Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11076C (10/08)

STATE OF WISCONSIN HFS 107.22, Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION / RESIDENTIAL CARE CENTER TREATMENT ATTACHMENT (PA/RCCA) COMPLETION INSTRUCTIONS for Initial Admissions, Unplanned Readmissions, and for Continuing Services
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 services. The use of this form is voluntary and providers may develop their own form as long as it includes all the information on this form and is formatted exactly like this form. 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. Attach the completed PA/RCCA with required information to the Prior Authorization Request Form (PA/RF), F-11018, and submit the PA request to ForwardHealth by fax at (608) 221-8616 or by mail 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 mailed 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). GENERAL INSTRUCTIONS The information contained in the PA/RCCA is used to make a decision about the duration of residential care center treatment services that are approved for ForwardHealth reimbursement. Thoroughly complete each section and include copies of medical record documents as requested. Residential Care Center Treatment Services for initial admissions and unplanned readmissions within 90 days of discharge (F-11076A) is used for new admissions to the RCC as well as for unplanned readmissions to the RCC. Residential Care Center Treatment Services for continuing services (F-11076B) is used for members who have been in the RCC beyond 30 days at the time this benefit is implemented and for those who have remained in the RCC continuously or as needed for stabilization beyond the initial authorization period. Authorization for children being admitted to the RCC for intermittent service is the same as for children in full-time residency. The expected intermittent schedule must be documented and submitted to ForwardHealth. Authorization will be granted for a maximum of one year; providers may claim only the intermittent services actually provided. 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.

PRIOR AUTHORIZATION / RESIDENTIAL CARE CENTER TREATMENT SERVICES ATTACHMENT COMPLETION INSTRUCTIONS F-11076C (10/08)

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Element 3 -- Member Identification Number Enter the member ID. Do not enter any other numbers or letters. Use the ForwardHealth ID card or the EVS to obtain the correct member ID. SECTION II -- PROVIDER INFORMATION Element 4 -- Name -- Residential Care Center (RCC) Enter the name of the Medicaid-certified Residential Care Center. Element 5 --National Provider Identifier Enter the Residential Care Center National Provider Identifier.

FOLLOW THE INSTRUCTIONS FOR SECTIONS III AND IV BELOW FOR F-11076A OR F-11076B
SECTION III -- CLINICAL INFORMATION FOR INITIAL ADMISSIONS AND UNPLANNED READMISSIONS WITHIN 90 DAYS OF DISCHARGE, F-11076A Element 6 -- The RCC clinical supervisor signing the PA/RCCA attests, by signature, that the following statements on the form are true. SECTION IV -- ATTACHMENTS AND SIGNATURE Element 7 -- The following materials must be attached and labeled. a. b. Attach a copy of the Admission Screening Report. Attach a copy of the initial admission treatment plan.

Element 8 -- Signature of Residential Care Center Clinical Supervisor Element 9 -- Date Signed SECTION III -- CLINICAL INFORMATION FOR CONTINUING SERVICES, F-11076B Element 6 -- Current HealthCheck Screen Attach documentation of a HealthCheck screen by a valid HealthCheck screener dated within one year prior to the first date of service requested. Element 7 -- In-Depth Assessment Attach a copy of the in-depth assessment performed within 30 days of admission which has been timely reviewed and signed by a physician or other licensed mental health professional. Element 8 -- Current Treatment Plan Attach a copy of the detailed narrative describing progress on the goals of earlier treatment plans, as well as a copy of the current treatment plan, dated within three months of the requested first date of service, which has been reviewed timely and signed by a physician or other licensed mental health professional. For members with intermittent RCC services, indicate the expected schedule at the RCC. SECTION IV -- SIGNATURE Element 9 -- Signature -- Residential Care Center Clinical Supervisor Element 10 -- Date Signed