| Program Name: | BadgerCare Plus and Medicaid | Handbook Area: | Physician | | 04/24/2024 | Prior Authorization : Forms and AttachmentsTopic #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 #527 Prior Authorization/Physician Attachment
The PA/PA allows a provider to document the clinical information used to determine whether the standards of medical necessity are met for the requested service(s). Physician services providers should use the PA/PA for most services requiring PA.
Prior Authorization/Physician-Administered Drug Attachment
The purpose of the PA/PAD form is to document the medical necessity of physician-administered drugs requiring PA.
Prior Authorization/Physician Otological Report
Completion of the PA/POR begins the process by which PA is obtained for a hearing aid by a hearing instrument specialist. The physician gives page one (or a copy) of the completed PA/POR to the member and keeps page two (or a copy of it) in the member's medical records. The member then takes the PA/POR to any Medicaid-enrolled hearing instrument specialist to receive a hearing aid. 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 #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 #4677 Prior Authorization Request Form Completion Instructions for Physician Services
A sample PA/RF for physician services is available.
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, accurate 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 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 all applicable, service-specific attachments, including the PA/PA form and the PA/PAD form 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 processing type "117" to indicate physician services, including
family planning clinics, RHCs, and FQHCs. The processing type is a three-digit code used to identify a category of service requested. PA requests will be returned without adjudication if no processing type is indicated.
Element 3 — Telephone Number — Billing Provider
Enter the phone 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 NPI of the billing provider. The NPI in this element must correspond with the provider 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 provider's name.
Element 6b — National Provider Identifier — Prescribing / Referring / Ordering Provider
Enter the prescribing 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 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. 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 date for service(s) in mm/dd/ccyy format, if a
specific start date is requested.
Element 17 — Rendering Provider Number
Enter the NPI of the provider who will be performing the service or prescribing the drug, only if
the NPI is different from the NPI of the billing provider listed in Element
5a.
Element 18 — Rendering Provider Taxonomy Code
Enter the national 10-digit alphanumeric taxonomy code that corresponds to
the provider who will be performing the service or prescribing the drug, 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.
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/item would be provided/performed/dispensed.
Element 22 — Description of Service
Enter a written description corresponding to the appropriate CPT code or
HCPCS code for each service/procedure/item requested.
Element 23 — QR
Enter the appropriate quantity (for example, number of services, days' supply)
requested for the procedure code listed.
Element 24 — Charge
Enter the provider's usual and customary charge for each
service/procedure/item requested. If the quantity 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 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).
 Topic #7797 Prior Authorization Request Form Completion Instructions for Prescribers for Drugs
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 this form is mandatory to receive PA of certain procedures/services/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 all applicable service-specific attachments, 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" and Wisconsin Chronic Disease Program (WCDP)
Leave the box next to HealthCheck "Other Services" blank. 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 117 — Physician 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 NPI of the billing provider. The NPI in this element must correspond with the provider 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/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 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. 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 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 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.
Element 17 — Rendering Provider Number
Enter the prescriber's NPI, only if the NPI is different from the NPI of the billing provider listed in Element 5a.
Element 18 — Rendering Provider Taxonomy Code
Enter the national 10-digit alphanumeric taxonomy code that corresponds to the prescriber only if this code is different from the taxonomy code listed for the billing provider in Element 5b.
Element 19 — Service Code (not required)
Element 20 — Modifiers (not required)
Element 21 — POS
Enter the appropriate place of service code designating where the requested item would be provided/performed/dispensed.
Element 22 — Description of Service
Enter the drug name and dose for each item requested (for example, drug name, milligrams, capsules).
Element 23 — QR
Enter the appropriate quantity (for example, days' supply) requested for each item requested.
Element 24 — Charge (not required)
Element 25 — Total Charges (not required)
Element 26 — Signature — Requesting Provider
The original signature of the provider requesting this 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). Topic #22580 Prior Authorization/Physician-Administered Drug Attachment
Individual sections on the PA/PAD form identify specific types of physician-administered drug PA requests that require clinical PA, and ForwardHealth has defined criteria for those sections. Prescribers must submit the PA/PAD form along with the PA/RF to request PA.
When completing the PA/PAD form, prescribers must complete the most appropriate section as it pertains to the physician-administered drug being requested. The specific sections are as follows:
- Clinical information for diagnosis-restricted physician-administered drug requests
- Clinical information for physician-administered drugs with specific PA criteria addressed in the ForwardHealth Online Handbook
- Clinical information for other physician-administered drug requests
- Additional information (Prescribers should complete this section if more space is needed on the PA/PAD form or the prescriber is including additional information.)
Prescribers must fill out the appropriate section(s), then sign and date the PA/PAD form.
PA requests for physician-administered drugs must be completed, signed, and dated by the prescriber. PA requests for physician-administered drugs must be submitted using the PA/PAD form. Clinical documentation supporting the use of a physician-administered drug must be submitted with the PA request.
Prescribers are required to submit the completed PA/PAD form and a completed PA/RF to ForwardHealth.
PA requests for physician-administered drugs may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).
Prescribers are reminded that they are required to complete, sign, and date each PA form when submitting the PA request. Prescribers are required to retain a completed copy of the PA request form(s).
Clinical Information for Diagnosis-Restricted Physician-Administered Drug Requests
If the prescriber orders a drug that is a physician-administered drug with a diagnosis outside the ForwardHealth-allowed diagnoses, the prescriber must submit peer-reviewed medical literature to support the proven efficacy and safety of the requested use of the physician-administered drug. Prescribers must also include documentation of previous treatments and detailed reasons why other covered drug treatments were discontinued or not used. Medical records should be provided as necessary to support the PA request.
This information should be documented in Section IV (Clinical Information for Diagnosis-Restricted Physician-Administered Drug Requests) of the PA/PAD form.
When completing the PA/PAD form, prescribers should provide the diagnosis code and description, complete Section IV, and use Section VII (Additional Information) if needed. Prescribers are reminded to sign and date the form before submitting the PA/PAD form and the PA/RF to ForwardHealth. Clinical documentation supporting the use of the physician-administered drug must be submitted with the PA request.
Clinical Information for Physician-Administered Drugs With Specific Criteria Addressed in the ForwardHealth Online Handbook
If the prescriber orders one of the following drugs, a PA request must be submitted on the PA/PAD form:
This information should be documented using Section V (Clinical Information for Physician-Administered Drugs With Specific Criteria Addressed in the ForwardHealth Online Handbook) of the PA/PAD form. Prescribers should refer to the appropriate topic in the Online Handbook for the drug-specific clinical PA criteria.
When completing the PA/PAD form, prescribers should provide the diagnosis code and description, complete Section V, and use Section VII (Additional Information) if needed. Prescribers are reminded to sign and date the form before submitting the PA/PAD with the PA/RF to ForwardHealth. Clinical documentation supporting the use of the physician-administered drug must be submitted with the PA request.
Clinical Information for Other Physician-Administered Drug Requests
If the prescriber orders a drug that is a physician-administered drug that requires the use of the PA/PAD form and has not been previously referenced in the above PA/PAD sections, the prescriber must document the clinical rationale to support the medical necessity of the physician-administered drug being requested. Documentation of previous treatments and detailed reasons why other covered drug treatments were discontinued or not used is required. Medical records and peer-reviewed medical literature should be provided as necessary to support the PA request.
PA documentation must demonstrate that the member has a medical condition for which the requested drug has FDA approval. (Medical records must be provided to verify the member's medical condition.)
Additionally, the drug must be prescribed in a dose and manner consistent with the FDA-approved product labeling.
This information should be documented in Section VI (Clinical Information for Other Physician-Administered Drug Requests) of the PA/PAD form.
When completing the PA/PAD form, prescribers should provide the diagnosis code and description, complete Section VI, and use Section VII (Additional Information) if needed. Prescribers are reminded to sign and date the form before submitting the PA/PAD form with the PA/RF to ForwardHealth. Clinical documentation supporting the use of the physician-administered drug must be submitted with the PA request.
Additional Information
Additional diagnostic and clinical information explaining the need for the drug requested may be included in Section VII of the PA/PAD form. If the space provided in the other sections is not sufficient, additional information may be included here. 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. |