Medical Necessity Form - LPHA Recommendation for Children & Family Treatment & Support Services
A clinical recommendation and medical necessity form to be completed and signed by a Licensed Practitioner of the Healing Arts (LPHA) to recommend children and family rehabilitative behavioral health services (OLP, CPST, PSR, FPSS, YPST) for Medicaid/Fidelis members. The form documents participant demographics, diagnosis, areas of functioning impairment, recommended services, interventions, and LPHA attestation.
No material clinical or coverage changes were reported for this form/policy.
Policy overview
This is the LPHA Recommendation medical necessity form for Children & Family Treatment and Support Services under Fidelis Care/Medicaid. It operationalizes that the form may only be completed and signed by a Licensed Practitioner of the Healing Arts (LPHA) and captures key participant identifying information including name, date of birth, parent/caregiver, contact/address, county of residence, Medicaid CIN #, and Fidelis ID #.