Healthy Pathways Request Form

Healthy Pathways

The Healthy Pathways program provides rapid engagement to members experiencing impaired emotional health because of a potential mental health or substance use disorder issue when; the member is ineligible for other case management services, eligibility is unknown, or the member is currently receiving a higher level of services and needs step-down support.
Submissions

Requests must be submitted within the calendar month of service (the month of the contact is the same month of authorization), and member and case manager assessments shall be completed the same day. This is part of the program design.

Example:
Assessment and Requested date: 03/15/2025
Auth Dates: 03/01/2025 - 05/31/2025
Next submission due: in June 2025 with assessments dates completed in June 2025
Eligibility
Confirm the below*

Member is enrolled with South Country Health Alliance and is age 17 or olderMember meets program criteria due to displaying behavioral health symptoms

Member and Case Manager Information
Member's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Member PMI*
8-digit PMI number
Primary Diagnosis Code(s):*
ICD 10 Codes and Descriptions (if unknown, please enter N/A)
Case Manager Name*

First NameLast Name
Case Manger Direct Phone Number*
Please enter a valid phone number.
Facility Fax Number*
Your agency fax number
Facility Name & NPI/UMPI*

Initial Form
When did the member get referred to your agency for Healthy Pathways?

MonthDayYear
The date the agency received/created the referral
How was the member referred into Healthy Pathways?
What is the first date of direct contact with the member by the Healthy Pathways Case Manager? (this date determines the starting month of the authorization)

MonthDayYear
First Date of Service (direct contact may be face-to-face or ITV contact)
Is the member transitioning from MH-TCM to Healthy Pathways?
When was the member's last date of service for MH-TCM?

MonthDayYear
Date
What is the reason the member is transitioning to Healthy Pathways from MH-TCM?

Continuing
What statement best fits the member's current situation. (Select 1)

Member is making progress and requires continuation of services to work on the previously identified goal.Member's status is improving but needs to work on a new goal. (i.e.: connecting with providers or other M.A. services, transitioning services, housing support or substance use disorder.)Member has encountered challenges with progress towards their goal. (i.e.: mental/chemical health worsened, relationship difficulties, loss of job or housing, or transportation struggles). Please submit treatment plan and/or clinical notes.For 2025 Only: Members on Healthy Pathways currently for 12+ months, please submit clinical notes and/or treatment plan.
Please upload treatment plan and/or notes when indicated

File type: PDF
Cancelof

REVIEW and PRINT for your records, BEFORE you Submit

Remember to mark your calendars for new submissions
Should be Empty:

	Mild	Moderate	Severe	N/A
Mental health symptoms
Drug or alcohol use
Lack of provider(s) to help with behavioral health or substance use
Feelings of isolation and/or loneliness
Lack of housing, food, transportation, employment or other financial problems

	Mild	Moderate	Severe	N/A
Impairment of functioning due to mental health symptoms
Impairment of functioning due to substance use
Impairment of functioning due to isolation/loneliness
Impairment of functioning due to social drivers of health, like financial concerns, housing, transportation, food, etc.

	Yes	No	NA
Member has a need for mental health services/provider selection
Member has a need for SUD services/provider selection
Member is receiving MH/SUD services/has a provider but is not engaged with treatment

Healthy Pathways