Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11044A (10/08)

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

FORWARDHEALTH

PRIOR AUTHORIZATION / HOME HEALTH THERAPY ATTACHMENT (PA/HHTA) 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 service. 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 handbook for service restrictions and additional documentation requirements. Provide enough information for ForwardHealth to make a reasonable judgment about the case. Attach the completed Prior Authorization/Home Health Therapy Attachment (PA/HHTA), F-11044, to the Prior Authorization Request Form (PA/RF), F-11018, and send it to ForwardHealth at the address listed below. If other home health services (e.g., nursing, aide services) are being provided in addition to home health therapy services, complete this attachment and submit it with the appropriate forms for the other services. Providers should make duplicate copies of all paper documents mailed to ForwardHealth. Providers may submit PA requests to ForwardHealth by fax 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, followed by his or her 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., 16, 21, 60). Element 3 -- Member Identification Number Enter the member ID. Do not enter any other numbers or letters. SECTION II PROVIDER INFORMATION Element 4 -- Name and Credentials -- Therapist Enter the name and credentials of the primary therapist who would be responsible for and participate in home health therapy services for the member. If the rendering provider would be a certified therapy assistant, enter the name of the certified therapist who will be physically present at the residence to supervise the certified therapy assistant. Element 5 -- Therapist's National Provider Identifier (NPI) Enter the National Provider Identifier (NPI) of the therapist who would provide the authorized service (rendering provider). If the rendering provider would be a therapy assistant, enter the NPI of the supervising therapist. If the therapist does not have an NPI and is employed by or under contract to the agency, enter the agency's NPI. Element 6 -- Telephone Number -- Therapist Enter the telephone number, including the area code, of the therapist who would provide the authorized service (rendering provider). If the rendering provider would be a therapy assistant, enter the telephone number of the supervising therapist.

PRIOR AUTHORIZATION / HOME HEALTH THERAPY ATTACHMENT (PA/HHTA) COMPLETION INSTRUCTIONS F-11044A (10/08)

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Element 7 -- Name -- Referring/Prescribing Physician Enter the name of the physician referring/prescribing the home health therapy evaluation and/or treatment. Element 8 -- Referring/Prescribing Physician's NPI Enter the NPI of the physician referring/prescribing home health therapy services. The remaining portions of this attachment are to be used to document the justification for home health therapy services. SECTION III DOCUMENTATION Complete Elements 9 through 17. The provider may refer to specific sections of the attachments rather than duplicating information. For example, the provider may indicate on the attachment, "Refer to Element 3 of therapy evaluation." Element 9 Provide a brief history pertinent to the service(s) requested. Element 10 Provide a description of the member's diagnosis and problems as they pertain to the need for the therapy services requested. Include the date of onset. Element 11 State therapy history. Include type/date/location for all types of therapy. Element 12 Indicate the date of initial evaluation. Supply dates/tests/results of additional evaluations. Element 13 Describe progress in measurable/functional terms since treatment was initiated or last authorized. Element 14 Attach a Plan of Care indicating specific, measurable goals and procedures to meet those goals. Element 15 Describe rehabilitation potential. Element 16 Signature Requesting Provider ForwardHealth requires the requesting provider's signature to process the PA request. Read the Prior Authorization Statement before dating and signing the attachment. Element 17 Date Signed Enter the month, day, and year the PA/HHTA was signed (in MM/DD/CCYY format). Other Required Information 1. 2. 3. 4. Attach a copy of the Physician's Plan of Care. Attach a copy of the therapy evaluation. If the request is for a member age 3 to 22, attach a copy of the Individualized Education Program or explain why there is none. If the request is for a child under age 3, attach a copy of the Individual Family Service Plan or explain why there is none.