Prior Authorization : Grant and Expiration Dates

Backdating for Initial and Renewal Requests

Initial Requests

An initial PA request is the original approved PA that starts specific medically necessary services for a member.

ForwardHealth may allow a PA request to be backdated if it is received within 14 calendar days of the requested start date. ForwardHealth will modify or deny a PA request if it is received more than 14 calendar days after the requested start date and does not meet the extraordinary circumstances criteria.

Renewal Requests

A renewal request is a new PA request to continue medically necessary services beyond the initial PA request's end date.

Backdating is not allowed when submitting an amendment request for continuous treatment. All PA amendment requests to extend treatment must be received by ForwardHealth prior to the expiration date of the current PA request.

Backdating may be allowed for all benefits that utilize a PA request (PA/RF) to continue treatment if it is received within 14 calendar days of the requested start date. ForwardHealth will modify or deny a PA request if it is received more than 14 calendar days after the requested start date and does not meet the extraordinary circumstances criteria.

Extraordinary Circumstances Criteria

ForwardHealth may approve a request for backdating if all of these conditions are met:

• The provider specifically requests backdating in writing on the PA request.
• The request includes clinical justification for beginning the service before PA was granted.
• The request includes the reason why the request was submitted more than 14 days after the requested start date.

Examples of extraordinary circumstances include:

• A court order or hearing decision requiring Wisconsin Medicaid coverage is attached to the PA request.
• The member is retroactively enrolled. (Indicate in Element 21 of the PA/RF that the service was provided during a period of member retroactive enrollment. In Element 15, indicate the actual date the service was provided.)
• The provider is on a correction plan.

If the PA request is modified or denied and a service has already been rendered, the provider cannot require payment from the member.

Behavioral treatment providers may request PA back to the date of eligibility for members who receive retroactive enrollment in Wisconsin Medicaid or BadgerCare Plus. However, services will not be authorized for dates prior to the date the member's medical provider prescribed or ordered the services. Providers are required to submit a PA request and receive approval from ForwardHealth before submitting a claim for behavioral treatment services.

Expiration Date

The expiration (end) date of an approved or modified PA request is the date through which services are prior authorized. PA requests are granted for varying periods of time. Expiration dates may vary and do not automatically expire at the end of the month or calendar year. In addition, providers may request a specific expiration date. Providers should carefully review all approved and modified PA requests and make note of the expiration dates.

Grant Date

The grant (start) date of an approved or modified PA request is the first date in which services are prior authorized and will be reimbursed under this PA number. On a PA request, providers may request a specific date that they intend services to begin. If no grant date is requested or the grant date is illegible, the grant date will typically be the date the PA request was reviewed by ForwardHealth.

Behavioral Treatment Services

The requested start date for behavioral treatment services on PA requests cannot precede the date of the medical examination, diagnostic evaluation, or prescription from a physician or medical provider authorized to write a prescription (for example, a nurse practitioner or physician assistant).

Services provided prior to the PA start date or after the PA end date are not considered authorized and will not be covered.