Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11039 (10/08)

STATE OF WISCONSIN HFS 107.18(2), 107.19(2), 107.20(2), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION / SPELL OF ILLNESS ATTACHMENT (PA/SOIA)
Providers may submit spell of illness (SOI) requests by fax to ForwardHealth at (608) 221-8616, or providers may send the completed form to: ForwardHealth, Prior Authorization, Suite 88, 6406 Bridge Road, Madison, WI 53784-0088. Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Spell of Illness Attachment (PA/SOIA) Completion Instructions, F-11039A. SECTION I -- MEMBER INFORMATION

1.

Name -- Member (Last, First, Middle Initial)

2.

Age -- Member

3.

Member Identification Number

SECTION II -- PROVIDER INFORMATION

4.

Name and Credentials -- Therapist

5.

Therapist's National Provider Identifier

6.

Telephone Number -- Therapist

7.

Name -- Prescribing Physician

SECTION III -- DOCUMENTATION

8. 9.

Requesting SOI for Requested Start Date

Physical Therapy (PT)

Occupational Therapy (OT)

Speech and Language Pathology (SLP)

10. Primary International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)
Diagnosis Code or ICD-9-CM Surgical Procedure Code

11. Indicate "yes" or "no" in response to each of the following statements (Only one of "A" through "F" in addition to "G" must be marked "yes" for SOI
approval. Otherwise, the PT, OT, or SLP provider should submit the Prior Authorization Request Form [PA/RF] and the Prior Authorization/Therapy Attachment [PA/TA]). A. The member experienced the onset of a new neuromuscular disease, injury, or condition six weeks ago or less. B. The member experienced the onset of a new musculoskeletal disease, injury, or condition six weeks ago or less. C. The member experienced the onset of a new problem or complication associated with physiologic disease, injury, or condition six weeks ago or less. D. The member experienced the onset of a new psychological disease, injury, or condition six weeks ago or less. E. The member experienced an exacerbation of a pre-existing condition six weeks ago or less. F. The member experienced a regression of his or her condition due to lack of therapy six weeks ago or less. AND G. There is a reasonable expectation that the member will return to his or her previous level of function by the end of this SOI or sooner. Yes No Yes Yes Yes Yes Yes Yes No No No No No No

I hereby certify that the documentation of the date of onset, exacerbation, or regression of the member's disease, injury, or condition is as stated above. The specific start date of the SOI is maintained in the member's medical record at my facility and I acknowledge that the SOI ends when the services of a therapist are no longer required or after the maximum allowable treatment days have been used, whichever comes first.

12. SIGNATURE -- Therapist Providing Evaluation / Treatment

13. Date Signed

Continued

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PRIOR AUTHORIZATION / SPELL OF ILLNESS ATTACHMENT (PA/SOIA) F-11039 (10/08)

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Examples of statements A-F from Element 11: A. The member experienced the onset of a new neuromuscular disease, injury, or condition six weeks ago or less. Examples of this situation include, but are not limited to:
· · · ·

Diabetic neuropathy. Multiple sclerosis. Parkinson's disease. Stroke-hemiparesis.

B.

The member experienced the onset of a new musculoskeletal disease, injury, or condition six weeks ago or less. Examples of this situation include, but are not limited to:
· · · ·

Amputation. Complications associated with surgical procedures. Fracture. Strains and sprains.

C.

The member experienced the onset of a new problem or complication associated with physiologic disease, injury, or condition six weeks ago or less. Examples of this situation include, but are not limited to:
· ·

Cardio-pulmonary conditions. Severe pain. · Vascular condition.

D.

The member experienced the onset of a new psychological disease, injury, or condition six weeks ago or less. Examples of this situation include, but are not limited to:
· · ·

Affective disorders. Organic conditions. Thought disorders.

E.

The member experienced an exacerbation of a pre-existing condition six weeks ago or less. Examples of this situation include, but are not limited to:
· · · ·

Multiple sclerosis. Parkinson's disease. Rheumatoid arthritis. Schizophrenia.

F.

The member experienced a regression of his or her condition due to lack of therapy six weeks ago or less. Examples of this situation include, but are not limited to:
· · · ·

Decrease of functional ability. Decrease of mobility. Decrease of motion. Decrease of strength.