Prior Authorization : Follow-Up to Decisions

Amendments

Providers are required to use the Prior Authorization Amendment Request to amend an approved or modified PA request.

ForwardHealth does not accept a paper amendment request submitted on anything other than the Prior Authorization Amendment Request. The Prior Authorization Amendment Request may be submitted through the ForwardHealth Portal as well as by mail or fax. If ForwardHealth receives a PA amendment on a previous version of the Prior Authorization Amendment Request form, a letter will be sent to the provider stating that the provider is required to submit a new PA amendment request using the proper forms.

Examples of when providers may request an amendment to an approved or modified PA request include the following:

• To temporarily modify a member's frequency of a service when there is a short-term change in their medical condition
• To change the rendering provider information when the billing provider remains the same
• To change the member's ForwardHealth identification number
• To add or change a procedure code

Note: ForwardHealth recommends that, under most circumstances, providers should enddate the current PA request and submit a new one if there is a significant, long-term change in services required.

Prior Authorization Amendments for Behavioral Treatment

Additional examples of when behavioral treatment providers may request an amendment to an approved or modified PA request include the following:

• To temporarily modify a member's frequency of service when there is a short-term increase in the member's behavioral treatment POC
• To change the grant or expiration date
• To identify co-treatment
• To amend a PA end date beyond the original expiration date (An approved or modified PA request initially approved for less than 12 months may be amended for up to a total of 12 months if additional services are medically necessary.)
• When changing from the commercial procedure code set to the Medicaid-allowable procedure code set after a member's commercial health insurance benefits have been exhausted

A request to amend the PA for behavioral treatment must include the following:

• The Prior Authorization Amendment Request form.
• The specific, requested changes (be as specific as possible).
• Documentation justifying the requested change. This may include the POC, a new written report of the member's evaluation, progress summary, etc.
• A corresponding prescription from a physician or medical professional, if needed.
• If the amendment request is to amend a PA end date beyond the original expiration date, an updated POC, progress summary, and updated behavioral treatment team (if there are changes in the team composition). The provider is required to include all documentation that was requested by ForwardHealth in the previous PA grant letter.

Note: Under most circumstances, providers should enddate the current PA request and submit a new one if there is a significant, long-term change in the services required.

ForwardHealth may approve a PA amendment request if the request is all of the following:

• Fully explained and documented. Clinical documentation of the medical necessity justifying the request is required.
• Medically necessary under Wis. Admin. Code § DHS 101.03(96m).
• Submitted before the date of the requested change.
• Submitted before the PA expires.
• Not solely for the convenience of the member, the member's family, or the provider.
• Not requested to allow for a vacation, missed appointments or treatment sessions, illness, or a leave of absence by the provider.