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Prior Authorization Spell Of Illness Attachment

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DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

ForwardHealth

Wis. Admin. Code §§ DHS 107.16(2), 107.17(2), 107.18(2)

F-11039 (10/15)

FORWARDHEALTH

PRIOR AUTHORIZATION / SPELL OF ILLNESS ATTACHMENT (PA/SOIA)

Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Spell of Illness Attachment (PA/SOIA)

Completion Instructions, F-11039A. Providers may submit SOI requests by fax to ForwardHealth at 608-221-8616, or providers may

send the completed form to: ForwardHealth, Prior Authorization, Suite 88, 313 Blettner Boulevard, Madison, WI 53784.

SECTION I — MEMBER INFORMATION

1. Name — Member (Last, First, Middle Initial)

2. Age — Member

3. Member Identification Number

SECTION II — PROVIDER INFORMATION

4. Name and Credentials — Therapist

5. National Provider Identifier (NPI) — Therapist

6. Telephone Number — Therapist

7. Name — Prescribing Physician

8. NPI — Prescribing Physician

SECTION III — DOCUMENTATION

 Physical Therapy (PT)

 Occupational Therapy (OT)

 Speech and Language Pathology (SLP)

9. Requesting SOI for

10. Requested Start Date

11. Primary International Classification of Diseases (ICD) Diagnosis Code or ICD Procedure Code and Description

12. Indicate the condition that qualifies this SOI request. (Check only one of the following options.)

The member requires therapy due to the following:

 An acute onset of a new disease, injury, or condition such as neuromuscular dysfunction, including stroke-hemiparesis,

multiple sclerosis (MS), Parkinson’s disease, and diabetic neuropathy.

 An acute onset of a new disease, injury, or condition such as musculoskeletal dysfunction, including fracture, amputation,

strains and sprains, and complications associated with surgical procedures.

 An acute onset of a new disease, injury, or condition such as problems and complications associated with physiological

dysfunction, including severe pain, vascular conditions, and cardio-pulmonary conditions.

 An exacerbation of a pre-existing condition including, but not limited to, MS, rheumatoid arthritis, or Parkinson’s disease.

 A regression in the member’s condition due to a lack of therapy, as indicated by a decrease of functional ability, strength,

mobility, or motion.

Note: Examples of member conditions for PT, OT, and SLP SOI approval may be found in the Prior Authorization section of the

Therapies: Physical, Occupational, and Speech and Language Pathology service area of the ForwardHealth Online Handbook on

the ForwardHealth Portal.

13. Indicate yes or no for the following statement.

 Yes

 No

The member displays the potential to re-achieve the skill level that he or she had previously.

Continued

Prior Authorization Spell Of Illness Attachment

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