Free ForwardHealth Record of Actual Daily Oxygen Use Completion Instructions, F11067A - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11067A (10/08)

STATE OF WISCONSIN HFS 107.24(3), Wis. Admin. Code

FORWARDHEALTH

RECORD OF ACTUAL DAILY OXYGEN USE 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 prior authorization for certain services. Instructions: Under HFS 106.02(9)(e), Wis. Admin. Code, the provider is solely responsible for the truthfulness, accuracy, timeliness, and completeness of PA requests. The provider is responsible for submitting sufficient information to support the medical necessity of the requested oxygen-related equipment or supplies. All oxygen-related services must be prescribed by a physician prior to providing the service. Information on this form must match the member's medical records exactly. A new form should be completed for each new PA request for oxygen-related services. Refer to the applicable service-specific publications for service restrictions and additional documentation requirements. Providers are required to attach a completed Record of Actual Daily Oxygen Use form, F-11067, or a copy of the member's oxygen use records to the PA/OA for members who reside in a nursing home. Providers may attach a photocopy of the physician's prescription to the completed Prior Authorization/Oxygen Attachment (PA/OA), F-11066, or the prescribing physician may sign and date the PA/OA in lieu of attaching the prescription. The prescription (or PA/OA) must be signed and dated within 30 days prior to receipt by ForwardHealth. Attach the PA/OA to the Prior Authorization Request Form (PA/RF), F-11018, and send it to ForwardHealth. Providers should make duplicate copies of all paper documents mailed to ForwardHealth. Providers may submit PA requests 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 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 -- PROVIDER INFORMATION Element 1 -- Name -- Prescribing Physician Enter the name of the prescribing physician. Element 2 -- National Provider Identifier Enter the National Provider Identifier (NPI) of the prescribing physician. The NPI in this element must correspond with the provider name listed in Element 1. SECTION II -- MEMBER INFORMATION Element 3 -- Name -- Member Enter the member's last name, followed by his or her 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 the spelling of the name on the ForwardHealth identification card and the EVS do not match, use the spelling from the EVS. Element 4 -- Member Identification Number Enter the member ID. Do not enter any other numbers or letters. SECTION III -- RECORD OF DAILY USE Element 5 -- Complete the date oxygen was initiated in MM/DD/CCYY format. This date is "Day 1." Place an "X" in each shift for each day that the member actually received oxygen. The member must receive oxygen for at least 15 days of a 30-day rental period for a PA request to be considered for approval. The oxygen need not be administered for the whole shift. Leave blank any shifts during which oxygen was not administered.