Free ForwardHealth Prior Authorization Drug Attachment for Alpha-1 Proteinase Inhibitor Completion Instructions, F11056A - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11056A (10/08)

STATE OF WISCONSIN HFS 107.10(2), 152.06(3)(h), Wis. Admin. Code HFS 153.06(3)(g), 154.06(3)(g), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION DRUG ATTACHMENT FOR ALPHA-1 PROTEINASE INHIBITOR 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 drugs. 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 should make duplicate copies of all paper documents mailed to ForwardHealth. INSTRUCTIONS Prescribers are required to complete and sign the Prior Authorization Drug Attachment for Alpha-1 Proteinase Inhibitor form, F-11056. Pharmacy providers are required to use the Prior Authorization Drug Attachment for Alpha-1 Proteinase Inhibitor form to request PA by using the Specialized Transmission Approval Technology-Prior Authorization (STAT-PA) system or by submitting a paper PA request. Prescribers and pharmacy providers are required to retain a completed copy of the form. Providers may submit PA requests on a Prior Authorization Drug Attachment form in one of the following ways: 1) For STAT-PA requests, pharmacy providers should call (800) 947-1197. 2) For paper PA requests by fax, pharmacy providers should submit a Prior Authorization Request Form (PA/RF), F-11018, and the appropriate Prior Authorization Drug Attachment form to ForwardHealth at (608) 221-8616. 3) For paper PA requests by mail, pharmacy providers should submit a PA/RF and the appropriate Prior Authorization Drug Attachment 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 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). 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. Use the ForwardHealth card or the EVS to obtain the correct member ID.

PRIOR AUTHORIZATION DRUG ATTACHMENT FOR ALPHA-1 PROTEINASE INHIBITOR COMPLETION INSTRUCTIONS F-11056A (10/08)

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SECTION II PRESCRIPTION INFORMATION Element 4 -- Drug Name Enter the drug name. Element 5 -- Strength Enter the strength of the drug listed in Element 4. Element 6 -- Date Prescription Written Enter the date the prescription was written in MM/DD/CCYY format. Element 7 -- Directions for Use Enter the directions for use of the drug. Element 8 -- Name -- Prescriber Enter the name of the prescriber. Element 9 -- National Provider Identifier (NPI) Enter prescribing provider's NPI. Element 10 -- Address and Telephone Number -- Prescriber Enter the complete address of the prescriber's practice location, including the street, city, state, and ZIP+4 code, as well as the telephone number. SECTION III CLINICAL INFORMATION FOR ALPHA-1 PROTEINASE INHIBITOR Element 11 -- Diagnosis -- Primary Code and / or Description Enter the appropriate International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code and/or description most relevant to the drug requested. The ICD-9-CM diagnosis code must correspond with the ICD-9-CM description. Element 12 Check the appropriate box to indicate whether or not the member has clinically significant panacinar emphysema due to congenital Alpha-1 Antitrypsin deficiency. If no, the PA request requires additional information. The provider should submit the PA request on paper with complete clinical documentation. Element 13 -- Signature -- Prescriber The prescriber is required to complete and sign this form. Element 14 -- Date Signed Enter the month, day, and year the form was signed in MM/DD/CCYY format. SECTION IV FOR PHARMACY PROVIDERS USING STAT-PA Element 15 -- National Drug Code Enter the appropriate 11-digit National Drug Code (NDC) for each drug. Element 16 -- Days' Supply Requested Enter the requested days' supply. Element 17 -- NPI Enter the pharmacy provider's NPI. Element 18 -- Date of Service Enter the requested first date of service (DOS) for the drug. For STAT-PA requests, the DOS may be up to 31 days in the future or up to 14 days in the past.

PRIOR AUTHORIZATION DRUG ATTACHMENT FOR ALPHA-1 PROTEINASE INHIBITOR COMPLETION INSTRUCTIONS F-11056A (10/08)

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Element 19 -- Patient Location Enter the appropriate National Council for Prescription Drug Programs patient location code designating where the requested item would be provided/performed/dispensed. Code 0 1 4 7 10 Description Not Specified Home Long Term/Extended Care Skilled Care Facility Outpatient

Element 20 -- Assigned Prior Authorization Number Record the PA number assigned by the STAT-PA system. Element 21 -- Grant Date Record the grant date of the PA as assigned by the STAT-PA system. Element 22 -- Expiration Date Record the date the PA expires as assigned by the STAT-PA system. Element 23 -- Number of Days Approved Record the number of days for which the STAT-PA request was approved by the STAT-PA system. SECTION V -- ADDITIONAL INFORMATION Element 24 Indicate any additional information in the space provided. Additional diagnostic and clinical information explaining the need for the product requested may be included here.