Prior Authorization Request For Hearing Instrument And Audiological Services printable pdf download

Prior Authorization Request For Hearing Instrument And Audiological Services

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

ForwardHealth

DHS 106.03(4), Wis. Admin. Code

F-11020 (05/13)

FORWARDHEALTH

PRIOR AUTHORIZATION REQUEST FOR HEARING INSTRUMENT

AND AUDIOLOGICAL SERVICES (PA/HIAS1)

Instructions: Type or print clearly. Providers may submit prior authorization (PA) requests with attachments to ForwardHealth by fax at (608) 221-8616 or by

mail to: ForwardHealth, Prior Authorization, Suite 88, 313 Blettner Boulevard, Madison, WI 53784. Refer to the Prior Authorization Request for Hearing

Instrument and Audiological Services (PA/HIAS1) Completion Instructions, F-11020A, for information on completing this form.

SECTION I — PROVIDER INFORMATION

1. Process Type

3. Name and Address — Testing Center (Street, City, State, ZIP+4 Code)

123

2. Telephone Number ― Testing Center

4a. Testing Center Provider Number

4b. Testing Center Taxonomy Code

5a. Name — Prescribing Physician

5b. National Provider Identifier — Prescribing Physician

SECTION II — MEMBER INFORMATION

6. Name and Address — Member (Last, First, Middle Initial; Street, City, State, ZIP Code)

7. Member Identification Number

8. Gender — Member



Male



Female

9. Date of Birth — Member

SECTION III — DIAGNOSIS / TREATMENT INFORMATION

10. Diagnosis — Code and Description

11. Rendering

12. Rendering

13. Procedure

14. Modifiers

15.

16. Description of Service

17. QR

18. Charge

Provider

Code

POS

Number

Taxonomy

An approved authorization does not guarantee payment. Reimbursement is contingent upon enrollment of the member and provider at the time the service is provided

19. Total

and the completeness of the claim information. Payment will not be made for services initiated prior to approval or after the authorization expiration date. Reimbursement

Charges

will be in accordance with Medicaid and BadgerCare Plus 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, Medicaid reimbursement will be allowed only if the service is not covered by the Managed Care Program.

20. SIGNATURE — Requesting Provider

21. Provider Type

22. Date Signed



Audiologist



Hearing Instrument Specialist

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