Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11032 (10/08)

STATE OF WISCONSIN HFS 107.13(3), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION / SUBSTANCE ABUSE ATTACHMENT (PA/SAA)
Providers may submit prior authorization (PA) requests and attachments to ForwardHealth by fax at (608) 221-8616 or by mail 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/Substance Abuse Attachment (PA/SAA) Completion Instructions, F-11032A. 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 -- Rendering Provider

5. Rendering Provider's National Provider Identifier (NPI)

6. Telephone Number -- Rendering Provider

7. Name -- Referring / Prescribing Provider

8. Referring / Prescribing Provider's NPI

SECTION III -- TYPE OF TREATMENT REQUESTED 9. Primary Intensive Outpatient Treatment · Individual Group Family · Number of minutes per session ____ Individual ____ Group ____ Family · Sessions will be Twice / month Once / month Once / week Other (specify) ______________ · Requesting ____ hours per week, for ____ weeks · Anticipating beginning treatment date ____ · Estimated intensive treatment termination date ____ · Attach a copy of treatment design, which includes the following: a) Schedule of treatment (day, time of day, length of session, and service to be provided during that time). b) Description of aftercare / follow-up component. Aftercare / Follow-Up Service Individual Group Family Number of minutes per session ____ Individual ____ Group ____ Family Sessions will be Twice / month Once / month Once / week Other (specify) ____ Requesting ____ hours per week, for ____ weeks Estimated discharge date from this component of care ____

· · · · ·

Continued

Reset Page 1 Only

PRIOR AUTHORIZATION / SUBSTANCE ABUSE ATTACHMENT (PA/SAA) F-11032 (10/08)

Page 2 of 4

SECTION III -- TYPE OF TREATMENT REQUESTED (Continued) Affected Family Member / Codependency Treatment · Individual Group Family · Number of minutes per session ____ Individual ____ Group ____ Family · Sessions will be Twice / month Once / month Once / week Other (specify) _____________ · Requesting ____ hours per week, for ____ weeks · Anticipating beginning treatment date ____ · Estimated affected family member / codependency treatment termination date ____ · Attach a copy of treatment design, which includes the following: a) Schedule of treatment (day, time of day, length of session, and service to be provided during that time) b) Description of aftercare / follow-up component. SECTION IV -- DOCUMENTATION 10. Was the member in primary substance abuse treatment in the last 12 months? If "yes," provide date(s), problem(s), outcome, and provider of service. Yes No Unknown

11. Enter the dates of diagnostic evaluation(s) or medical examination(s).

12. Specify diagnostic procedures employed.

Reset Page 2 Only

Continued

PRIOR AUTHORIZATION / SUBSTANCE ABUSE ATTACHMENT (PA/SAA) F-11032 (10/08)

Page 3 of 4

SECTION IV -- DOCUMENTATION (Continued) 13. Provide current primary and secondary diagnosis (refer to the current Diagnostic and Statistical Manual of Mental Disorders) codes and descriptions.

14. Describe the member's current clinical problems and relevant history. Include substance abuse history.

15. Describe the member's family situation. Include how family issues are being addressed and if family members are involved in treatment. If family members are not involved in treatment, specify why not.

16. Provide a detailed description of treatment objectives and goals.

Continued

Reset Page 3 Only

PRIOR AUTHORIZATION / SUBSTANCE ABUSE ATTACHMENT (PA/SAA) F-11032 (10/08)

Page 4 of 4

SECTION IV -- DOCUMENTATION (Continued) 17. Describe expected outcome of treatment (include use of self-help groups, if appropriate).

SECTION V -- SIGNATURES

I have read the attached request for PA of substance abuse services and agree that it will be sent to ForwardHealth for review. 18. SIGNATURE -- Member or Representative (optional) 19. Date Signed

20. Relationship (if representative)

Attach a photocopy of the physician's prescription for treatment. The prescription must be signed and dated within three months of receipt by ForwardHealth (initial request) or within 12 months of receipt by ForwardHealth (subsequent request). (Physician providers need not attach a prescription unless treatment is prescribed by another physician). 21. SIGNATURE -- Rendering Provider 22. Date Signed

23. Discipline of Rendering Provider

24. Rendering Provider's NPI

25. SIGNATURE -- Supervising Provider

26. Date Signed

Reset Page 4 Only

Reset Form