Prior Authorization (Care Extension Request) Member Name * First Name Last Name Date of Birth * MM DD YYYY MassHealth Subscriber ID * Category of Primary Complication * maternal physical health condition maternal behavioral health condition social risk factor(s) health conditions of newborn infant Primary Complication(s) * diabetes mellitus hypertensive conditions cardiovascular conditions hypercoagulable conditions intensive care unit admission depression anxiety bipolar disorder posttraumatic stress disorder substance use disorder housing insecurity food insecurity experience of bias and discrimination in healthcare setting neonatal intensive care unit (NICU) admission congenital anomalies or disorders feeding difficulties neonatal abstinence syndrome Onset of Primary Complication * existed prior to perinatal period developed during perinatal period exacerbated during perinatal period Additional Complications diabetes mellitus hypertensive conditions cardiovascular conditions hypercoagulable conditions intensive care unit admission depression anxiety bipolar disorder posttraumatic stress disorder substance use disorder housing insecurity food insecurity experience of bias and discrimination in healthcare setting neonatal intensive care unit (NICU) admission congenital anomalies or disorders feeding difficulties neonatal abstinence syndrome Summary of Prenatal, Labor and Delivery, and Postpartum Course with Specific Details on Aforementioned Complications. * Additional Supports Utilized by Member * care management care coordination/navigation Community Partners program other none social services Number of Additional Perinatal Visit Hours Requested * Proposed Schedule for Care Extension * daily visits during first week postpartum (in-person) daily visits during first two weeks postpartum (in-person) daily phone calls weekly visits (in-person) weekly appointments (virtual) biweekly visits (in-person) biweekly appointments (virtual) weekly phone calls multiple phone calls per week other Proposed Services for Care Extension * physical support newborn care breastfeeding support social support general peer support Extension Term End Date * MM DD YYYY Signed (Doula Provider) * Your request has been submitted!
