Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11066A (10/08)

STATE OF WISCONSIN HFS 107.24(3), Wis. Admin. Code HFS 152.06(3)(h), 153.06(3)(g), 154.06(3)(g), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION / OXYGEN ATTACHMENT (PA/OA) 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 items. Instructions: Under HFS 106.02(9)(e), Wis. Admin. Code, the provider is solely responsible for the truthfulness, accuracy, timeliness, and completeness of PA requests. The provider is responsible for submitting sufficient information to support the medical necessity of the requested oxygen-related equipment or supplies. All oxygen-related services must be prescribed by a physician prior to providing the service. Refer to the applicable service-specific publications for service restrictions and additional documentation requirements. Providers may attach a photocopy of the physician's prescription to the completed Prior Authorization/Oxygen Attachment (PA/OA), F-11066, or the prescribing physician may sign and date the PA/OA in lieu of attaching the prescription. The prescription (or PA/OA) must be signed and dated within 30 days prior to receipt by ForwardHealth. Attach the PA/OA to the Prior Authorization Request Form (PA/RF), F-11018, and send it to ForwardHealth. Providers are required to attach a completed Record of Actual Daily Oxygen Use form, F-11067, or a copy of the member's oxygen use records to the PA/OA for members who reside in a nursing home. 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 -- PROVIDER INFORMATION Element 1 -- Name -- Medical Equipment Vendor Enter the name of the medical equipment vendor (oxygen provider). Element 2 -- Medical Equipment Vendor's National Provider Identifier (NPI) Enter the NPI of the medical equipment vendor (oxygen provider). The NPI in this element must correspond with the provider name listed in Element 1. Element 3 -- Telephone Number -- Medical Equipment Vendor Enter the medical equipment vendor's telephone number, including area code. Element 4 -- Requested Start Date Enter the requested grant date for this PA request in MM/DD/CCYY format. Element 5 -- Name -- Person Completing Form Enter the name of the person completing this form if other than the treating physician. Element 6 --Title -- Person Completing Form Enter the title of the person completing this form if other than the treating physician (e.g., respiratory therapist, home health nurse, billing manager).

PRIOR AUTHORIZATION / OXYGEN ATTACHMENT (PA/OA) COMPLETION INSTRUCTIONS F-11066A (10/08)

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Element 7 -- Name -- Prescribing Physician Enter the name of the prescribing physician. Element 8 -- Prescribing Physician's NPI Enter the NPI of the prescribing physician. The NPI in this element must correspond with the provider name listed in Element 7. Element 9 -- Address -- Prescribing Physician Enter the complete address (street, city, state, and ZIP+4 code) of the prescribing physician. Element 10 -- Telephone Number -- Prescribing Physician Enter the prescribing physician's telephone number, including area code. SECTION II -- MEMBER INFORMATION Element 11 -- Name -- Member Enter the member's last name, followed by his or her first name and middle initial. Use the Wisconsin's Enrollment Verification System (EVS) to obtain the correct spelling of the member's name. If the name or the spelling of the name on the ForwardHealth identification card and the EVS do not match, use the spelling from the EVS. Element 12 -- Member Identification Number Enter the member ID. Do not enter any other numbers or letters. Element 13 -- Height and Weight -- Member Enter the member's height in inches and weight in pounds. This field is optional unless height and weight are related to respiratory diagnosis. Element 14 -- Date of Birth -- Member Enter the member's date of birth in MM/DD/CCYY format. Element 15 -- Place of Service Select the appropriate place of service code. If place of service code "31" (Skilled nursing facility) or "32" (nursing facility) are selected, complete Element 16. Element 16 -- Name and Address -- Facility (if applicable) Enter the name and address of the nursing facility in which the member resides, if applicable. SECTION III -- CLINICAL INFORMATION Element 17 -- Estimated Length of Need Enter the estimated time (in months) that the member will require oxygen. If the physician expects that the member will require the item for the duration of his or her life, then enter "99." Element 18 -- Diagnosis -- Codes and Descriptions Enter the appropriate International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes and descriptions most relevant to the oxygen-related services requested. Note: Medical equipment vendors may choose to provide only a written description. Element 19 -- Qualifying Test Enter the results of the qualifying test taken within 60 days prior to the date of submission or requested start date of the PA request. The criteria for coverage of oxygen-related services include one or both of the following: Oxygen saturation level (SAO2) of 88 percent or lower. Arterial blood gas level (PO2) of 55 mm/Hg or lower. Test results must have been taken within 60 days prior to the date of submission or the requested start date. Test results are to be available in the member's record or case file. Element 20 Enter the oxygen liter flow rate/number of hours per day prescribed by a physician. If not used on a scheduled basis, describe circumstances and frequency of use.

PRIOR AUTHORIZATION / OXYGEN ATTACHMENT (PA/OA) COMPLETION INSTRUCTIONS F-11066A (10/08)

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Element 21 -- Type of Oxygen Prescribed Indicate the type of oxygen requested. Element 22 -- Means of Delivery Prescribed Indicate the means of delivery of the oxygen. Element 23 Answer questions a-c about portable oxygen and member mobility information. Element 24 If the member's arterial blood gas level (PO2) is 56 mm/Hg or above or the member's oxygen saturation level (SAO2) is 89 percent or above, answer questions a-d. Element 25 Describe the medical condition of the member that supports the use of oxygen (e.g., describe why the member needs this equipment). SECTION IV -- PHYSICIAN PRESCRIPTION Element 26 -- Date of Prescription Enter the date of the physician's prescription in MM/DD/CCYY format. Element 27 -- Prescription as Written Enter the physician's prescription as it is written. If the prescribing physician signs the PA/OA, ForwardHealth will accept it in lieu of the physician's written prescription, and there is no need to attach a photocopy of the prescription to the PA/OA. The prescription or this attachment must be signed and dated by the physician within 30 days prior to the date of receipt by ForwardHealth or the requested start date of the PA request. Element 28 -- SIGNATURE -- Prescribing Physician The original signature of the provider prescribing the oxygen-related services must appear in this element, or the physician's prescription must be attached to the PA request. Element 29 -- Date Signed Enter the month, day, and year the PA/OA was signed in MM/DD/CCYY format.