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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11038A (10/08)

STATE OF WISCONSIN HFS 107.13(4), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION / ADULT MENTAL HEALTH DAY TREATMENT ATTACHMENT (PA/AMHDTA) 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 services. The use of this form is mandatory to receive PA for certain procedures/services/items. 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. Attach the completed Prior Authorization/Adult Mental Health Day Treatment Attachment (PA/AMHDTA), F-11038, to the Prior Authorization Request Form (PA/RF), F-11018, physician prescription (if necessary), and Section I of the Mental Health Day Treatment Functional Assessment, F-11090, and send it to ForwardHealth. Providers should make duplicate copies of all paper documents mailed to ForwardHealth. Providers may submit PA requests by fax to ForwardHealth 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 -- 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 -- Age -- Member Enter the age of the member in numerical form (e.g., 21, 60). 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. SECTION II -- PROVIDER INFORMATION Element 4 -- Name and Credentials -- Requesting / Rendering Provider Enter the name and credentials of the therapist who will be providing treatment. Element 5 -- Requesting / Rendering Provider's National Provider Identifier (NPI) (not required) Element 6 -- Telephone Number -- Requesting / Rendering Provider Enter the rendering provider's telephone number, including area code.

PRIOR AUTHORIZATION / ADULT MENTAL HEALTH DAY TREATMENT ATTACHMENT (PA/AMHDTA) COMPLETION INSTRUCTIONS F-11038A (10/08)

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Element 7 -- Name -- Referring / Prescribing Provider Enter the name of the provider referring/prescribing treatment. Element 8 -- Referring / Prescribing Provider's NPI Enter the National Provider Identifier of the referring/prescribing provider. SECTION III -- DOCUMENTATION Per HFS 101.03(37), Wis. Admin. Code, "Adult Mental Health Day Treatment" is described by the following definition: "Day treatment" or "day hospital" means a non-residential program in a medically supervised setting that provides case management, medical care, psychotherapy and other therapies, including recreational, physical, occupational and speech therapies, and follow-up services, to alleviate problems related to mental illness or emotional disturbances. Note: Day treatment services are provided by an interdisciplinary team on a routine, continuous basis for a scheduled portion of a 24hour day and may include structural rehabilitative activities including training in basic living skills, interpersonal skills, and problemsolving skills. Element 9 -- Number of Hours per Week Requested Enter the number of hours requested per week. Element 10 -- Estimated Final Treatment Date Enter the estimated final treatment date. Element 11 Indicate whether or not the member has had previous day treatment at the provider's facility or elsewhere. Element 12 -- Evaluation(s) Describe evaluation(s), including date(s), tests used, and results. Element 13 Attach Section I of the member's most recent functional assessment. (The Mental Health Day Treatment Functional Assessment must be signed and dated within three months of receipt by ForwardHealth.) Element 14 Indicate whether or not the member's intellectual functioning is below average. Element 15 Provide a brief history pertinent to requested services. (Include psycho-social history, hospitalization history, family history, living situation history, etc.). Element 16 Describe progress/status since treatment began or was last authorized, if applicable. Element 17 Specify overall character of the service to be provided. Rehabilitation. This category is used for all of the adult mental health day treatment population who may benefit by intensive adult mental health day treatment. Maintenance. This category is for those members who, by diagnosis and history, are suffering from a chronic mental disorder as indicated by diagnosis, signs of illness for two or more years, and past intensive adult mental health day treatment that has already been tried for six months or more with no apparent change in functional assessment and/or narrative history. The major goal of treatment is to maintain the individual in the community and prevent hospitalization. Stabilization. This category is for those members who decompensate and/or have an acute exacerbation of a chronic condition. The goal in this category is to increase structure, stabilize the member, prevent harm to self and/or others, and/or prevent hospitalization. Decompensation would be indicated by a recent hospitalization (i.e., within the last 30 days), and/or other acceptable signs of a clear deterioration (in level and course of functioning).

PRIOR AUTHORIZATION / ADULT MENTAL HEALTH DAY TREATMENT ATTACHMENT (PA/AMHDTA) COMPLETION INSTRUCTIONS F-11038A (10/08)

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Element 18 Identify measurable treatment goals. Element 19 Attach a specific schedule of activities, including date, time of day, length of session, and service to be provided. Element 20 Estimate the member's rehabilitation potential for employment (competitive, supported, sheltered, etc.), social interaction, and independent living. Element 21 -- Signature -- Member or Representative Enter the signature of the member or representative. Element 22 -- Date Signed Enter the month, day, and year the PA/AMHDTA was signed (in MM/DD/CCYY format) by the member or representative. Element 23 -- Relationship (If Representative) Include relationship to member (if a representative signs). Element 24 -- Signature -- Prescribing Physician Enter the signature of the prescribing physician. Element 25 -- Date Signed Enter the month, day, and year the PA/AMHDTA was signed (in MM/DD/CCYY format) by the prescribing physician. Element 26 -- Signature -- Therapist Providing Treatment Enter the signature of the therapist providing treatment. Element 27 -- Date Signed Enter the month, day, and year the PA/AMHDTA was signed (in MM/DD/CCYY format) by the therapist providing the treatment. Element 28 -- Signature -- 51.42 Board Director / Designee (no longer required) Element 29 -- Date Signed (no longer required)