Questionnaires

Thank you for your interest in using Acentra Health Atrezzo. To access Acentra Health Atrezzo, our Web based authorization system, please contact our provider relations staff at (866)521-0027, Option 3 or email ProviderRelationsME@Kepro.com.

Questionnaires

As part of the utilization review process, Acentra Health has developed service specific questionnaires to capture the required clinical information in order to establish eligibility and medical necessity criteria according to the MaineCare Benefits Manual. These questionnaires are updated from time to time, however, the most up-to-date version can be found within the Atrezzo platform.

• ASAM Assessment  (Updated 9/12/2023)
• Child & Adolescent Needs and Strengths (CANS) Admission
• Child & Adolescent Needs and Strengths (CANS) Discharge
• Baxter Invoice (Posted 6/28/2023)
• Behavioral Health Homes (BHH) (Posted 6/28/2023)
• Child Assertive Community Treatment (ACT) (Posted 6/28/2023)
• Child Behavioral Health Homes (BHH) (Posted 6/28/2023)
• Child Inpatient DDU (Posted 7/5/2023)
• Child Inpatient (Posted 7/5/2023)
• Child Private Non-Medical Institution (PNMI) (Posted 7/5/2023)
• Clubhouse (Posted 7/5/2023)
• Critical Incident Report  (Posted 7/5/2023)
• Day Treatment(Posted 7/5/2023) 
• ECSII Scoring  Sheet (Posted 7/5/2023)
• General (Posted 7/5/2023)
• Home and Community Based Treatment (Posted 7/5/2023)
• Hospital and State Hospital (Posted 7/5/2023)
• Intensive Outpatient Program (IOP) (Posted 7/5/2023)
• LOCUS Scoring Sheet (Posted 7/5/2023)
• Long-Term Supported Employment (LTSE) Clinical (Posted 7/5/2023)
• Long-Term Supported Employment (LTSE) Invoice (Posted 7/5/2023)
• Medication Management (Posted 7/5/2023)
• Opioid Health Homes (OHH) (Posted 7/5/2023)
• Partial Hospitalization (Posted 7/5/2023)
• PNMI Referral (Updated 8/3/2023)
• Resource Data Summary (OBH Funded Services) (Posted 7/5/2023)
• Referral Acknowledgement (Posted 7/5/2023)
• Referral Management (Posted 7/5/2023)
• Referral Refusal (Updated 7/5/2023)
• Rehabilitative and Community Support (RCS) (Posted 7/5/2023)
• Section 17 (Posted 7/5/2023)
• Section 21 (Posted 7/5/2023)
• SMI Termination Request (Posted7/5/2023)
• Substance Use Treatment Admission (Posted 8/3/2023)
• Substance Use Treatment Follow Up (Posted 7/5/2023)
• Substance Use Treatment Discharge (Posted 8/3/2023)
• Targeted Case Management (TCM) (Posted7/5/2023)
• Temporary High Intensity Service for Residents of Appendix E (Posted7/5/2023)
• Treatment Foster Care (TFC) (Posted7/5/2023)
• Upstaffing (Posted 7/5/2023)
  
  

Atrezzo 

For questions about the Atrezzo Questionnaires, please contact Acentra Health Provider Relations at 866.521.0027, Option 1, through our online chat feature, or via email at ProviderRelationsME@Kepro.com