This form is not for claiming, service must be documented in a progress note in order to be claimed

Client Information
Client:
InSyst #	Last Name	First Name
Location:
Agency:	RU:
Services were provided in:	by ☐ interpreter or ☐ clinician
Instructions
For each beneficiary, Continuing Services Justification (CSJ) must be completed no sooner than 5 months and no later than 6 months after date of admission or date of last CSJ. When an unlicensed LPHA establishes medical necessity, a licensed LPHA must review and co-sign this document (within 15 days and by medical necessity due date).
Episode Opening Date:	Date of last CSJ (if applicable):
Medical Necessity
LPHA completing this Form, must check the appropriate box below:
☐ LPHA met face-to-face with the beneficiary
☐ LPHA met face-to-face with the beneficiary’s primary SUD Counselor
To ensure fulfillment of their role for establishing medical necessity, the physician shall determine whether continued services are medically necessary using DSM-5 criteria to document the basis for the diagnosis
Primary Included SUD ICD-10 Code:
Primary Included SUD DSM-5 Name:
Additional Diagnosis ICD-10 Code:
Additional Diagnosis DSM-5/ICD-10 Name:
Written Basis for Diagnosis Must be completed by LPHA & include specific criteria of Medi-Cal included primary SUD diagnosis):
Indicate all ASAM Levels of Care recommended
LPHA determined ASAM Level of Care:
LPHA determined ASAM Level of Care:
LPHA determined ASAM Level of Care:
Is level of care recommendation different than the previously assessed ALOC? ☐ Yes ☐ No Explain if yes:
Patient Information that has been considered includes the following: The beneficiary’s personal, medical and substance use history The beneficiary’s progress notes and treatment plan goals The beneficiary’s prognosis The therapist or counselor’s recommendation (initial or justification) *Physical Exam (if not available, a treatment goal to obtain within 6 months)
Medical Necessity is determined by the following factors (Is not established if all are not yes): a) The client has a primary Medi-Cal Included SUD diagnosis from the Diagnostic and Statistical Manual (DSM-5) that is substantiated by chart documentation. b) SUD Health Care Services are medically necessary and consistent with 22 CCR Section 51303: “…which are reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness or injury…” c) The basis for the diagnosis is documented in the client’s individual client record. d) DSM diagnostic criteria for each diagnosis that is a focus of treatment is identified above e) Evidence based treatment is known to improve health outcomes and will be provided in accordance with generally accepted practices. (f) LPHA has considered LPHA/SUD Counselor recommendation	☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No
Physical Exam Requirement: 1) M.D. conducts physical exam or client provides copy 2) Client will provide copy of recent physical exam (within 12 months) or 3) The client must schedule an exam. Options 2 & 3 must be added to client tx plan. Physical Examination generally includes vital signs; head, face, ear, throat, & nose; evaluation of organs for infectious disease; and neurological assessment conducted by a qualified physician.
Medical Director or LPHA MUST INITIAL one of the Following: 1. After in-person review of the above information with the SUD counselor, I have determined there are no known physical or mental disorders or conditions that would place the beneficiary at excess risk in the treatment program planned, and that the beneficiary is receiving appropriate and beneficial treatment that can reasonably be expected to improve the diagnosed condition. 2. After review of the above named information, I have determined that continued treatment is not medically necessary and the beneficiary should be discharged from treatment.
Unlicensed LPHA Signature (if completing form)	Printed Name/Credentials	Date
Licensed LPHA Signature (required)	Printed Name/Credentials	Date