Service Request Forms
The following forms are for services requiring prior authorization. Please complete and submit the request before providing the service to a member. For information regarding the Idaho Medicaid Behavior Modification and Consultation Program, please refer to the Provider Express portal by clicking here.
Case Management Service Request Form
Day Treatment Service Request Form
Extended Psychotherapy Service Request Form
Family Support Service Request Form
Intensive Home and Community Based Services Request Form
Peer Support Service Request Form
Skills Building/CBRS Request Form This form replaces both the CBRS Adult and Child Service Request Forms.
EPSDT provides a comprehensive array of prevention, diagnostic, and treatment services for low-income infants, children and adolescents under age 21, as specified in Section 1905(r) of the Social Security Act (the Act). The EPSDT benefit is more robust than the Medicaid benefit for adults and is designed to assure that children receive early detection and care, so that health problems are averted or diagnosed and treated as early as possible. The goal of EPSDT is to assure that individual children get the health care they need when they need it. EPSDT entitles enrolled infants, children and adolescents to any treatment or procedure that fits within any of the categories of Medicaid-covered services listed in Section 1905(a) of the Act if that treatment or service is necessary to “correct or ameliorate” defects and physical and mental illnesses or conditions. EPSDT requires a prior authorization. Please complete and submit the request form before providing the service to a member.
Early Periodic Screening Diagnosis Treatment (EPSDT) Form
Field Care Coordinator Referral Form
*Please call the Optum Idaho Provider Line at (855) 202-0983 Option 1 for form log in and form submission issues.*
Global Distress Scale
The Optum Wellness Assessment is an integral part of the Idaho Clinical Model. Analyses demonstrate that the Wellness Assessment scales, comprised of items from well-validated public domain scales, are both valid and reliable. Both have been independently validated to ensure psychometric integrity as an outcome tool and to affirm the tool's use as an objective assessment tool with external credibility. For additional detail of the Global Distress Scale, its reliability and validity, please click on the link below:
Global Distress Scale
Provider Clinical Questions: (855) 202-0983 | Primary Care Provider Psychiatric Consult press option 1