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Community Behavioral Health Services Coverage and Limitations Handbook

Assessment Services, continued

Bio-Psychosocial A bio-psychosocial evaluation describes the biological, psychological, and


Evaluation social factors that may have contributed to the recipient’s need for services.
The evaluation includes a brief mental status exam and preliminary service
recommendations.

When it is consistent with the recipient’s treatment needs, bio-psychosocial


evaluations can be completed using telemedicine.

Evaluation A bio-psychosocial evaluation must provide information on all the following


Components components:

• Presenting problems
• Biological factors
• Psychological factors
• Social factors
• Mental health status examination
• Summary of findings
• Diagnostic impression
• Treatment recommendations or plan

Who Must Provide A bio-psychosocial evaluation must be provided by one of the following
qualified practitioners:

• Physician
• Psychiatrist
• LPHA
• Master’s level CAP
• Master’s level practitioner
• CAP
• Bachelor’s level practitioner

Who Must Review A bio-psychosocial evaluation completed by a bachelor’s level practitioner


must be reviewed, signed, and dated by a master’s level practitioner,
bachelor’s level CAP, or a treating practioner prior to completion of the
treatment planning process. The review must include clinical impressions, a
provisional diagnosis, and a statement by the reviewer that indicates
concurrence or alternative recommendations regarding treatment.

March 2014 2-11

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