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BEHAVIORAL HEALTH PRIOR AUTHORIZATION REQUEST …

BEHAVIORAL HEALTH PRIOR AUTHORIZATION REQUEST BEHAVIORAL HEALTH Std. PA Form Aetna Better HEALTH of Louisiana 2400 Veterans Memorial Blvd, Ste 200 Kenner, LA 70062 Telephone Number: 855-242-0802 Fax Number: 844-634-1109 TTY: 855-242-0802, 711 SERVICE TYPE: psychological / NE URO P S Y CHO LO GI CAL APPLIED BEHAVIOR ANALYSIS (ABA) ELECTROCONVULSIVE THERAPY (ECT) / TRANSCRANIAL MAGNETIC STIMULATION (TMS) OUTPATIENT TREATMENT REQUEST (OTR) URGENT When a non-urgent PRIOR AUTHORIZATION REQUEST could seriously jeopardize the life or HEALTH of a member.

PSYCHOLOGICAL / NEUROPSYCHOLOGICAL . APPLIED BEHAVIOR ANALYSIS (ABA) ... PSYCHOLOGICAL / NEUROPSYCHOLOGICAL TESTING REQUEST Complete all fields in their entirety. 34. SERVICE TYPE REQUESTED ... (if request is for a Neuropsychological Evaluation) • Any prior testing completed SECTION 6 – APPLIED BEHAVIORAL ANALYSIS …

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