Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11054A (10/08)

STATE OF WISCONSIN HFS 107.10(2)(c), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION / ENTERAL NUTRITION PRODUCT ATTACHMENT (PA/ENPA) 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 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/Enteral Nutrition Product Attachment (PA/ENPA), F-11054, to the Prior Authorization Request Form (PA/RF), F-11018, and send it 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 Providers should make duplicate copies of all paper documents mailed to ForwardHealth. 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 -- Date of Birth -- Member Enter the member's date of birth in MM/DD/CCYY format. Element 3 -- Member Identification Number Enter the member ID. Do not enter any other numbers or letters. SECTION II -- TYPE OF REQUEST Element 4 Indicate the start date requested for PA or the date the prescription was filled. Element 5 Check the appropriate box to indicate if this product has been requested previously. SECTION III -- PRESCRIPTION INFORMATION If this section is completed, providers do not need to include a copy of the prescription documentation used to dispense the product requested. Element 6 -- Product Name Enter the product name.

PRIOR AUTHORIZATION / ENTERAL NUTRITION PRODUCT ATTACHMENT (PA/ENPA) COMPLETION INSTRUCTIONS F-11054A (10/08)

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Element 7 -- Quantity Ordered Enter the quantity that was ordered. Element 8 -- Date Order Issued Enter the date the order was issued. Element 9 -- Directions for Use of Product Enter the directions for use of the product. Element 10 -- Daily Dose Enter the daily dose. Element 11 -- Refills Enter the amount of refills. Element 12 -- Name -- Prescriber Enter the name of the prescriber. Element 13 -- National Provider Identifier Enter the National Provider Identifier of the prescribing provider. SECTION IV -- CLINICAL INFORMATION Include diagnostic, as well as clinical, information explaining the need for the product requested. Element 14 List the member's condition the product is intended to treat. Include the expected length of need. If requesting a renewal or continuation of a previous PA approval, indicate any changes to the clinical condition, progress, or known results to date. Attach another sheet if additional room is needed. Element 15 Indicate source of clinical information. Element 16 Indicate use of the product requested. Element 17 Indicate dosage of the product requested. SECTION V -- ADDITIONAL INFORMATION REQUIRED FOR ENTERAL NUTRITION SUPPLEMENTS Element 18 Enter the percentile (children only) and the height. If this is other than the first request, please include the first measurements from the initial request as well as the current information. Element 19 Enter the percentile (children only) and the weight. If this is other than the first request, please include the first measurements from the initial request as well as the current information. Element 20 Enter the amount of weight loss, if any, and within what specific time span the weight was lost. Element 21 Check all that apply. Element 22 -- Signature -- Pharmacist or Dispensing Physician The pharmacist/dispenser must review this information and sign this form. Element 23 Date Signed Enter the month, day, and year the PA/ENPA was signed in MM/DD/CCYY format.