Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11020 (10/08)

STATE OF WISCONSIN HFS 106.03(4), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION REQUEST FOR HEARING INSTRUMENT AND AUDIOLOGICAL SERVICES (PA/HIAS1)
Providers may submit prior authorization (PA) requests with attachments to ForwardHealth by fax at (608) 221-8616 or by mail to: ForwardHealth, Prior Authorization, Suite 88, 6406 Bridge Road, Madison, WI 53784-0088. Instructions: Type or print clearly. Refer to the Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) Completion Instructions, F-11020A, for information on completing this form.

SECTION I -- PROVIDER INFORMATION
1. Process Type 3. Name and Address -- Testing Center (Street, City, State, ZIP+4 Code)

123
2. Telephone Number Testing Center 4a. Testing Center Provider Number 4b. Testing Center Taxonomy Code

5. Name -- Referring Physician

6a. Referring Physician Provider Number or License Number

6b. Referring Physician Taxonomy Code

SECTION II -- MEMBER INFORMATION
7. Name and Address -- Member (Last, First, Middle Initial; Street, City, State, ZIP Code) 8. Member Identification Number 9. Gender -- Member Male Female 10. Date of Birth -- Member

SECTION III -- DIAGNOSIS / TREATMENT INFORMATION
11. Diagnosis -- Code and Description

12. Rendering Provider Number

13. Rendering Provider Taxonomy

14. Procedure Code

15. Modifiers 1 2 3 4

16. POS

17. Description of Service

18. QR

19. Charge

An approved authorization does not guarantee payment. Reimbursement is contingent upon enrollment of the member and provider at the time the service is provided and the completeness of the claim information. Payment will not be made for services initiated prior to approval or after the authorization expiration date. Reimbursement will be in accordance with ForwardHealth payment methodology and policy. If the member is enrolled in a BadgerCare Plus Managed Care Program at the time a prior authorized service is provided, ForwardHealth reimbursement will be allowed only if the service is not covered by the Managed Care Program.

20. Total Charges

$0.00

21. SIGNATURE -- Requesting Provider

22. Provider Type Audiologist Hearing Instrument Specialist

23. Date Signed

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