Free ForwardHealth Medical Professional Statement in Support of Request for Variance of 60-Day Supervisory Visit Requirement, F01174 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1174 (10/08)

STATE OF WISCONSIN HFS 106.13, 105.17(2)(b)(3), 107.112 (3)(c)

FORWARDHEALTH

MEDICAL PROFESSIONAL STATEMENT IN SUPPORT OF REQUEST FOR VARIANCE OF 60-DAY SUPERVISORY VISIT REQUIREMENT
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 (HFS 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. This form is authorized under HFS 106.13, Wis. Admin. Code. Completion of this form is mandatory to obtain a variance from ForwardHealth's 60-day registered nurse (RN) visit requirement under s. HFS 105.17(2)(b)(3) and 107.112(3)(c), Wis. Admin. Code, such that visits may be made less often than every 60 days. The variance may be granted only to personal care-only agencies, not home health agencies. Instructions: Submit this completed and signed form with a completed and signed Member Request for Variance of 60-Day Supervisory Visit Requirement (F-1175) and an updated plan of care to: ForwardHealth Prior Authorization Ste 88 6406 Bridge Rd Madison WI 53784-0088 Retain a copy of this form in the member's medical record. Name -- Personal Care Agency Telephone Number -- Personal Care Agency

Address -- Personal Care Agency (Street, City, State, ZIP+4 Code)

Subcontracted Personal Care Agency (if applicable)

Name -- Member

Member Identification Number

1. In my professional judgment, this member does not require a supervisory home visit by a registered nurse (RN) supervisor every 60 days. 2. The frequency of supervisory home visits by an RN supervisor under the variance is specified in the plan of care (attached). (Period may not exceed 365 days.) I have read the updated, attached plan of care and I agree with the period between RN visits indicated. 3. The variance in frequency of visits will not adversely affect the health, safety, or welfare of the member. 4. The findings indicated above are based upon such examinations, reviews and/or other inquiries as I find to be necessary and appropriate within my professional judgment. 5. I will monitor the member's condition as I find to be necessary and appropriate to determine whether the frequency of RN visits should be changed. 6. I will continue to follow the ForwardHealth requirements not affected by this variance, as defined in the ForwardHealth administrative rules. 7. The member has been instructed how to get in touch with me for routine matters or in case of an emergency. 8. I will change the plan of care or sign a medical order increasing the frequency of RN visits if I feel that the member requires more visits than specified in the plan of care.

MEDICAL PROFESSIONAL STATEMENT IN SUPPORT OF REQUEST FOR VARIANCE OF 60-DAY SUPERVISORY VIST REQUIREMENT F-1174 (10/08)

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SIGNATURE -- Member's Physician*

Date Signed

SIGNATURE -- RN Supervisor

Date Signed

*The physician who signed written orders for the member's personal care.

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