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Welcome  » March 28, 2024 11:38 AM
Program Name: BadgerCare Plus and Medicaid Handbook Area: Personal Care
03/28/2024  

Prior Authorization : Forms and Attachments

Topic #960

An Overview

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

Topic #446

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.

Topic #3183

Documentation Required for Requesting Prior Authorization

To obtain PA for personal care services, providers are required to submit documents to ForwardHealth that accurately and completely demonstrate the need for the requested personal care services. If the documentation contains errors or is incomplete, adjudication of the PA will be delayed while the request is returned to the provider to supply the required information.

Completion of the Personal Care Screening Tool

The provider is required to complete the PCST for a member each time PA is requested for that member. Also, the PCST is required to be completed as often as necessary when preparing a PA amendment for an adjudicated PA. PA may be granted for varying periods of time, depending on the circumstances, but is never granted for longer than a 12-month period.

The PCST may not be completed more than 90 days before the requested PA start date. ForwardHealth will authorize the requested start date only when the requested start date is on or after the PCST completion date and all other requirements are met.

Minimum Documentation That Providers Are Required to Submit

To request PA for personal care services, providers are required to submit the following documents to ForwardHealth:

Documentation Providers Are Required to Maintain on File

Providers are required to maintain all of the following on file to support their reimbursement for personal care services:

  • Copies or the originals, as appropriate, of all documents submitted with the PA request to ForwardHealth. (Providers are required to maintain the Full PCST on file, not just the PCST Summary Sheet.)
  • The POC.
  • Signed and dated physician orders reflecting the number of hours per day and days per week that personal care services are to be provided. Physician orders are required to be expressed as hours per day, days per week.
  • The nursing assessment. Standards of Practice for Registered Nurses and Licensed Practical Nurses, ch. N 6.03(1), defines the nursing assessment as the "systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis." Nursing assessment forms are created by the provider. ForwardHealth does not prescribe a format for nursing assessments.
  • The record of all PCW assignments for the member, and the record of the RN supervisory visits.
  • The time and activity records of all visits by PCWs, including observations and assigned activities, completed and not completed.
  • Documentation of travel time if claimed for reimbursement.
  • The list of the member's medications, regardless of the involvement with medication administration assistance.
  • The list of the member's regularly scheduled activities outside the home.
  • The copy of written agreements between the personal care providers and the RN supervisor, if applicable.
  • The clinical rationale making the services medically necessary must be clearly documented.
Topic #447

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.

Topic #3182

Personal Care Addendum

The Personal Care Addendum form is to be completed as directed for PA requests and with PA amendment requests.

ForwardHealth requires the POC to be submitted with every Personal Care Addendum. When completing the Personal Care Addendum, rather than repeating information that has been included in the POC, providers may refer to specific locations (for example, page and item numbers) in the POC as long as the referenced item in the POC contains all of the required components. Stating "See POC" is too general. ForwardHealth requires providers to include all of the requested Personal Care Addendum components.

Topic #3181

Personal Care Prior Authorization Provider Acknowledgement

The Personal Care Prior Authorization Provider Acknowledgement indicates that the supervising RN will perform each of the following tasks before personal care services are provided for the claims submitted to ForwardHealth:

  • Obtain physician's signed and dated orders.
  • Conduct an assessment at the member's place of residence.
  • Develop the POC.

Providers are required to submit the completed Personal Care Prior Authorization Acknowledgement with each request for PA.

Topic #3180

Personal Care Screening Tool

Providers are required to complete the PCST before requesting PA.

The PCST assists providers in determining the number of units to request for PA of medically necessary personal care services. Providers may choose to complete either the web-based PCST or the paper PCST.

Topic #448

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.

Topic #2459

Prior Authorization Request Form Completion Instructions for Personal Care Services

A sample PA/RF for personal care services is available.

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

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

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 for 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 PA requests, along with the PCST 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" and Wisconsin Chronic Disease Program (WCDP)
Enter an "X" in the box next to HealthCheck "Other Services" if the services requested on the PA/RF are for HealthCheck "Other Services." Enter an "X" in the box next to WCDP if the services requested on the PA/RF are for a WCDP member.

Element 2 — Process Type
Enter process type "121" for personal care services. The process type is a three-digit code used to identify a category of service requested. PA requests will be returned without adjudication if no process type is indicated.

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 name and complete address (street, city, state, and ZIP+4 code) of the billing provider. 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 provider number of the billing provider. The provider number in this element must correspond with the provider name listed in Element 4.

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

Element 6a — Name — Prescribing/Referring/Ordering Provider
Enter the prescribing/referring/ordering provider's name.

Element 6b — National Provider Identifier — Prescribing/Referring/Ordering Provider
Enter the prescribing/referring/ordering provider's 10-digit NPI.

SECTION II ― MEMBER INFORMATION

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

Element 8 — Date of Birth — Member
Enter the member's date of birth in MM/DD/CCYY format (for example, September 8, 1966, would be 09/08/1966).

Element 9 — Address — Member
Enter the complete address of the member's place of residence, including the street, city, state, and ZIP code. If the member is a resident of a nursing home or other facility, include the name of the nursing home or facility.

Element 10 — Name — Member
Enter the member's last name, followed by his or her 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 highest 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 highest 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 DOS in MM/DD/CCYY format, if a specific start date is requested.

Element 17 — Rendering Provider Number (not required)

Element 18 — Rendering Provider Taxonomy (not required)

Element 19 — Service Code
Enter the appropriate HCPCS procedure code for each service/procedure/item requested.

Note: If the provider needs additional spaces for Elements 18-23 for the PA request, the provider may complete additional PA/RF(s). The PA/RFs should be identified, for example, as "page 1 of 2" and "page 2 of 2."

Element 20 — Modifiers
Enter the modifier(s) corresponding to the procedure code listed if a modifier is required.

Element 21 — POS
Enter the appropriate POS code designating where the requested service/procedure would be provided/performed/dispensed.

Element 22 — Description of Service
Enter a written description corresponding to the appropriate HCPCS procedure code for each service/procedure/item requested.

When requesting personal care services, indicate the number of units per week multiplied by the total number of weeks being requested. The total number of units requested on the PA/RF must be equivalent to the number of hours ordered by the physician (4 units = 1 hour). If requesting travel time, enter this as a separate item using procedure code T1019 and modifier U3.

If sharing a case with another provider, enter "shared case with (name of provider)" and include a statement that the total number of units of all providers will not exceed the combined and total number of units ordered on the plan of care.

Element 23 — QR
Enter the appropriate quantity in units for the procedure code listed. To calculate total quantity requested, multiply the number of hours per week by the number of units per hour (4 units = 1 hour). Multiply that number by the number of weeks requested (for example, hours/week x 4 units/hour x number of weeks). For example, 14 hours/week x 4 units/hour x 53 weeks = 2968 units.

Element 24 — Charge
Enter the provider's usual and customary charge for each service/procedure/item requested. If the quantity is greater than "1," 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. If the provider completed a multiple-page PA/RF, indicate the total charges for the entire PA request on Element 22 of the last page of the PA/RF. On the preceding pages, Element 22 should refer to the last page (for example, "SEE PAGE TWO").

Element 26 — Signature — Requesting Provider
The original signature of the provider requesting/performing/dispensing this service/procedure/item 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).

 

Sample PA/RF for Personal Care Services
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.

 
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