Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11096A (10/08)

STATE OF WISCONSIN HFS 107.11(3), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION / HOME CARE ATTACHMENT (PA/HCA) 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 Prior Authorization/Home Care Attachment (PA/HCA), F-11096, is a plan of care (POC) that may be completed for ForwardHealth members receiving home care 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. Provide enough information for ForwardHealth to make a determination about the request. Retain the original, signed PA/HCA, F-11096. Attach a copy of the PA/HCA to the Prior Authorization Request Form (PA/RF), F-11018, and submit it to ForwardHealth along with any attached additional information. 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 which are greater than or significantly different from those authorized may result in nonpayment of the billing claim(s). SECTION I -- MEMBER INFORMATION Element 1a -- 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 1b -- Telephone Number -- Member Enter the telephone number, including the area code, of the member. If the member's telephone number is not available, enter "N/A." Element 2 -- Member Identification Number Enter the member ID. Do not enter any other numbers or letters. Element 3 -- Start of Care Date Enter the date that covered services began for the member in MM/DD/CCYY format. The start of care date is the date of the member's first billable home care visit. This date remains the same on subsequent POC until the member is discharged. Element 4 -- Certification Period Enter the beginning and ending dates of the member's certification period respectively in the "From" and "To" portions of this element in the MM/DD/CCYY format. The certification period identifies the period of time approved by the attending physician for the POC. The "To" date can be up to, but not more than, 62 days later than the "From" date. (Medicare-certified agencies should use the timeframe of up to, but not more than, 60 days later.) For certification periods that cover consecutive 31-day months, providers should be careful not to exceed 62 days.

PRIOR AUTHORIZATION / HOME CARE ATTACHMENT (PA/HCA) COMPLETION INSTRUCTIONS F-11096A (10/08)

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Services provided on the "To" date are included in the certification period. On subsequent periods of recertification, the certification period should begin with the day directly following the date listed as the "To" date in the immediately preceding certification period. Example: Initial Certification Period "From" date 12/01/04 "To" date 01/31/05 Subsequent Recertification Period "From" date 02/01/05 "To" date 04/03/05

SECTION II -- PERTINENT DIAGNOSES AND PROBLEMS TO BE TREATED Element 5 -- Principal Diagnosis Enter the principal diagnosis information. Include the appropriate International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code, diagnosis code description, and the date of onset in MM/DD/CCYY format. If the member's condition is chronic or long-term in nature, use the date of exacerbation. Element 6 -- Surgical Procedure and Other Pertinent Diagnoses Enter the surgical procedure information, if any, that is relevant to the care rendered or the services requested. Include the appropriate ICD-9-CM diagnosis code, diagnosis code description, and the date of the surgical procedure in MM/DD/CCYY format. The month and year of the date of the surgical procedure must be included. Use "00" if the exact day of the month is unknown. Enter all other diagnoses pertinent to the care rendered for the member. Include the appropriate narrative or ICD-9-CM diagnosis code, code description, and the date of onset in MM/DD/CCYY format. Include all conditions that coexisted at the time the POC was established or that subsequently developed. Exclude conditions that relate to an earlier episode not associated with this POC. Other pertinent diagnoses in this element may be changed to reflect changes in the member's condition. If a relevant surgical procedure was not performed and there are no other pertinent diagnoses, enter "N/A" (do not leave the element blank). SECTION III -- BRIEF MEDICAL AND SOCIAL INFORMATION Element 7 -- Durable Medical Equipment Identify the item(s) of durable medical equipment (DME) ordered by the attending physician and currently used by the member. Enter "N/A" if no known DME has been ordered. Element 8a -- Functional Limitations Enter an "X" next to all items that describe the member's current limitations as assessed by the attending physician and the nurse or therapist. If "Other" is checked, provide further explanation in Element 8b. Element 8b If "Other" is checked in Element 8a, specify the other functional limitations. Element 9a -- Activities Permitted Enter an "X" next to all activities that the attending physician permits and/or that are documented in the attending physician's orders. If "Other" is checked, provide further explanation in Element 9b. Element 9b If "Other" is checked in Element 9a, specify the other activities the member is permitted. Element 10 -- Medications Enter the attending physician's orders for all of the member's medications, including the dosage, frequency, and route of administration for each. If any of the member's medications cause severe side effects or reactions that necessitate the presence of a nurse, therapist, home health aide, or personal care worker, indicate the details of these circumstances in this element. Element 11 -- Allergies List any medications or other substances to which the member is allergic (e.g., adhesive tape, iodine, specific types of food). If the member has no known allergies, indicate "no known allergies." Element 12 -- Nutritional Requirements Enter the attending physician's instructions for the member's diet. Include specific dietary requirements, restrictions, fluid needs, tube feedings, and total parenteral nutrition.

PRIOR AUTHORIZATION / HOME CARE ATTACHMENT (PA/HCA) COMPLETION INSTRUCTIONS F-11096A (10/08)

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Element 13 -- Mental Status Enter an "X" next to the term(s) that most accurately describes the member's mental status. If "Other" is checked, provide further explanation. Element 14 -- Prognosis Enter an "X" next to the one term that specifies the most appropriate prognosis of the member. SECTION IV -- ORDERS Element 15 -- Orders for Services and Treatments Indicate the following as appropriate for each individual service: · Number of member visits (e.g., home health skilled nursing, home health aide, or medication management), frequency of visits, and duration of visits ordered by the attending physician's orders (e.g., 1 visit, 3 times/week, for 9 weeks). · Number of hours required for member visits (e.g., private duty nursing [PDN] or personal care), frequency of visits, and duration of visits ordered by the attending physician (e.g., 8 hours/day, 7 days/week, for 9 weeks). · Duties and treatments to be performed. · Methods for delivering care and treatments. · Procedures to follow in the event of accidental extubation, as applicable. · Ventilator settings and parameters, as applicable. Services include, but are not limited to, the following: · Home health skilled nursing. · Home health aide. Private duty nursing. · Orders must include all disciplines providing services for the member and all treatments the member receives regardless of whether or not the services are billable to ForwardHealth. Orders indicated on this POC should be as detailed and specific as those ordered and written by the attending physician. Pro re nata (PRN), or "as needed," home care visits or hours may be ordered on a member's POC only when indicating how these visits or hours will be used in a manner that is specific to the member's potential needs. Both the nature of the services provided and the number of PRN visits or hours to be permitted for each type of service must be specified. Open-ended, unqualified PRN visits or hours do not constitute an attending physician's orders because both the nature and frequency of the visits or hours must be specified. When flexible use of PDN hours is requested, specify the date on which the flexibility period begins. The begin date specified for the use of flexible hours must be a date covered under this POC. Nurses in independent practice (NIP) are required to include the name and license number of the registered nurse (RN) providing coordination services under this element. An NIP that is a licensed practical nurse is required to include the name and license number of the RN supervisor under this element. Element 16 -- Goals / Rehabilitation Potential / Discharge Plans Enter the attending physician's description of the following: · Achievable and measurable goals for the member. · The member's ability to attain the set goals, including an estimate of the length of time required to attain the goals. · Plans for the member's care after discharge. SECTION V -- SUPPLEMENTARY MEDICAL INFORMATION Element 17 -- Date Physician Last Saw Member Enter the date the attending physician last saw the member in MM/DD/CCYY format. If this date cannot be determined during the home visit, enter "Unknown." Element 18 -- Dates of Last Inpatient Stay Within 12 Months Enter the admission and discharge dates of the member's last inpatient stay within the previous 12 months, if known. Enter "N/A" if this element does not apply to the member.

PRIOR AUTHORIZATION / HOME CARE ATTACHMENT (PA/HCA) COMPLETION INSTRUCTIONS F-11096A (10/08)

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Element 19 -- Type of Facility for Last Inpatient Stay Enter one of the following single-letter responses to identify the type of facility of the member's last inpatient stay, if applicable: · · · A S R (Acute hospital). (Skilled nursing facility). (Rehabilitation hospital). · · · I O U (Intermediate care facility). (Other). (Unknown).

This element must be completed if a surgical procedure was entered in Element 6. Enter "N/A" if this element does not apply to the member. Element 20 -- Current Information For initial certifications, enter the clinical findings of the initial assessment visit for each discipline involved in the POC. Describe the clinical facts about the member that require home care services and include specific dates in MM/DD/CCYY format. For recertifications, enter significant clinical findings about the member's symptoms, new orders, new treatments, and any changes in the member's condition during the past 60 days for each discipline involved in the POC. Document both progress and lack of progress for each discipline. Include specific dates in MM/DD/CCYY format. Include any pertinent information about any of the member's inpatient stays and the purpose of contact with the physician, if applicable. Element 21 -- Home or Social Environment Enter information that will justify the need for home care services and enhance the ForwardHealth consultant's understanding of the member's home situation (e.g., member lives with mentally disabled son who is unable to provide care or assistance to member). Include the availability of caretakers (e.g., parent's work schedule). The description may document problems that are, or will be, an impediment to the effectiveness of the member's treatment or rate of recovery. Element 22 -- Medical and / or Nonmedical Reasons Member Regularly Leaves Home Enter the reasons that the member usually leaves home. Indicate both medical and nonmedical reasons, including frequency of occurrence of the trips (e.g., doctor appointment twice a month, barbershop once a month, school every weekday for three hours). Element 23 -- Back-up for Staffing and Medical Emergency Procedures This element is required for all providers requesting PDN services. It is optional for all other home care providers. Enter the back-up plan for staffing and medical emergency procedures. The following information must be included in this element: A plan for medical emergency, including: · A description of back-up personnel needed. Provision for reliable, 24 hours a day, 7 days a week emergency service for repair and delivery of equipment. Specification of an emergency power source. · A plan to move the member to safety in the event of fire, flood, tornado warning or other severe weather, or any other condition that threatens the member's immediate environment. SECTION VI -- SIGNATURES Those signing the POC are to acknowledge their responsibilities and consequences for non-compliance. Provider-created formats must contain the following statement that is included on the PA/HCA: "Anyone who misrepresents, falsifies, or conceals essential information required for payment of state and/or federal funds may be subject to fine, imprisonment, or civil penalty under applicable state and/or federal laws." Elements 24 and 25 -- Signature and Date Signed -- Authorized Nurse Completing Form The RN completing this PA/HCA is required to sign and date this form. The signature certifies that the nurse has received authorization from the attending physician to begin providing services to the member. These elements must be completed on or before the certification period "From" date indicated in Element 4. Provider-created formats must contain the following statement accompanying the authorized nurse's signature: "As the nurse completing this plan of care, I confirm the following: All information entered on this form is complete and accurate and I am familiar with all of the information entered on this form. When I am providing services, I am responsible for ensuring that this plan of care is carried out as specified." Element 26 -- Date of Verbal Orders for Initial Certification Period Enter the date the nurse signing in Element 24 receives verbal orders from the attending physician to start care for the initial certification period. If the nurse did not receive verbal orders, leave this element blank.

PRIOR AUTHORIZATION / HOME CARE ATTACHMENT (PA/HCA) COMPLETION INSTRUCTIONS F-11096A (10/08)

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Element 27 -- Date Received Physician-Signed Form Enter the date the PA/HCA signed by the attending physician was received by the nurse or in the agency. Element 28 -- Name and Address -- Attending Physician Enter the attending physician's name and complete address. The street, city, state, and ZIP+4 code must be included. The attending physician establishes the POC, certifies, and recertifies the medical necessity of the visits and/or services provided. Elements 29 and 30 -- Signature and Date Signed -- Attending Physician The attending physician is required to sign and date the PA/HCA within 20 working days following the initial start of care. A recertification of the POC requires the attending physician to sign and date the new PA/HCA prior to the continued provision of services to the member. Provider-created formats must contain the following statement accompanying the attending physician's signature: "The member is under my care, and I have authorized the services on this plan of care." Verbal authorization may be obtained from the attending physician for the initial certification period PA request. The member may then begin receiving home care services; however, the attending physician is required to sign the PA/HCA within 20 working days of the start of care date. The attending physician may not give verbal authorization for certification period renewal PA requests. The attending physician is required to sign the PA/HCA prior to the continued provision of services to the member; home care services may not be provided until the attending physician's signature is obtained on the form. The form may be signed by another physician who is authorized by the attending physician to care for the member in his or her absence. The nurse or agency staff may not predate the PA/HCA for the attending physician or write the date in the field after it has been returned. If the attending physician has left Element 30 blank, the nurse or agency staff should enter the date the signed PA/HCA was received in Element 27. Elements 31 and 32 -- Countersignature and Date Signed -- Nurse in Independent Practice When two or more NIP share a case, it is necessary to designate only one RN who receives the physician's orders to complete Element 24. Often, the designated RN is also the case coordinator. Each NIP sharing the case is required to obtain a copy of the PA/HCA for the effective certification period and countersign and date Elements 31 and 32 to document that he or she has reviewed the POC and will execute it as written. Provider-created formats must contain the following statement accompanying the authorized nurse's countersignature: "As the nurse countersigning this plan of care, I confirm the following: All information on this form is complete and accurate and I am familiar with all of the information entered on this form. When I am providing services, I am responsible for ensuring that this plan of care is carried out as specified."