Prior Authorization / Oxygen Attachment

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
DHS 107.24(3), Wis. Admin. Code
F-11066 (07/12)
DHS 152.06(3)(h), DHS 153.06(3)(g), DHS 154.06(3)(g), Wis. Admin. Code
FORWARDHEALTH
PRIOR AUTHORIZATION / OXYGEN ATTACHMENT (PA/OA)
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. Instructions: Type or print
clearly. Before completing this form, read the Prior Authorization/Oxygen Attachment (PA/OA) Completion Instructions,
F-11066A. Providers are required to attach a completed Record of Actual Daily Oxygen Use form, F-11067, or a copy of the
member's oxygen use records to the PA/OA for members who reside in a nursing home.
SECTION I — PROVIDER INFORMATION
1.
Name — Medical Equipment Vendor
2.
Medical Equipment Vendor’s National Provider Identifier
(NPI)
3.
Telephone Number — Medical Equipment Vendor
4.
Requested Start Date
5.
Name — Person Completing Form
6.
Title — Person Completing Form
7.
Name — Prescribing Physician
8.
Prescribing Physician’s NPI
9.
Address — Prescribing Physician (Street, City, State, and
10. Telephone Number — Prescribing Physician
ZIP+4 Code)
SECTION II — MEMBER INFORMATION
11. Name — Member (Last, First, Middle Initial)
12. Member Identification Number
13. Height and Weight — Member
14. Date of Birth — Member
Height _______ inches
Weight ________ lbs
15. Place of Service (choose one)
16. Name and Address — Facility (if applicable)
11 = Office
12 = Home
31 = Skilled Nursing Facility
32 = Nursing Facility
 99 = Other Place of Service
SECTION III — CLINICAL INFORMATION
17. Estimated Length of Need (1-98 months; 99 = Lifetime)
18. Diagnosis — Codes and Descriptions
Primary —
____________ months
Secondary —
19. Qualifying Test — Enter results of test taken within 60 days prior to the date of submission or requested start date of the PA
request. Test results are to be available in the member’s record or case file. Note: Criteria for coverage of oxygen-
related services include either an oxygen saturation level (SAO
) of 88 percent or lower or an arterial blood gas
2
level (PO
) of 55 mm/Hg or lower at rest.
2
a)
Date
e)
Name, Address, and Credentials — Provider Performing
Qualifying Test
b)
Member condition during test (choose one)
 At rest
 During exercise
 During sleep
c)
Arterial blood gas level (PO
) ______________ mm/Hg
2
d)
Oxygen saturation level (SAO
) ______________%
2
Continued

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