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-13074A (10/08)

STATE OF WISCONSIN

FORWARDHEALTH

PHARMACY SPECIAL HANDLING REQUEST 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 for any paper claims submitted by a pharmacy provider that require special handling and cannot be processed as normal claims. Refer to the ForwardHealth Online Handbook for service restrictions and additional documentation requirements. Provide enough information for ForwardHealth to make a reasonable judgment about the case. Pharmacy providers are required to complete and sign the Pharmacy Special Handling Request, F-13074, when appropriate. Pharmacy providers submitting paper claims that require the Pharmacy Special Handling Request may submit the paper claim form with the Pharmacy Special Handling Request to the following address: ForwardHealth Pharmacy Special Handling Unit Suite 20 6406 Bridge Rd Madison WI 53784-0020 SECTION I -- PROVIDER INFORMATION Element 1 -- National Provider Identifier Enter the National Provider Identifier. Element 2 --Telephone Number -- Pharmacy Provider Enter the telephone number, including the area code, of the provider. SECTION II -- REASON FOR REQUEST (Choose one.) Element 3 -- Emergency Supply Dispensed Check the box to indicate that the pharmacy dispensed an emergency supply of up to 14 days per fill. Element 4 -- Original Claim Denied Check the box to indicate that the original claim was denied and that the pharmacy provider is resubmitting the claim for reconsideration. Include the following information: · Date of denial. · Authorization/Internal Control Number. · National Council for Prescription Drug Program (NCPDP) Reject Code and/or Explanation of Benefits (EOB) Number. Description of issue for reconsideration. · Element 5 -- National Drug Code (NDC) Not on File Check the box to indicate that the NDC submitted on the claim is not on the drug file. Include the following information: · National Drug Code. · Description of NDC.

PHARMACY SPECIAL HANDLING REQUEST COMPLETION INSTRUCTIONS F-13074A (10/08)

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Element 6 -- Pharmacy Consultant Review Check the box to indicate that a pharmacy consultant review is being requested. Also check a box to indicate that the pharmacy provider is requesting a review for quantity limits exceeded or "other" reason. Include the following information when requesting an "other" review: · Explanation of review needed. · Supporting documentation such as Remittance Advice or manufacturer-reviewed and/or peer-reviewed medical literature. When requesting a review for quantity limits exceeded for triptans, include the following information: · Complete directions for use. ("As needed" or "PRN" are not sufficient.) · The maximum triptan dose the prescriber has established by day, week, or month. · The migraine prophylactic medication the member is taking. Specify the drug name, strength, directions for use and compliance. · Indicate other abortive analgesic headache medications the member is taking. Specify the drug name, strength, quantity, directions for use and how frequently the medication is being filled. · Indicate clinical information from the prescriber regarding the frequency of headaches and either why prophylactic treatment is not being used or why prophylactic treatment has been unsuccessful in reducing the headache frequency. SECTION III -- CERTIFICATION Element 7 -- Signature -- Pharmacist or Dispensing Physician The pharmacy provider or dispensing physician is required to complete and sign this form. Element 8 -- Date Signed Enter the month, day, and year the Pharmacy Special Handling Request was signed (in MM/DD/CCYY format).