How to Complete Hawaii Form DHS 1157: Eligibility, Sections, and Filing

Hawaii Form DHS 1157 is the referral used by health plans and treating providers to enroll an adult Medicaid beneficiary with serious mental illness into the Community Care Services (CCS) program. To complete it, you confirm the patient meets all five eligibility criteria, fill out the three-page form with diagnoses, hospitalization history, medications, mental status, and functional scales, collect the required clinical documentation, and submit the packet through the patient’s health plan to the Med-QUEST Division’s Clinical Standards Office for evaluation.

Confirm the Patient Qualifies Before You Start

The form only moves forward if the patient satisfies every one of these five criteria:¹

Age 18 or older and currently Medicaid-eligible.
Not already successfully engaged in existing case management, including Adult Mental Health Division case management.
Diagnosed with a qualifying serious mental illness.
That diagnosis has been present for at least 12 months or is expected to persist that long.
Meets at least one functional benchmark: GAF scores consistently below 50 over the past six months, clinical instability under current treatment, or involvement with Adult Protective Services, housing, or law enforcement.

Clinical instability covers a wide range of situations: repeated hospitalizations with ongoing instability, a history of crises, consistent medication noncompliance, disengagement from providers, significant isolation, resource deficits that destabilize the patient, or imminent risk of hospitalization.¹

Qualifying Diagnoses

The DSM code you enter on the form must correspond to one of the following conditions:²

Schizophrenic disorders
Schizoaffective disorders
Delusional disorders
Bipolar disorders
Severe depressive disorders (major depressive disorder with psychotic features or recurrent severe episodes)
Post-traumatic stress disorder
Substance-induced psychosis

If the patient’s primary diagnosis sits outside this list but a secondary diagnosis qualifies, identify the qualifying diagnosis clearly on the referral.

Filling Out the Three Pages

The treating provider completes most of the form. The health plan medical director or attending physician must then review it and sign to concur before the packet goes anywhere.¹

Page 1 — Section A: Patient Information and Hospital History

Enter the patient’s full name, gender, home address, mailing address (if different), date of birth, age, phone number, DHS case number, client ID number, Social Security number, county, and health plan. Every identifier must match what Med-QUEST already has on file. Mismatched case numbers or client IDs are the fastest way to get a packet returned.

Record the primary and secondary psychiatric diagnoses, current medical conditions, and the DSM code. The qualifying diagnosis must have been present for at least 12 months or be expected to continue that long. Add the referral date, the primary care provider’s name, and whether the PCP knows about the referral.

The patient initials an acknowledgment that they will comply with CCS program directions and understand their current providers may change on enrollment, then signs the form. Without that signature, nothing moves.

Close page 1 with hospitalization data. Note whether the patient is currently hospitalized and, if so, where. Then list every other psychiatric hospitalization: facility, location, admission date, discharge date, and diagnosis. The evaluation panel leans on this history when it judges clinical instability.

Page 2 — Medications, Therapists, and Sections B Through D

Section A continues with two blocks. List the patient’s routine psychiatric medications and any frequently used PRN psychiatric medications, with strength, dosage, start date, and end date for each. Then list current and past outpatient mental health therapists, the diagnosis each treated, and treatment start and end dates.¹

Leave Section B blank. The MQD/CSO evaluation panel uses it to record the evaluation date, enrollment date, requests for more information, re-evaluation decisions, and any denial reasons.

Section C covers Mental States, and Section D covers Functional Scales and Supporting Documentation. The treating psychiatrist or psychologist completes both. If the patient has no treating psychiatrist or psychologist, the treating medical provider may sign in their place. The health plan medical director or behavioral health specialist signs to indicate review and concurrence.

Documents to Attach

The form on its own won’t get a determination. Submit the full packet:¹

All three pages of the DHS 1157.
Clinical notes from the past year outlining the current plan of care and treatment.
Hospital admission and discharge notes from the past year, if applicable.
A psychiatric or psychosocial assessment from the past year.
GAF scores from within the last six months, plus the highest score within the last year, with supporting clinical documentation.

Incomplete packets are the most common reason referrals stall. If the evaluation panel cannot answer all five eligibility questions from what you sent, the file comes back for more information. Gathering every document before you start the form saves weeks.

Where to Send It

The standard route is through the patient’s health plan. Fax or mail the completed form and all supporting documentation to the health plan, which forwards the packet for CCS referral processing. Providers who have been authorized to bypass the health plan can fax directly to the Med-QUEST Division at 808-692-8131.¹

If you mail the packet, the Med-QUEST Division’s address on file is 1350 S. King Street, Suite 200, Honolulu, HI 96814. Confirm the current address with your health plan contact before sending. Fax is faster and more common.

What Happens After You Submit

Once the MQD/CSO evaluation panel has a complete packet, it reviews the referral against the five eligibility criteria and reaches one of three outcomes:¹

Approved. The enrollment date is set five business days after the approval date, and CCS then assesses the beneficiary to develop a care plan.
Returned for more information. The panel could not decide from what was submitted and asks the provider or health plan for specific missing documentation.
Denied. The panel documents the reason in Section B. A new referral can be submitted later if the patient’s condition worsens or circumstances change.

Approval at the MQD level opens the door, but it isn’t the last word. CCS conducts its own initial evaluation after enrollment, and if that assessment finds the beneficiary does not meet or no longer meets admission criteria, CCS completes its portion of the DHS 1157 to document why.

1
Med-QUEST Division. DHS 1157 Instructions – Referral for Serious Mental Illness (SMI) Community Care Services (CCS) Program
2
Department of Human Services. Attachment F – Behavioral Health Protocol