Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11033A (10/08)

STATE OF WISCONSIN HFS 107.13, Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION / MENTAL HEALTH AND / OR SUBSTANCE ABUSE EVALUATION ATTACHMENT (PA/EA) 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. Provide enough information for ForwardHealth to make a determination about the request. Attach the completed Prior Authorization/Mental Health and/or Substance Abuse Evaluation Attachment (PA/EA), F-11033, to the Prior Authorization Request Form (PA/RF), F-11018, and send it to ForwardHealth. Providers should make duplicate copies of all paper documents mailed 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 The provision of services that are greater than or significantly different from those authorized may result in nonpayment of the billing claim(s). GENERAL INSTRUCTIONS The information contained in the PA/EA is used to make a decision about the amount and type of mental health and substance abuse evaluation that is approved for ForwardHealth reimbursement. Thoroughly complete each section and include any information that supports the medical necessity of the services being requested. GENERAL INFORMATION ABOUT MENTAL HEALTH AND SUBSTANCE ABUSE EVALUATIONS A mental health and substance abuse evaluation is an examination of the medical, biopsychosocial, behavioral, developmental, and environmental aspects of the member's situation and an assessment of the member's immediate and long-range therapeutic needs, developmental priorities, personal strengths and liabilities, and potential resources of the member's family and supports. Typically, the provider documents the results by using either the multiaxial system or nonaxial format, as described in the current Diagnostic and Statistical Manual of Mental Disorders (DSM) developed by the American Psychiatric Association or the current Diagnosis Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood: 0-3 (DC:0-3) for children up to age 4. A mental health and substance abuse evaluation is performed to serve as a guide to optimal treatment and prediction of outcomes for the patient, including diagnosing a mental disorder. Formulating a diagnosis is only the first step in an evaluation. To develop an adequate treatment plan, the clinician invariably requires considerable additional information about the person being evaluated beyond that required to make a diagnosis. The scope, as well as the medical necessity, of the evaluation is based on the presenting problem/circumstance, including symptoms indicative of a disorder (as defined in the current DSM/DC:0-3) and may include one or more of the following common clinical activities: · Diagnostic/assessment interviews with the member. · Assessment interviews with the member's family and supports. · Review of history and previous treatment. · Psychological testing. · Documenting the results.

PRIOR AUTHORIZATION / MENTAL HEALTH AND / OR SUBSTANCE ABUSE EVALUATION ATTACHMENT (PA/EA) COMPLETION INSTRUCTIONS F-11033A (10/08)

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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 -- Date of Birth -- Member Enter the date of birth of the member (in MM/DD/YY format). Element 3 -- Member Identification Number Enter the member ID. Do not enter any other numbers or letters. Use the ForwardHealth card or the EVS to obtain the correct member ID. SECTION II -- PROVIDER INFORMATION Element 4 -- Name -- Rendering Provider Enter the name of the therapist who will be performing the evaluation. Element 5 -- Rendering Provider National Provider Identifier Enter the National Provider Identifier of the rendering provider. Element 6 -- Telephone Number -- Rendering Provider Enter the telephone number, including the area code, of the office, clinic, facility, or place of business of the rendering provider. Element 7 -- Discipline -- Rendering Provider Enter the discipline (credentials) of the therapist who will be performing the evaluation. The discipline should correspond with the name listed in Element 4. SECTION III -- DOCUMENTATION Element 8 Document the type of evaluation being requested and why it is needed. For instance, the evaluation may be a competency examination or it may be necessitated by the need to confirm a diagnosis. If the member was referred for evaluation, indicate who made the referral and why. Indicate how the results of the evaluation or testing will be used. Indicate how the member will benefit (e.g., indicate if the evaluation might be used to place the member in a less restrictive setting or to obtain guardianship that would be in the member's best interest). Providers requesting retroactive authorization must document the emergency situation on the court order that justifies such a request and indicate the initial date of service. Requests for authorization to perform Central Nervous Assessments (Current Procedural Terminology procedure codes 9610196120) should not be included in these requests. Element 9 Indicate other evaluations the provider is aware of that have been conducted on this member in the past two years. Indicate why the requested evaluation does not duplicate earlier evaluations. A physician's prescription is not required for these evaluation services. Element 10 -- Signature -- Rendering Provider Enter the signature of the rendering provider. Element 11 -- Date Signed Enter the month, day, and year the PA/EA was signed (in MM/DD/CCYY format).