Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11014 (10/08)

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

FORWARDHEALTH

PRIOR AUTHORIZATION / DENTAL ATTACHMENT 2 (PA/DA2) ORAL SURGERY, ORTHODONTIC, AND FIXED PROSTHETIC SERVICES
Instructions: Complete Section I for all orthodontics, oral surgery, and fixed prosthetic services. Complete Section II when anesthesia or a professional visit is necessary. Complete Section III for orthodontic services only. The requested identifying information will only be used to process the prior authorization (PA) request. If necessary, attach additional pages for provider responses. Refer to the dental publications for service restrictions and additional documentation requirements. Provide enough information for ForwardHealth to make a determination about the request. The use of this form is mandatory when requesting PA for certain procedures.
Member Identification Number Billing Provider's National Provider Identifier (NPI) Rendering Provider's NPI

SECTION I -- ORAL SURGERY, ORTHODONTIC, AND FIXED PROSTHETIC SERVICES Diagnosis

Treatment Plan

Treatment Prognosis (Check one. If "poor," explain the reason for the requested treatment.) Excellent Good Fair Poor

Indicate if the member is physically, psychologically, or otherwise indefinitely disabled, or has a medical condition that impacts the treatment requested.

SECTION II -- ANESTHESIA PROCEDURE CODES (Check All That Apply) D9220 D9241 D9248 (Prior authorization not required for the following: · Services performed in a hospital or ambulatory surgery center. · Services for members ages 0-20 when performed by a pediatric dentist or oral surgeon.) TREATMENT PLAN JUSTIFICATION (Check All That Apply) Behavior Disability (describe) Geriatric Physician consult Complicated medical history Extensive restoration Maxillofacial surgery (describe) Three or more extractions in more than one quadrant REQUIRED DOCUMENTATION Submit medical documentation to support special circumstances. ______

SECTION III -- ORTHODONTIC SERVICES ONLY Anticipated Number of Monthly Adjustments HealthCheck referral for orthodontic treatment.

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PRIOR AUTHORIZATION / DENTAL ATTACHMENT 2 (PA/DA2) ORAL SURGERY, ORTHODONTIC, AND FIXED PROSTHETIC SERVICES F-11014 (10/08)

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Submitting Prior Authorization Requests ForwardHealth requires certain information to enable the programs to authorize and pay for dental 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.

Dentists may submit PA requests by fax to ForwardHealth at (608) 221-8616 if X-rays or models are not required for documentation purposes. Providers should make duplicate copies of all paper documents mailed to ForwardHealth. 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