Enhanced Adult Day Step 1 of 3 33% Member InformationEnter Member Id and Date of Birth to validate Member before proceeding with the form. Member's ID#* Member's DOB* MM slash DD slash YYYY Start Date* MM slash DD slash YYYY End Date* MM slash DD slash YYYY Member's Name* First Last Error Message This request is for: <br>REMINDER: Basic level of care does not require prior authorization.*This request is for: REMINDER: Basic level of care does not require prior authorization. *Initial RequestContinuation of ServicesFacility InformationAdult Day facility NPI* 10 digitsAdult Day Facility Name* Error Message Phone #*Fax #*Contact Name* Email address in order to receive confirmation of request receipt* Clinical InformationDiagnosis (Click + or - at the right to add up to 5 Diagnoses)*DiagnosisICD 10 Diagnosis Code Example ICD 10 Diag Code: Z87.890Adult Day Interventions Qualifying Interventions at the Adult Day Facility* Daily Assistance on site in the center, with at least two (2) Activities of Daily Living (ADL). Daily Assistance on site in the center, at least one (1) Activity of Daily Living Which requires a two-person Assist to complete ADL. Daily Assistance on site in the center, at least 3 Activities of Daily Living when supervision and cueing are needed to complete the ADLs identified. An individual who has been diagnosed with Alzheimer's disease or other related dementia, or a mental health diagnosis, as determined by a physician, requires regular staff interventions due to safety concerns related to elopement risk or other behaviors and inappropriate behaviors that adversely impact themselves or others. Such behaviors and interventions must be documented in the participant's care plan and in the required progress notes. Daily assistance on site in the center, with at least one skilled service, by a Registered Professional Nurse (RN) or a Licensed Practical Nurse (LPN). Attendance Schedule: Anticipated number of days attending* Sunday Monday Tuesday Wednesday Thursday Friday Saturday Date of Last Physical Exam* MM slash DD slash YYYY Attach Clinical*Please see the Reference Guide for Adult Day Services Requests for guidance on submitting for prior authorization.Accepted file types: pdf, doc, docx, Max. file size: 50 MB.Request Method*Request Method *StandardExpedited: By checking Expedited, you are stating that processing this request in the standard time (7 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited.Attach additional Clinical documents for Expedited request*Accepted file types: pdf, doc, docx, Max. file size: 23 MB.Upload only PDF or Word DocumentsSignature of Physician or Licensed Provider (Required for Expedited request)*Signature Date:* CommentsAuthorization is not a guarantee of paymentCAPTCHA CommentsThis field is for validation purposes and should be left unchanged.