Free ForwardHealth Abortion Certification Statements, F01161 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1161 (10/08)

STATE OF WISCONSIN s. 20.927, Wis. Stats.

FORWARDHEALTH

ABORTION CERTIFICATION STATEMENTS
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. Coverage Policy In accordance with s. 20.927, Wis. Stats., ForwardHealth covers abortions when one of the following situations exists: · The abortion is directly and medically necessary to save the life of the woman, provided that prior to the abortion the physician attests in a signed, written statement, based on his or her best clinical judgment, that the abortion meets this condition. · In a case of sexual assault or incest, provided that prior to the abortion the physician attests in a signed, written statement, to his or her belief that sexual assault or incest has occurred and provided that the crime has been reported to the law enforcement authorities. · Due to a medical condition existing prior to the abortion, the physician determines that the abortion is directly and medically necessary to prevent grave, long-lasting physical health damage to the woman, provided that prior to the abortion, the physician attests in a signed, written statement, based on his or her best clinical judgment, that the abortion meets this condition. INSTRUCTIONS When filing a claim for reimbursement of an abortion with ForwardHealth, physicians are required to attach a written certification statement attesting to one of the following circumstances. The following are sample certification statements that providers may use to certify the medical necessity of the abortion. The use of this form is mandatory when filing a claim for reimbursement of an abortion.

SECTION I -- LIFE OF THE WOMAN I, __________________________________________________________________________________________ , certify that
(Name -- Provider)

on the basis of my best clinical judgment, abortion is directly and medically necessary to save the life of __________________________________________________________________________________________________, of
(Name -- Member)

____________________________________________________________________________________________________,
(Address -- Member)

for the following reasons: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________.

___________________________________________________________________
SIGNATURE -- Physician

_____________________
Date Signed

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ABORTION CERTIFICATION STATEMENTS F-1161 (10/08)

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SECTION II -- VICTIM OF SEXUAL ASSAULT OR INCEST I, ___________________________________________________________________________ , certify that it is my belief that
(Name -- Provider)

__________________________________________________________________________________________________, of
(Name -- Member)

__________________________________________________________________ , was the victim of sexual assault or incest.
(Address -- Member)

___________________________________________________________________
SIGNATURE -- Physician SECTION III -- GRAVE AND LONG-LASTING DAMAGE TO PHYSICAL HEALTH

_____________________
Date Signed

I, _________________________________________________________________________________ , certify on the basis of
(Name -- Provider)

my best clinical judgment that due to an existing medical condition, grave, long-lasting physical health damage to __________________________________________________________________________________________________, of
(Name -- Member)

____________________________________________________________________________________________________,
(Address -- Member)

would result if the pregnancy were carried to term. The following medical condition necessitates the abortion (specify the medical condition / diagnosis): ____________________________________________________________________________________________________

____________________________________________________________________________________________________

___________________________________________________________________
SIGNATURE -- Physician

_____________________
Date Signed

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