Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11034A (10/08)

STATE OF WISCONSIN HFS 107.06(2), Wis. Admin. Code HFS 152.06(3)(h), 153.06(3)(g), 154.06(3)(g), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION / "J" CODE ATTACHMENT (PA/JCA) 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 (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. The use of this form is mandatory when requesting PA for certain procedures. Refer to the applicable service-specific publications for service restrictions and additional documentation requirements. Provide enough information for ForwardHealth to make a determination about the case. Physicians use this form to request PA for injectable drug ("J") codes. Attach the completed Prior Authorization/"J" Code Attachment (PA/JCA), F-11034, 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 6406 Bridge Rd Madison WI 53784-0088 The provision of services that are greater than or significantly different from those authorized may result in nonpayment of the billing claim(s). Providers should amend a PA request before it expires if services are significantly different from or greater than those services prior authorized. SECTION I -- MEMBER INFORMATION 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 spelling of the name on the ForwardHealth identification card and the EVS do not match, use the spelling from the EVS. Element 2 -- Date of Birth -- Member Enter the member's date of birth in MM/DD/CCYY format. Element 3 -- Member Identification Number Enter the member ID. Do not enter any other numbers or letters. SECTION II -- DRUG ORDER INFORMATION Complete all of Section II. SECTION III -- CLINICAL INFORMATION Element 14 -- Diagnosis List the member's condition the prescribed drug is intended to treat. Include the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code and the expected length of need. Element 15 -- Changes to Previous Clinical Condition If requesting a renewal or continuation of a previous PA approval, indicate any changes to the clinical condition, progress, or known results to-date.

PRIOR AUTHORIZATION / "J" CODE ATTACHMENT (PA/JCA) COMPLETION INSTRUCTIONS F-11034A (10/08)

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Element 16 -- Use Any of the compendium standards may be used. If an intended use is not in the drug package insert, providers may want to check the United States Pharmacopeia Dispensing Information (USP-DI) for the most inclusive reference for diagnosis. Drugs not listed in compendium standards may be covered by ForwardHealth; therefore, the PA/JCA must be submitted for processing and denied before the member is told a particular drug is not reimbursable by ForwardHealth. Element 17 -- Dose Any of the compendium standards may be used. If a prescribed dosage is not in the drug package insert, you may want to check the USP-DI (the most inclusive reference for diagnosis). Drugs not listed in compendium standards may be covered by ForwardHealth; therefore, the PA/JCA must be submitted for processing and denied before the member is told a particular drug is not covered by ForwardHealth. Elements 18 and 19 -- Signature -- Prescriber and Date Signed The prescriber is required to review the information, verifying that the information is accurate to the best of his or her knowledge, and sign the PA/JCA.