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Date: January 27, 2009
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State: Wisconsin
Category: Health Care
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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11062A (10/08)

STATE OF WISCONSIN HFS 107.06(2), Wis. Admin. Code


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 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 services. If necessary, attach additional pages if more space is needed. 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 request. Providers may submit Prior Authorization/Environmental Lead Inspection requests in one of the following ways: 1) For Specialized Transmission Approval Technology-Prior Authorization (STAT-PA) requests, providers should call (800) 947-1197. 2) For paper PA requests by fax, providers should submit a Prior Authorization Request Form (PA/RF), F-11018, and the Prior Authorization/Environmental Lead Inspection form, F-11062, by fax to ForwardHealth at (608) 221-8616. 3) For paper PA requests by mail, providers should submit a PA/RF and the PA/Environmental Lead Inspection form to the following address: ForwardHealth Prior Authorization Ste 88 6406 Bridge Rd Madison WI 53784-0088 Providers should make duplicate copies of all paper documents sent to ForwardHealth. The provision of services that are greater than or significantly different from those authorized may result in nonpayment of the billing claim(s). Environmental Lead Inspection Information and Requirements (Technical Aspects of Inspections) 1. Determine the most likely sources of high-dose exposure to lead. 2. Investigate the child's home, giving special attention to painted surfaces, dust, soil, and water. 3. Advise parents about identified and potential sources of lead and ways to reduce exposure. 4. Notify the property owner immediately that a child residing on the property has lead poisoning. 5. Monitor the effectiveness and timeliness of abatement procedures closely. 6. Coordinate environmental activities with those of other public health and social management agencies. SECTION I MEMBER INFORMATION Element 1 Name Member Enter the member's last name, 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.


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SECTION II PROVIDER INFORMATION Element 4 Provider Name Enter the name of the provider who would perform/provide the requested service/procedure. Element 5 National Provider Identifier Enter the National Provider Identifier of the provider performing the service. SECTION III CLINICAL INFORMATION FOR ENVIRONMENTAL LEAD INSPECTION Element 6 Member's Blood Lead Level Enter the member's two-digit blood lead level. (If the blood level is a one-digit number, please precede the number with a zero when entering.) Element 7 Date of Testing Enter the date of testing in MM/DD/CCYY format. Element 8 Check the appropriate box to indicate whether or not the previous lead level test taken by the same member at least 90 days prior to the most recent test had a blood lead level greater than 15. Element 9 Check the appropriate box to indicate whether or not the inspection staff has completed the Department of Health Services-approved lead inspection training. SECTION IV FOR PROVIDERS USING STAT-PA Element 10 Procedure Code Enter procedure code "T1029" (Comprehensive environmental lead investigation, not including laboratory analysis, per dwelling). Element 11 Diagnosis Code Enter the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code "984" (Toxic effect of lead and its compounds [including fumes]). Element 12 Place of Service Enter the only allowable place of service code for environmental lead inspection ("12," the child's home). Element 13 Date of Service The date of service may be up to 31 days in the future or up to 14 days in the past. Enter in MM/DD/CCYY format. Element 14 Total Number of Services Requested Enter "1." Element 15 Assigned Prior Authorization Number Record the PA number assigned by the STAT-PA system. Element 16 Grant Date Record the grant date of the PA as assigned by the STAT-PA system. Element 17 Expiration Date Record the date that the PA expires as assigned by the STAT-PA system. SECTION V SIGNATURE Element 18 SIGNATURE Provider The provider must sign this Element. Element 19 Date Signed Enter the date signed in MM/DD/CCYY format.