Prior Authorization : Forms and Attachments

An Overview

Depending on the service being requested, most PA requests must be comprised of the following:

• The PA/RF, PA/DRF, or PA/HIAS1
• A service-specific PA attachment(s)
• Additional supporting clinical documentation (Typical PA requirements regarding attachments may not apply for some HealthCheck "Other Services" PA requests.)

Attachments

In addition to the PA/RF, PA/HIAS1, or PA/DRF, a service-specific PA attachment must be submitted with each PA request. The PA attachment allows a provider to document the clinical information used to determine whether or not the standards of medical necessity are met for the requested service(s). Providers should include adequate information for ForwardHealth to make a reasonable judgment about the case.

ForwardHealth will scan each form with a barcode as it is received, which will allow greater efficiencies for processing PA requests.

Behavioral Treatment Benefit

All of the following must be included as part of the PA request for behavioral treatment:

• A completed PA/RF
• A completed PA/BTA
• Documentation supporting the PA approval criteria
• A prescription for behavioral treatment from a physician or medical provider authorized to prescribe

Note: Providers are not required to submit the PA/BTA form for comprehensive services for members under the age of 6.

PA/BTA

The PA/BTA must be submitted with each PA request. The PA/BTA allows a provider to document the clinical information used to determine whether or not the standards of medical necessity are met for the requested service(s) and the proposed POC. Providers are required to ensure that the PA/BTA is correct and complete; providers may only indicate "See attached" when the form or instructions indicate that this is a valid entry. When noting "See attached," the information requested on the PA/BTA must be easily located and adequately answered in the attached information. Providers should include adequate information for ForwardHealth to make a reasonable judgment about the case. The PA request will be returned if the attached information is unclear, incomplete, or difficult for a PA reviewer to locate.

Obtaining Forms and Attachments

Providers may obtain paper versions of all PA forms and attachments. In addition, providers may download and complete most PA attachments from the ForwardHealth Portal.

Paper Forms

Paper versions of all PA forms and PA attachments are available by writing to ForwardHealth. Include a return address, the name of the form, the form number (if applicable), and mail the request to the following address:

ForwardHealth
Form Reorder
313 Blettner Blvd
Madison WI 53784

Providers may also call Provider Services to order paper copies of forms.

Downloadable Forms

Most PA attachments can be downloaded and printed in their original format from the Portal. Many forms are available in fillable PDF and fillable Microsoft Word formats.

Web PA Via the Portal

Certain providers may complete the PA/RF and PA attachments through the Portal. Providers may then print the PA/RF (and in some cases the PA attachment), and send the PA/RF, service-specific PA attachments, and any supporting documentation on paper by mail or fax to ForwardHealth.

Prior Authorization Request Form

The PA/RF is used by ForwardHealth and is mandatory for most providers when requesting PA. The PA/RF serves as the cover page of a PA request.

Providers are required to complete the basic provider, member, and service information on the PA/RF. Each PA request is assigned a unique ten-digit number. ForwardHealth remittance information will report to the provider the PA number used to process the claim for prior authorized services.

Prior Authorization Request Form Completion Instructions for Behavioral Treatment Services

A sample PA/RF for behavioral treatment services is available. The information presented in the sample is for illustrative purposes only and does not constitute guidance from ForwardHealth regarding specific entries that a provider should make on a PA/RF for a specific PA request for a specific member.

ForwardHealth requires certain information to enable the programs to authorize and pay for medical services provided to eligible members.

ForwardHealth members are required to give providers full, correct, and truthful information for the submission of correct and complete claims for reimbursement. Per Wis. Admin. Code § DHS 104.02(4), this information should include, but is not limited to, information concerning enrollment status, name, address, and member ID number.

Under Wis. Stat. § 49.45(4), personally identifiable information about program applicants and members is confidential and is used for purposes directly related to ForwardHealth administration such as determining eligibility of the applicant, processing PA requests, or processing provider claims for reimbursement. The use of the PA/RF is mandatory to receive PA of certain items. Failure to supply the information requested by the form may result in denial of PA or payment for the service.

Providers should make duplicate copies of all paper documents mailed to ForwardHealth. Providers may submit the PA/RF and other required documentation via the ForwardHealth Portal, by fax to ForwardHealth at 608-221-8616, or by mail to the following address:

ForwardHealth
Prior Authorization
Ste 88
313 Blettner Blvd
Madison WI 53784

The provision of services that are greater than or significantly different from those authorized may result in nonpayment of the billing claim(s).

SECTION I ― PROVIDER INFORMATION

Element 1 — HealthCheck "Other Services"
Enter an "X" in the box next to HealthCheck "Other Services" if the services requested on the PA/RF are for HealthCheck "Other Services." The provider is required to select HealthCheck "Other Services" when requesting comprehensive behavioral treatment.

Element 2 — Process Type
Enter process type "142" for behavioral treatment. The process type is a three-digit code used to identify a category of service requested.

Element 3 — Telephone Number — Billing Provider
Enter the telephone number, including the area code, of the office, clinic, facility, or place of business of the billing provider.

Element 4 — Name and Address — Billing Provider
Enter the Medicaid-enrolled behavioral treatment provider's name and complete address (street, city, state, and ZIP+4 code). Providers are required to include both the ZIP code and four-digit extension for timely and accurate billing. The name listed in this element must correspond with the billing provider number listed in Element 5a.

Element 5a — Billing Provider Number
Enter the NPI of the billing provider. The NPI in this element must correspond with the Medicaid-enrolled behavioral treatment provider's name listed in Element 4.

Element 5b — Billing Provider Taxonomy Code
Enter the national 10-digit alphanumeric taxonomy code that corresponds to the NPI of the billing provider in Element 5a.

Element 6a — Name — Prescribing/Referring/Ordering Provider
Enter the prescribing medical provider's name. This is the name of the Medicaid-enrolled medical provider writing the prescription for behavioral treatment. The prescribing, referring, or ordering provider whose information is submitted on the PA request or claim for behavioral treatment services must match the prescribing provider on the prescription for behavioral treatment services.

Element 6b — National Provider Identifier — Prescribing/Referring/Ordering Provider
Enter the prescriber's 10-digit NPI. The NPI in this element must correspond with the provider's name listed in Element 6a.

SECTION II ― MEMBER INFORMATION

Element 7 — Member Identification Number
Enter the member ID. Do not enter any other numbers or letters. Use the ForwardHealth ID card or Wisconsin's EVS to obtain the correct number.

Element 8 — Date of Birth — Member
Enter the member's date of birth in MM/DD/CCYY format.

Element 9 — Address — Member
Enter the complete address of the member's place of residence, including the street, city, state, and ZIP code.

Element 10 — Name — Member
Enter the member's last name, followed by their first name and middle initial. Use the EVS to obtain the correct spelling of the member's name. If the name or spelling of the name on the ForwardHealth card and the EVS do not match, use the spelling from the EVS.

Element 11 — Gender — Member
Enter an "X" in the appropriate box to specify male or female.

SECTION III ― DIAGNOSIS / TREATMENT INFORMATION

Element 12 — Diagnosis — Primary Code and Description
Enter the appropriate ICD diagnosis code and description with the greatest level of specificity most relevant to the service/procedure requested. The ICD diagnosis code must correspond with the ICD description.

Element 13 — Start Date — SOI (not required)

Element 14 — First Date of Treatment — SOI (not required)

Element 15 — Diagnosis — Secondary Code and Description
Enter the appropriate secondary ICD diagnosis code and description with the greatest level of specificity most relevant to the service/procedure requested, if applicable. The ICD diagnosis code must correspond with the ICD description.

Element 16 — Requested PA Start Date
Enter the requested start date for service(s) in MM/DD/CCYY format.

Element 17 — Rendering Provider Number
Enter the NPI of the provider who will be performing the service, only if the NPI is different from the NPI of the billing provider listed in Element 5a. The rendering provider is required to be a Medicaid-enrolled behavioral treatment provider.

Element 18 — Rendering Provider Taxonomy Code
Enter the national 10-digit alphanumeric taxomony code that corresponds to the provider who will be performing the service, only if this code is different from the taxonomy code listed for the billing provider in Element 5b.

Element 19 — Service Code
Enter the appropriate CPT code or HCPCS code for each service/procedure/item requested using the procedure code set that is allowable for the member's primary insurance.

If the member has Medicaid only (including Medicaid HMO only), the allowable procedure code is 97153 (Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified healthcare professional, face-to-face with one patient, each 15 minutes).

To simplify the PA submission process, providers may request all direct treatment units for CPT codes 97153 and 97155 by including the cumulative total of requested treatment units as a single line item, using a single code (97153).

Note: Direct treatment units submitted on claims using any of these CPT codes will be deducted from the cumulative total of approved treatment units.

Family Treatment Guidance

Family treatment guidance services must be requested as a separate line item on the PA/RF using CPT procedure code 97156.

Team Meeting

Team meeting services must be requested on a separate line item on the PA/RF using CPT procedure code 97156.

Group Behavioral Treatment

Group behavioral treatment services must be requested as separate line items on the PA/RF using CPT procedure codes 97158 and 97154.

Element 20 — Modifiers
Enter the modifier corresponding to the level of service requested using the modifiers required by the member's primary insurance.

If the member has Medicaid only (including Medicaid HMO only), use the following modifier(s):

• Comprehensive Behavioral Treatment (modifier TG).
• Focused Behavioral Treatment (modifier TF).
• Team Meeting (modifier AM). Modifier AM is used only with procedure code 97156 when 97156 is used to indicate team meetings. Do not use modifier AM with procedure code 97156 when it is used to indicate family treatment guidance.

Element 21 — POS
Enter the appropriate POS code designating where the requested service will be provided. If the service will be provided in more than one place, the provider should list the POS code that reflects the place that the majority of the service will be provided.

Element 22 — Description of Service
Enter a written description of the allowable procedure code that corresponds to the procedure code listed in Element 19 for each service requested. Also indicate the number of weeks for which the service is requested.

Element 23 — QR
Enter the appropriate quantity (for example, number of units) requested for the procedure code listed in Element 19.

Element 24 — Charge
Enter the provider's usual and customary charge for each service/procedure/item requested. If the quantity requested (Element 23) is greater than "1.0," multiply the quantity by the charge for each service/procedure/item requested. Enter that total amount in this element.

Note: The charges indicated on the request form should reflect the provider's usual and customary charge for the procedure requested. Providers are reimbursed for authorized services according to provider Terms of Reimbursement issued by the Wisconsin DHS.

Element 25 — Total Charges
Enter the anticipated total charges for this request.

Element 26 — Signature — Requesting Provider
The original signature of the provider (first and last name) requesting this service must appear in this element.

Element 27 — Date Signed
Enter the month, day, and year the PA/RF was signed (in MM/DD/CCYY format).

Topic #449

Supporting Clinical Documentation

Certain PA requests may require additional supporting clinical documentation to justify the medical necessity for a service(s). Supporting documentation may include, but is not limited to, X-rays, photographs, a physician's prescription, clinical reports, and other materials related to the member's condition.

All supporting documentation submitted with a PA request must be clearly labeled and identified with the member's name and member identification number. Securely packaged X-rays and dental models will be returned to providers.

Photographs submitted to ForwardHealth as additional supporting clinical documentation for PA requests will not be returned to providers and will be disposed of securely.

Topic #3759

Utilizing Medical Record Documentation

Providers may submit selected existing medical documentation with a PA request in lieu of writing the same required information on the PA attachment.

For example, as supportive documentation, the current treatment plan could be attached rather than rewritten on the PA attachment. In this case, the provider should write, "See attached treatment plan dated MM/DD/YY" in the element requesting the current treatment plan on the PA attachment.