List objectives directed at reducing symptoms and impairment in functioning.)
Progress Rating Scale:
N–New Objective 1–Much Worse
2–Somewhat Worse 3– No Change 4–Slight Improvement 5–Great Improvement R–Resolved
Measurable Objective
Intervention/Method(s) for Achieving Objective
Progress to Date
Resolution Date
If child/adolescent: Is family involved?
Explain
Services:
Dates Requested:
FROM
TO
Number Requested:
90804: #
90805: #
90806: #
90847: #
90853 #
90862: #
90870: #
Other:
Medication:
Has patient been evaluated for psychiatric meds. within last 12 months?
Patient refused Prescribing M.D. Name
List all current medications/dose:
Estimated compliance with medication regime:
• Compliant with psychotropic as prescribed?
n/a
• Compliant with medical as prescribed?
Provider’s Signature and Date:
*Supervisor Signature and Date:
*Client/Patient Signature and Date:
*If required
Administrative Uniformity Committee 2002
Release Required on all Behavioral Healthcare Providers (BHP) Managed Patients
I understand the confidentiality of my records as protected by law. Information about me cannot be released without my consent. I understand I may revoke this consent at any time, and it will automatically expire without my revocation after one (1) year from the date of signature. I do not authorize release of this information by the recipient unless further release is specifically authorized.
I hereby give authorization for
(provider name)
to contact and
inform BHP Intake of all medical information included in this treatment plan, and
inform my Primary Care Physician of all medical information included in this treatment plan; and
I hereby give authorization for BHP Intake to contact and inform my Primary Care Physician of all medical information included in this treatment plan.
Patient Signature/Date Signed:
/
INSTRUCTIONS
Clinic Assigned Member Number: This is an optional item that clinics/providers may use to record their internal account or reference number for the purpose of internally tracking submitted authorization forms.
Referral Request or Authorization Request: Check the appropriate box to indi- cate whether the document is being used to request authorization of services (including concurrent reviews for subsequent services) or to request a referral for services. A refer- ral request is generally a request submitted by an out-of-network provider who is request- ing that his/her services be covered under the patient's in-network benefits. Providers may need to check with the patient's health plan for specific requirements.
PATIENT/PROVIDER BLOCKS
Patient Address: Current address of patient, NOT subscriber's address. If the patient is a child who is in foster care, the patient address should reflect the foster care address.
Subscriber Name: Provide the name of the individual who is the subscriber of the insurance.
Health Plan Name: Provide the name of the health insurance company/plan.
Health Plan/Group Number: Provide the appropriate health plan/payer-assigned health plan or group number off of the patient's identification card.
Member ID: Provide the appropriate health plan/payer-assigned member identification number off of the patient's identification card.
Patient DOB: Provide the patient's date of birth.
Is this treatment court-ordered: Indicate whether the treatment is court-ordered and, if so, provide a copy of the order and the evaluation. The law requires that the health plan be given a copy of the court order and the behavioral care evaluation.
Provider Name: Provide the full name of the treating health care professional.
Degree/License Type: Provide the professional degree of the treating provider (e.g., M.D., Ph.D., Psy.D., M.S.W, M.A., R.N.); and provide the licensure type of the treating provider (e.g., LP, LICSW, LMFT, LACD, LPP).
Clinic Name: Provide the name of the clinic where the patient is being treated.
Mailing Address & Fax Number: Provide the mailing address, and a fax number, where authorizations/responses to this request should be sent. Note that this address may be different than the address where services will be provided.
Provider ID: Provide the appropriate health plan/payer-assigned provider identification number if available. Note that some health plans/payers may require this information to process this authorization request.
Clinic ID: Provide the appropriate health plan/payer-assigned clinic identification number where care is to be provided.
Supervising Provider Name: Provide the name of the supervising provider, if required for supervision or other appropriate circumstances.
Supervising Provider ID: Provide the health plan/payer-assigned provider identification number of the supervising provider, if required for supervision or other appropriate circum- stances.
Provider Phone: Provide a phone number for the treating provider.
Provider Fax: Provide a fax number for the treating provider.
Number of Sessions to Date/Frequency: Indicate the total number sessions, to date, that this patient has been seen by you/your clinic; and, indicate the frequency of those sessions (e.g., weekly, monthly, quarterly, etc.).
Release of Information for payer signed: Indicate whether the patient has signed a release of information form allowing information to be shared with his/her insurer/payer. Note that some health plans/payers (e.g., BHP) may have specific release of information requirements for initial requests. Providers may need to check with the patient's insurer/health plan for specific requirements.
Release of Information for PCP signed: Indicate whether the patient has signed a release of information form allowing information to be shared with his/her primary care provider (PCP). The attached release (page 2) is specifically required for BHP. Providers may need to check with the patient's insurer/health plan for other specific requirements.
Release of Information for other treating professionals signed: Indicate whether the patient has signed a release of information form allowing information to be shared with his/her other treating professionals. Providers may need to check with the patient's insurer/health plan for specific requirements.
Information Release Actions: Place a check mark before those statements that are true (TX plan or Summary sent to patient's PCP; Patient/Parent/Guardian refused consent for release to PCP; patient state they have no PCP).
Prior Treatment: If available, indicate for both mental health (MH) and chemical dependency (CD) treatment, the number of episodes of outpatient, inpatient, partial hospi- talization program (PHP), or intensive outpatient therapy (IOP) treatment provided in the past year.
CURRENT SYMPTOMS BLOCK
Identify the symptoms that the patient is currently experiencing. Attach additional sheet if nec- essary.
DIAGNOSIS BLOCK
Axis I: List the appropriate diagnosis code(s) for primary and secondary diagnoses, and other diagnoses as appropriate.
Axis II: List the appropriate diagnosis code(s).
Axis III: List the appropriate diagnosis code(s)
Axis IV: Identify patient stressors as appropriate.
Axis V (GAF): Provide the current GAF and the highest GAF within the last 12 months.
Target Problems/Symptoms: Summarize the patient's target problems/symptoms (attach additional sheet if necessary).
RISK ASSESSMENT BLOCK
Specify the patient's risk factors.
GOALS: EXPECTED OUTCOME & PROGNOSIS BLOCK
Indicate which of the four categories (return to normal functioning; relieve acute symptoms, return to baseline functioning; expect improvement, anticipate less than normal functioning; or, maintain current status/prevent deterioration) best describes the expected outcome and prognosis.
TREATMENT BLOCK
For each measurable objective identified (e.g., improve sleep patterns for three-five nights), identify the interventions/methods for achieving the objective (e.g., encourage exercise, provide and give instructions in use of sleep journal), the progress to date in achieving the objectives (using the progress rating scale provided), and the targeted resolution date.
SERVICES BLOCK
Dates Requested: Indicate the range of dates for which services are being requested (from date and to date).
Number Requested: Provide the number of sessions/visits requested by procedure code. Requests for psychological testing, and any other services that are not listed under the codes provided, should be included on the "other" line with the appropriate service code.
MEDICATION BLOCK
Has patient been evaluated for psychiatric medication within last 12 months? Indicate whether the patient has been evaluated for psychiatric medication with- in the last 12 months, or if patient refused to respond.
Prescribing MD Name(s): Provide the name(s) of the prescribing physician(s) for patient's current medication(s).
Current Medications & Dosages: For initial requests, provide a list of all psy- chotropic and medical prescriptions, with dosages, the patient currently is using. For sub- sequent requests/reviews, list any changes to medications or dosages (attach additional sheet as necessary).
Estimated compliance with medication regime: Evaluate the patient's compli- ance with his/her medication regime for both psychotropic and medical prescriptions, as applicable.
Patient Signature: Obtain the patient's signature, if required. Note that some health plans/payers may require the patient's signature before authorization can be provided. Providers may need to check with the patient's health plan for specific requirements.
Filling out the Minnesota (MN) Health Authorization form is an important process for ensuring timely approval and continuation of healthcare services, particularly those related to mental and chemical health outpatient care. This document is a tool for healthcare providers to communicate necessary information to health insurance plans and other entities involved in the care and funding of patient treatment. The form seeks comprehensive details surrounding the patient's current treatment plan, diagnosis, and historical health information, aimed at delivering a streamlined approach to healthcare authorization and referrals. Below are the steps to complete the MN Health Authorization form accurately and efficiently.
Understanding and meticulously completing the MN Health Authorization form is essential for healthcare providers. It facilitates the authorization process, supports continuity of care, and ensures that patients receive the necessary treatments without undue delay. Providers should review all sections of the form for accuracy and completeness before submission to ensure a smooth process for service authorization or referral.
What is the Minnesota Universal Outpatient Mental Health/Chemical Health Authorization Form? The Minnesota Universal Outpatient Mental Health/Chemical Health Authorization Form is a document used by healthcare providers to request authorization for outpatient mental and chemical health services. It collects detailed information about the patient, including diagnosis and treatment plan, to be reviewed by the payer for coverage determination.
Who needs to sign the Mn Health Authorization form? The form requires signatures from the provider, the supervising provider (if applicable), and the patient. For minors, a parent or guardian's signature is also necessary. It's crucial to obtain these signatures to comply with consent and confidentiality laws and ensure the payer can process the authorization request.
Is a release of information necessary for this form? Yes, the form asks whether a release of information for the payer, primary care provider (PCP), and other treating professionals has been signed. This is crucial for the processing of the form, as it allows necessary information to be shared with parties involved in the patient's care and with the payer for authorization purposes.
What should be included in the diagnosis block of the form? In the diagnosis block, providers need to include diagnoses using DSM-IV codes across all applicable axes: Axis I for primary and secondary diagnoses; Axis II for personality disorders and mental retardation; Axis III for medical or neurological conditions relevant to the patient's mental condition; Axis IV for psychosocial and environmental problems; and Axis V for the current Global Assessment of Functioning (GAF) score and the highest GAF score in the past 12 months.
How should treatment goals and objectives be documented on the form? Treatment goals and objectives should be clearly laid out in the form, specifying the expected outcome and prognosis. Each goal should have measurable objectives, intervention methods, progress to date, and a targeted resolution date. This section helps to articulate the intended path of treatment and benchmarks for evaluating progress.
What information is required about previous and current treatment? The form requests details on the number of sessions to date and their frequency, as well as any prior treatment episodes within the past year across different settings (outpatient, inpatient, partial hospitalization, and intensive outpatient therapy) for both mental health (MH) and chemical dependency (CD). It also asks about the patient’s history with medication, including compliance and current medications being taken.
What happens if treatment is court-ordered? If treatment is court-ordered, the form requires an indication of this fact along with a submission of the court order and evaluation. This information is necessary for the health plan to understand the legal context of the treatment and to ensure that the authorization process considers any court-mandated service requirements.
Filling out Minnesota's Universal Outpatient Mental Health/Chemical Health Authorization Form requires careful attention to detail. Unfortunately, some people make several common errors during this process. Recognizing these mistakes can help ensure the form is completed accurately and efficiently.
Not checking the appropriate box at the top of the form to indicate whether it's a Referral Request or Authorization Request can lead to processing delays.
Entering the subscriber's address instead of the patient’s current address, especially relevant if the patient is a child in foster care or has a different residence from the subscriber.
Omitting the health plan/group number or member ID, which are crucial for identifying the patient's health insurance coverage.
Failing to specify if the treatment is court-ordered. If it is, a copy of the court order and evaluation must be submitted along with the form.
Incorrectly listing the provider’s details, such as name, degree/license type, and contact information, can misdirect communication.
Not obtaining or inaccurately documenting consent for the release of information to the payer, PCP, or other treating professionals.
Errors in detailing the diagnosis and current symptoms, including omitting DSM-IV codes or not accurately describing the patient’s condition.
Overlooking the patient's risk assessment section, particularly in noting suicidality, homicidality, or history of substance abuse, neglect, or abuse.
Setting vague goals and expected outcomes without clearly defined, measurable objectives or failing to detail the intervention methods for achieving these objectives.
Misunderstanding medication compliance, by not correctly evaluating or reporting the patient’s compliance with both psychotropic and medical prescriptions.
Correctly filling out the authorization form is critical for ensuring timely and appropriate care. Small mistakes can lead to significant delays in treatment. Thus, it's beneficial for both patients and caregivers to review the form carefully before submission.
When managing healthcare, especially mental and chemical health treatment in Minnesota, several forms and documents are often used in conjunction with the Minnesota Health Authorization Form to ensure comprehensive care and legal compliance. These documents facilitate a multidimensional approach to patient care, addressing various aspects from medical history to privacy and consent for treatment.
Together with the Minnesota Health Authorization Form, these documents create a comprehensive framework for managing a patient’s care, ensuring that all aspects from legal authorization to treatment objectives and respect for patient autonomy and privacy are addressed. Utilizing these forms in unison enhances the effectiveness of the treatment process, fosters clear communication between all parties involved, and ensures adherence to legal and ethical healthcare standards.
One document similar to the Minnesota Health Authorization form is a HIPAA Authorization Form. Like the Minnesota form, a HIPAA Authorization Form allows for the release and sharing of an individual's health information. They both require patient consent to disclose health details to specified parties, ensuring that sensitive information is handled in accordance with privacy laws. However, the HIPAA form is used more broadly across the United States, not just for mental or chemical health services.
A Medical Power of Attorney is another document that shares similarities with the Minnesota form. It authorizes another person to make healthcare decisions on behalf of someone else, typically when they are unable to do so themselves. While a Medical Power of Attorney covers a broader scope of decision-making authority, both it and the Minnesota Authorization form center on the patient's health matters and require a formal documentation process to designate another's involvement in personal health issues.
An Advanced Healthcare Directive, also known as a living will, allows individuals to outline their preferences for medical treatment in advance. This document and the Minnesota Health Authorization form both serve to communicate the patient's wishes regarding health care, though the directive focuses more on future treatments under specific health conditions, whereas the Minnesota form addresses the sharing of information regarding current treatments.
A Release of Information form in the context of mental health services also shares similarities with the Minnesota Health Authorization form. Both documents are designed to ensure that a patient's health information can be shared with designated health professionals or entities, but with explicit consent from the patient. The Release of Information form may not be as specific as the Minnesota form, which is tailored for both mental and chemical health services.
A Consent to Treat form is another similar document, as it is required before a healthcare provider can administer treatment. While the Minnesota Health Authorization form is focused on authorizing the release of health information, a Consent to Follow for Monitors consent for the actual treatment process. However, both are integral to the patient care process, ensuring that legal and ethical standards for consent and information sharing are met.
A Patient Intake Form typically gathers a patient's medical history, current health status, and contact information at the beginning of a healthcare encounter. It resembles the Minnesota form in its collection of detailed patient information, but it serves a different primary purpose. The Patient Intake Form is more about establishing a baseline for care, whereas the Minnesota form specifically addresses the authorization to share information related to that care with others.
Last, a Court Order for Treatment resembles the Minnesota Health Authorization form when the treatment is court-ordered. Both documents involve legal authorization concerning an individual's health care, but the court order directly mandates treatment rather than merely authorizing the release and sharing of health information. This distinction is critical in cases where compliance with treatment is obligatory as opposed to voluntary or consent-based sharing of information.
When completing the Minnesota Health Authorization form, attention to detail and understanding the instructions are critical. Here are ten essential dos and don'ts to keep in mind:
Adhering to these guidelines will help ensure the form is filled out thoroughly and accurately, facilitating a smoother process for authorization or referral.
There are several misconceptions surrounding Minnesota's Health Authorization form, which can often lead to confusion for both patients and providers. Clarifying these misunderstandings is essential for ensuring the smooth operation of medical services and the protection of patient rights.
Understanding these key points about the Minnesota Health Authorization form can greatly improve the administration of healthcare services and protect patient privacy. It's important for both healthcare providers and patients to be aware of the specifics of the consent process and the rights entailed within it.
When filling out and using the Minnesota Health Authorization form, understanding its key components ensures the process is handled accurately and efficiently. Here are four key takeaways to guide you through the form:
Utilizing the Minnesota Health Authorization Form efficiently requires attention to detail, clear communication with the patient, and an understanding of the healthcare system's requirements. Proper completion and use of this form play a significant role in facilitating patient care and ensuring compliance with healthcare regulations.
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