Free ForwardHealth Announces Changes to Paper and Electronic Claims for Pharmacy Services - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-13074 (10/08)

STATE OF WISCONSIN

FORWARDHEALTH PHARMACY SPECIAL HANDLING REQUEST
Instructions: Providers may submit the Pharmacy Special Handling Request and paper drug claim to ForwardHealth, Pharmacy Special Handling Unit, Suite 20, 6406 Bridge Road, Madison, WI 53784-0020. Type or print clearly. Refer to the Pharmacy Special Handling Request Completion Instructions, F-13074A, for more information. SECTION I -- PROVIDER INFORMATION 1. National Provider Identifier 2. Telephone Number --Provider

SECTION II -- REASON FOR REQUEST (Choose one.) 3. Emergency Supply Dispensed 4. Original Claim Denied Date of Denial Authorization / Internal Control Number Explanation of Benefits (EOB) Number and / or National Council for Prescription Drug Program (NCPDP) Reject Code Description of Issue for Reconsideration

5. National Drug Code (NDC) Not on File

NDC Description

6. Pharmacy Consultant Review

Other: Explanation of review needed. (Provide the explanation in the space below.) Quantity limits exceeded. (Provide the required documentation in the space below.)

Provide supporting documentation when available.

SECTION III -- CERTIFICATION 7. SIGNATURE -- Pharmacist or Dispensing Physician 8. Date Signed

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