Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11039A (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) 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 the Prior Authorization/Spell of Illness Attachment (PA/SOIA), F-11039, is mandatory when requesting spell of illness (SOI). 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 PA/SOIA to the Prior Authorization Request Form (PA/RF), F-11018, and send it 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 Providers should make duplicate copies of all paper documents mailed to ForwardHealth. The provision of services that are greater than or significantly different from those authorized may result in nonpayment of the billing claim(s). An SOI ends when the maximum allowable treatment days have been used or when the physical therapy (PT), occupational therapy (OT), or speech and language pathology (SLP) services are no longer required, whichever comes first. If, near the end of the maximum allowable treatment days, the skills of a PT, OT, or SLP provider are still needed, the provider should submit the PA/RF and the Prior Authorization/Therapy Attachment (PA/TA), F-11008, to continue services. SECTION I -- MEMBER INFORMATION Element 1 -- 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 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. Use the ForwardHealth card or the EVS to obtain the correct member ID. SECTION II -- PROVIDER INFORMATION Element 4 -- Name and Credentials -- Therapist Enter the name and credentials of the primary therapist participating in therapy services for the member. If the rendering provider is a therapy assistant, enter the name of the supervising therapist. Element 5 -- Therapist's National Provider Identifier Enter the rendering provider's National Provider Identifier (NPI). If the rendering provider is a therapy assistant, enter the NPI of the supervising therapist. Rehabilitation agencies do not indicate a rendering provider.

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

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Element 6 -- Telephone Number -- Therapist Enter the rendering provider's telephone number, including the area code, of the office, facility, or place of business. If the rendering provider is a therapy assistant, enter the telephone number of the supervising therapist. Element 7 -- Name -- Prescribing Physician Enter the name of the prescribing physician. SECTION III -- DOCUMENTATION Element 8 Enter an "X" in the appropriate box to indicate a PT, OT, or SLP SOI request. Element 9 -- Requested Start Date Enter the requested start date for service(s) in MM/DD/CCYY format. Element 10 -- Primary International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Diagnosis Code or ICD-9-CM Surgical Procedure Code Enter the appropriate primary ICD-9-CM diagnosis code or surgical procedure code. Element 11 Enter an "X" in the appropriate box to indicate "yes" or "no" in response to each statement. Only one of "A" through "F" must be marked "yes" in addition to "G" for SOI approval. Otherwise, the PT, OT, or SLP provider should submit the PA/RF and the PA/TA. Element 12 -- Signature Therapist Providing Evaluation / Treatment The signature of the therapist providing evaluation/treatment must appear in the space provided. Element 13-- Date Signed Enter the month, day, and year the PA/SOIA was signed in MM/DD/CCYY format.