DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1118A (02/09)
STATE OF WISCONSIN
CHILD CARE COORDINATION FAMILY QUESTIONNAIRE 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, 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. Instructions: The provider is required to administer the ForwardHealth-approved assessment tool (the Family Questionnaire) to determine eligibility for the benefit. The member must score 70 points or more to be eligible for child care coordination services. The assessment tool is designed to identify the member's strengths and needs. In addition to the Family Questionnaire, the provider may use any commercial or self-designed form to conduct a more detailed assessment. Note: The Family Questionnaire includes several questions to which the member may object. Prior to administering the Family Questionnaire, explain the assessment and care planning process, acknowledge the intrusiveness of some of the questions and explain why you need to ask the questions. If necessary, share your agency's confidentiality policies with the member, including who will have access to the information provided.