Prior Authorization Therapy Attachment Completion printable pdf download

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Health Care Access and Accountability

DHS 107.18(2), Wis. Admin. Code

F-11008A (07/12)

DHS 152.06(3)(h), 153.06(3)(g), 154.06(3)(g), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION / THERAPY ATTACHMENT (PA/TA) COMPLETION INSTRUCTIONS

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 (DHS 104.02[4], Wis. Admin. Code).

Under s. 49.45(4), Wis. Stats., 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 prior authorization

(PA) requests, or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in

denial of PA or payment for the service.

The use of this form is mandatory when requesting PA for certain services. If necessary, attach additional pages if more space is

needed. Refer to the applicable service-specific publications for service restrictions and additional documentation requirements. Provide

enough information for ForwardHealth to make a reasonable judgment about the case.

Each provider must submit sufficient detailed information. Sufficient detailed information on a PA request means enough clinical

information regarding the member to meet ForwardHealth’s definition of “medically necessary.” “Medically necessary” is defined in

DHS 101.03(96m), Wis. Admin. Code. Each PA request is unique, representing a specific clinical situation. Therapists typically consider

a number of issues that influence a decision to proceed with therapy treatment at a particular frequency to meet a particular goal. Those

factors that influence treatment decisions should be documented on the PA request. ForwardHealth’s therapy consultants will consider

documentation of those same factors to determine whether or not the request meets ForwardHealth’s definition of “medically

necessary.” ForwardHealth’s consultants cannot “fill in the blanks” for a provider if the documentation is insufficient or unclear. The

necessary level of detail may vary with each PA request and within the various sections of a PA request.

These directions are formatted to correspond to each required element on the Prior Authorization/Therapy Attachment (PA/TA),

F-11008. The bold headings directly reflect the name of the element on the PA/TA. The proceeding text reflects instructions, hints,

examples, clarification, etc., that will help the provider document medical necessity in sufficient detail.

Attach the completed PA/TA to the Prior Authorization Request Form (PA/RF), F-11018, and send it to ForwardHealth. Providers

should make duplicate copies of all paper documents mailed to ForwardHealth. Providers may submit PA requests 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

SECTION I — MEMBER / PROVIDER INFORMATION

Enter the following information into the appropriate box:

Element 1 — Name — Member

Enter the member’s last name, followed by his or her first name and middle initial. Use Wisconsin’s Enrollment Verification System

(EVS) to obtain the correct spelling of the member’s name. If the name or the spelling of the name on the ForwardHealth

identification card and the EVS do not match, use the spelling from the EVS.

Element 2 — Member Identification Number

Enter the member ID. Do not enter any other numbers or letters.

Element 3 — Age — Member

Enter the age of the member in numerical form (e.g., 16, 21, 60).

Element 4 — Name and Credentials — Therapist

Enter the treating therapist’s name and credentials. If the treating therapist is a therapy assistant, enter the name of the supervising

therapist and the name of the therapy assistant.

Prior Authorization Therapy Attachment Completion

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