Form F-11035 - Prior Authorization Dental Request Form (Pa/drf)

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
DHS 106.03(4), Wis. Admin. Code
F-11035 (07/12)
DHS 152.06(3)(h), Wis. Admin. Code
FORWARDHEALTH
PRIOR AUTHORIZATION DENTAL REQUEST FORM (PA/DRF)
Providers may submit prior authorization (PA) requests by fax to ForwardHealth at (608) 221-8616 or by mail to: ForwardHealth, Prior Authorization, Suite 88,
313 Blettner Boulevard, Madison, WI 53784. Instructions: Type or print clearly. Before completing this form, read the Prior Authorization Dental Request Form
(PA/DRF) Completion Instructions, F-11035A.
SECTION I — PROVIDER INFORMATION
3. Telephone Number ― Billing Provider
1. Check only if applicable
2. Process Type (Check one)
HealthCheck “Other Services”
124 (Dental)
Wisconsin Chronic Disease Program
125 (Ortho)
4. Name and Address — Billing Provider (Street, City, State, ZIP+4 Code)
5a. Billing Provider Number
5b. Billing Provider Taxonomy Code
6a. Rendering Provider Number
6b. Rendering Provider Taxonomy Code
SECTION II — MEMBER INFORMATION
7. Member Identification Number
8. Date of Birth — Member
9. Address — Member (Street, City, State, ZIP+4 Code)
10. Name — Member (Last, First, Middle Initial)
11. Gender — Member
Male
Female
SECTION III — DIAGNOSIS / TREATMENT INFORMATION
12. Place of Service
13. Dental Diagram
Dental Office (POS “11”)
Outpatient Hospital (POS “22”)
Ambulatory Surgical Center (POS “24”)
Check periodontal case type if
Skilled Nursing Facility (POS “31”)
Other (specify): _
____________________________
applicable.
14.
15.
16.
17.
18.
19.
20.
I
Area of Oral
Tooth
Procedure Code
Modifier
Description of Service
Quantity
Charge
II
Cavity
Requested
III
IV
V
Cross out missing teeth.
Circle teeth to be extracted.
An approved authorization does not guarantee payment. Reimbursement is contingent upon enrollment of the member and
21. Total
provider at the time the service is provided and the completeness of the claim information. Payment will not be made for
Number of X-rays _________________
Charges
services initiated prior to approval or after the authorization expiration date. Reimbursement will be in accordance with
Type of X-rays ____________________
ForwardHealth payment methodology and policy. If the member is enrolled in a BadgerCare Plus Managed Care Program at
the time a prior authorized service is provided, ForwardHealth reimbursement will be allowed only if the service is not covered
by the Managed Care Program.
22. SIGNATURE — Rendering Provider
23. Date Signed
24. SIGNATURE — Member / Guardian (if applicable)
25. Date Signed
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