Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11010A (10/08)

STATE OF WISCONSIN HFS 107.07(2), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION / DENTAL ATTACHMENT 1 (PA/DA1) 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 when requesting PA for certain services. If necessary, attach additional pages if more space is needed. Refer to the applicable service-specific publications for service restrictions and additional documentation requirements. When completing PA requests, answer all elements as thoroughly as possible. Provide enough information (check all boxes that apply) for ForwardHealth to make a determination about the request. Submitting Prior Authorization Requests Dentists may submit PA requests by fax to ForwardHealth at (608) 221-8616 if X-rays or models are not required for documentation purposes. Dentists who wish to continue submitting PA requests by mail or who are submitting PA requests that require X-rays or models may do so by submitting them to the following address: ForwardHealth Prior Authorization Ste 88 6406 Bridge Rd Madison WI 53784-0088 Providers should make duplicate copies of all paper documents mailed to ForwardHealth. HEADER COMPLETION INSTRUCTIONS Complete the numeric information at the top of each page of the PA/DA1. This information ensures accurate tracking of the PA/DA1 with the Prior Authorization Dental Request Form (PA/DRF), F-11035, through the PA review process. This attachment will be returned to the provider if the numeric information is not completed at the top of each page submitted. Member Identification Number Enter the member ID. Do not enter any other numbers or letters. Billing Provider's National Provider Identifier (NPI) Enter the NPI of the billing provider. Rendering Provider's NPI (if different) Enter the NPI of the rendering provider who will actually provide the service if the rendering provider is different from the billing provider. SERVICE SECTION COMPLETION INSTRUCTIONS Category Select the category that describes the requested service(s). Procedure Codes Check the box for the appropriate procedure code(s) that represents the service(s) being requested. Treatment Plan Justification Check all boxes that apply for the appropriate reason(s) to the procedure(s) being performed. Required Documentation Refer to this column to determine the documentation that must be submitted with the PA reques