Privacy Issues in Mental Health and Substance Abuse Treatment: Information Sharing Between Providers and Managed Care Organizations: Final Report. 1. Maryland Uniform Treatment Plan Form

01/17/2003

The Maryland Uniform Treatment Plan Form, which is reproduced in Appendix B, was mandated by the state legislature (Title 15, subtitle 10B of the Insurance Article and COMAR 31.10.21) in response to providers’ complaints about the administrative burden of having to complete many different forms for different MCOs.  A committee comprising MCOs and provider representatives, led by the Maryland Department of Health and Mental Hygiene, developed the form, which was implemented in October 2000.  A provider we spoke with in Maryland said the form has considerably reduced the amount of personal health information he must send to MCOs.  This provider always talks with his patients about what information will be sent to their insurer and reports that he “has never had a patient tell him not to send the information, although some have been anxious about it.  Now that the Maryland treatment form is in place, patients are much less concerned.”  One respondent noted, however, that the form is not as sensitive to the information needs for substance abuse treatment as for mental health treatment.  Some revisions might therefore be warranted if it were to be more widely adopted for both types of treatment.

Table IV.1 
Comparison of Personal Health Information Shared via Three Approaches Viewed
as Privacy-sensitive Outpatient Treatment Requiring Pre-authorization
Type of Information Magellan TRF Maryland Uniform Treatment Plan Form APA Guidelines
Patient Information First name 
Date of birth 
Membership number 
Is patient on mental health or chemical dependency long-term or short-term disability?
First name 
Date of birth 
Membership and group number 
Relationship to insured
Name 
Date of birth 
Address 
Insurance information/ID number, 
Patient’s status (voluntary, involuntary)
Diagnosis Dx code-Axis I and II 
Axis III: 
Does patient have a general medical condition potentially relevant to understanding or managing the Axis I or II conditions (yes/no)

Axis IV:
Severity of psychosocial stresses (none, mild, moderate, or severe)

Axis V: GAF score (highest past year, at first session, current)

Dx code Axis I-IV

Axis V: GAF score (current, highest in past year)

Axis I or “v” code

Axis II or III if relevant

Axis IV or level of distress (none, mild, moderate, or severe)

Axis V: GAF (current, highest in past year) or functional status (impairment: none, mild, moderate, or severe)

Previous Treatment Number of times provider has seen the patient to date, by CPT code

First date seen (this episode)

Past two years:

Outpatient, partial hospital, residential treatment center, substance abuse intensive outpatient, other [all yes/no/unknown]

Medical Hx

Psychiatric meds (list, including name and dose)

Compliance (yes/no)

Side effects (yes/no)

Comments

Allergies

Date first seen for current episode

 
Current Medications Type, if any: anti-psychotic, hypnotic, anti-anxiety, etc. List of psychiatric meds, with name and dose, in past two years

Has patient been evaluated for medication (yes/no)

Does patient follow medication regimen (yes/no)

Comments (e.g., lab results, side effects)

On psychiatric medications (yes/no)
Communicated with PCP or other relevant health care practitioners about treatment Yes/no Yes/no  
Symptoms/Risk Assessment Rate the following symptoms as mild, moderate, or severe: 
self-injurious behavior

suicidal ideation

homocidal ideation

substance abuse problems

Rate a list of symptoms that apply as mild, moderate, or severe and indicate if it is a target or treatment; list of 56 symptoms in the following categories:

social functioning/behavior

cognitive/memory/attention

mood/affect disturbance

somatic disturbances

anxiety

perceptual disturbance

substance use

Risk assessment:

 

suicidality: ideation, plan, prior attempts (if known)

other risk behavior

comments

Other assessment info (e.g., psych testing)

Risk or relapse into chronic/acute symptoms: high, moderate, low, comments

Level of distress (none, mild, moderate, or severe) or Axis IV rating
Other Services Client Receives   Other psychiatric, medical, or community support services client receives

(type, e.g., group therapy, supportive housing)

 
Functional Assessment Axis V: GAF score (highest past year, at first session, current) Degree of illness-related impairment (none, mild, moderate, severe) by category:

family relations

job/school

financial

physical health

legal

friends/social

Functional status (impairment: none, mild, moderate, severe) or Axis V (GAF: current, highest in past year)
Planned Treatment Number of sessions requested, by CPT code

Duration for requested sessions

Proposed treatment modality, with frequency and CPT code for each:

individual

group

family

medication

conjoint

other

Estimated discharge date

Expected number of visits

Treatment plan discussed with patient, guardian, or other legal representative (if applicable) or parent of a minor (yes/no)

Are additional health services required (yes/no, or referred to:)

CPT codes, including recommended/expected frequency
Expected Treatment Outcomes   Check all that apply:

reduction in symptoms and discharge from active treatment

return to highest GAF and discharge from active treatment

transfer to self help/other supports and discharge from active treatment

ongoing supportive counseling to maintain stabilization of symptoms

ongoing medication management to maintain stabilization of symptoms

Prognosis: the estimated minimum duration of treatment for which authorization is sought

Estimated GAF at treatment’s completion

Additional Information   For first reviews, state additional information that may help clarify the need for this outpatient treatment

For subsequent reviews, briefly state what progress has been made

If no progress, indicate reasons and whether treatment plan is being

revised to address targeted symptoms

 

As shown in Table IV.1, the Maryland Outpatient Treatment Plan Form requests more information than the other two approaches, including previous treatment in the past two years, current medications, symptoms, functional assessment, and planned treatment. 

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