Prior Authorization Therapy Attachment Completion (Page 2 of 8) in pdf

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

Page 2 of 8

F-11008A (07/12)

Element 5 — Therapist’s National Provider Identifier

Enter the treating therapist’s National Provider Identifier (NPI). If the treating therapist is the therapy assistant, enter the NPI of the

supervising therapist. Rehabilitation agencies do not indicate an NPI.

Element 6 — Telephone No. — Therapist

Enter the treating therapist’s telephone number, including area code and extension (if applicable). If the treating therapist is a therapy

assistant, enter the telephone number of the supervising therapist.

Element 7 — Name — Referring / Prescribing Physician

Enter the referring or prescribing physician’s name.

Element 8 — Requesting PA for Physical Therapy, Occupational Therapy, Speech and Language Pathology

Check the appropriate box on the PA/TA for the type of therapy service being requested.

Element 9 — Total Time Per Day Requested

Enter the anticipated number of minutes a typical treatment session will require. It is expected the requested minutes per session will

be consistent with the member’s history, age, attention span, cognitive ability, medical status, treatment goals, procedures,

rehabilitation potential, and any other intervention the member receives. Intensity of intervention is determined by rate of change,

rather than level of severity.

Element 10 — Total Sessions Per Week Requested

Enter the number of treatment days per week requested. It is expected the requested number of treatment days per week will be

consistent with the member’s history, medical status, treatment goals, rehabilitation potential, and any other intervention the member

receives. Intensity of intervention is determined by rate of change, rather than level of severity.

Element 11 — Total Number of Weeks Requested

Enter the number of weeks requested. The requested duration should be consistent with the member’s history, medical status,

treatment goals, rehabilitation potential, and any other intervention the member receives. The requested duration should correspond

to the number of weeks required to reach the goals identified in the plan of care. Intensity of intervention is determined by rate of

change, rather than level of severity.

Element 12 — Requested Start Date

Enter the requested start date for this PA request in MM/DD/CCYY format.

Be sure:

• The member’s name corresponds with the member ID listed.

• The member ID has all digits correctly listed.

• The member is currently enrolled for ForwardHealth.

• The provider’s name and NPI match.

Note: All of the information in this section must be complete, accurate, and exactly the same as the information from

ForwardHealth’s EVS and on the PA/RF before the PA request is forwarded to a ForwardHealth’s consultant. Incomplete or

inaccurate information will result in a returned PA request.

SECTION II — PERTINENT DIAGNOSES / PROBLEMS TO BE TREATED

Element 13 — Provide a description of the member’s current treatment diagnosis, any underlying conditions, and

problem(s) to be treated, including dates of onset.

Indicate the pertinent medical diagnoses that relate to the reasons for providing therapy for the member at this time AND any

underlying conditions that may affect the plan of care or outcome (e.g., dementia, cognitive impairment, medications, attention

deficits). Include dates of onset for all diagnoses. If the date of onset is unknown, state “unknown.”

If this documentation is on a previous PA request and is still valid, indicate “this documentation may be found on PA No. (provide the

correct number for new PAs) XXXXXXXXXX.” Providers should review this information for accuracy each time that they submit a PA

request.

Note: Avoid copying the same information on subsequent PA requests without verifying that the information continues to be

accurate. A PA request may be returned if it appears as if there has been no change documented under Section II, but other

sections of the PA suggest there have been some changes to the member’s medical/functional condition/need.

Prior Authorization Therapy Attachment Completion Page 2

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