Complete all of the following:
1. CQRT Date:	5. Reporting Unit:
2. Client Name:	6. Primary:
3. Client InSyst #:	7. Episode Opening Date:
4. Provider Name:	8. SUD Program Type:
9. OS/IOS Substance Use Disorder Services request as indicated on treatment plan (check all that apply):
☐ Individual Counseling	Frequency:	and As Needed	Duration:
☐ Group Counseling	Frequency:	and As Needed	Duration:
☐ Medication Services	Frequency:	and As Needed	Duration:
☐ Family Therapy (LPHAs Only)	Frequency:	and As Needed	Duration:
☐ Collateral Services	Frequency:	and As Needed	Duration:
☐ Patient Education (Grp/Ind)	Frequency:	and As Needed	Duration:
☐ Group Multi-Family Counseling - ADOL	Frequency:	and As Needed	Duration:
Withdrawal Management Services request as indicated on treatment plan (check all that apply)
☐ Observation	Frequency:	and As Needed	Duration:
☐ Medication Services	Frequency:	and As Needed	Duration:
Recovery Support Services request as indicated on treatment plan (check all that apply)
☐ Individual Counseling	Frequency:	and As Needed	Duration:
☐ Group Counseling	Frequency:	and As Needed	Duration:
☐ Recovery Service Monitoring/SAA	Frequency:	and As Needed	Duration:
10. Case Management Services request as indicated on treatment plan (check all that apply)
☐ Case Management: Care Coordination	Frequency:	and As Needed	Duration:
☐ Case Management: Service Coordination	Frequency:	and As Needed	Duration:
11. Medical Necessity (both required for medical necessity):
☐	Included SUD Diagnosis with individualized written basis (LPHA completing the diagnosis and written basis must meet face-to-face or via telehealth with beneficiary or SUD counselor who completed the assessment. Unlicensed LPHAs must have licensed LPHA co-signature)
☐	ASAM Level of Care (ALOC). May be completed by SUD counselor or LPHA. Differences in LOC and placement must have clinical explanation.
12. Primary Counselor/LPHA:	Recommend Approval: ☐ Yes ☐ No
Signature/Credentials
13. Agency Supervisor:	Recommend Approval: ☐ Yes ☐ Pending (30 Day Return) ☐ No
Signature/Credentials
14. CQRT Reviewer (REQUIRED):	Recommend Approval: ☐ Yes ☐ Pending (30 Day Return) ☐ No
Printed Name
Signature/Credentials (LPHA or Certified SUD Counselor)	Date
15. CQRT Chair (REQUIRED): ☐ Full Authorization–Start Date:	End Date:
Returns: ☐ Authorization pending return in 30 Days, by this date:
☐ No Authorization for DMC-ODS Services, chart to be returned to CQRT, by this date:
CQRT Chair Comments: Indicate if any services that have been claimed need to be voided and/or any future services should not be claimed (including time period).
CQRT Chair Signature (Must be Licensed LPHA)	InSyst ID	Date

Use this Addendum if Chart is to be returned
1st Return
Primary Counselor/LPHA Comments:	Supervisor Comments:
Primary LPHA/Counselor:	Recommend Approval: ☐ Yes ☐ No
Signature/Credentials
Agency Supervisor:	Recommend Approval: ☐ Yes ☐ Pending (30 Day Return) ☐ No
CQRT Reviewer or Chair Comments:
CQRT Reviewer:	Recommend Approval: ☐ Yes ☐ Pending (30 Day Return) ☐ No
Signature/Credentials (must be a Licensed, Registered or Waivered LPHA)
CQRT Chair: ☐ Full Authorization–Start Date:	End Date:
Returns: ☐ Authorization pending return in 30 Days, by this date:
☐ No Authorization for SUD DMC-ODS Services – Chart to be returned to CQRT, by this date:
CQRT Chair Comments: Indicate if any services that have been claimed need to be voided and/or any future services should not be claimed (including time period).
CQRT Chair Signature/License:	InSyst ID	Date
2nd Return
Primary Counselor/LPHA Comments:	Supervisor Comments:
Primary LPHA/Counselor	Recommend Approval: ☐ Yes ☐ No
Signature/Credentials
Agency Supervisor:	Recommend Approval: ☐ Yes ☐ Pending (30 Day Return) ☐ No
CQRT Reviewer or Chair Comments:
CQRT Reviewer:	Recommend Approval: ☐ Yes ☐ Pending (30 Day Return) ☐ No
Signature/Credentials (must be a Licensed, Registered or Waivered LPHA)
CQRT Chair: ☐ Full Authorization–Start Date:	End Date:
Returns: ☐ Authorization pending return in 30 Days, by this date:
☐ No Authorization for SUD DMC-ODS Services – Chart to be returned to CQRT, by this date:
CQRT Chair Comments: Indicate if any services that have been claimed need to be voided and/or any future services should not be claimed (including time period).
CQRT Chair Signature/License:	InSyst ID	Date