Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11037A (10/08)

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

FORWARDHEALTH

PRIOR AUTHORIZATION / SUBSTANCE ABUSE DAY TREATMENT ATTACHMENT (PA/SADTA) 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 to receive PA for certain procedures/services/items. 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/Substance Abuse Day Treatment Attachment (PA/SADTA), F-11037, to the Prior Authorization Request Form (PA/RF), F-11018, and physician prescription (if necessary) 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). SECTION I MEMBER INFORMATION Element 1 -- Name -- Member (Last, First, Middle Initial) 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 -- Requesting / Rendering Provider Enter the name and credentials of the therapist who will be providing treatment/service. Element 5 -- Telephone Number -- Requesting / Rendering Provider Enter the rendering provider's telephone number, including area code. Element 6 -- Name -- Referring / Prescribing Provider Enter the name of the provider referring/prescribing treatment. Element 7 -- Referring / Prescribing National Provider Identifier (NPI) Enter the referring/prescribing NPI.

PRIOR AUTHORIZATION / SUBSTANCE ABUSE DAY TREATMENT ATTACHMENT (PA/SADTA) COMPLETION INSTRUCTIONS F-11037A (10/08)

Page 2 of 2

The remaining portions of this attachment are to be used to document the justification for the service requested. Substance abuse day treatment is not a covered service for members who are residents of a nursing home or who are hospital inpatients. SECTION III DOCUMENTATION Element 8 Describe the length and intensity of treatment requested. Include the anticipated beginning treatment date and estimated substance abuse day treatment discharge date, and attach a copy of treatment design. Element 9 List the dates of diagnostic evaluations or medical examinations and specific diagnostic procedures that were employed. Element 10 List the codes and descriptions from the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM) for the member's current primary and secondary diagnosis. Allowable DSM diagnoses are 303.90 (alcohol dependence), 304.00304.90 (drug dependence), 305.00 (alcohol abuse), or 305.20-305.90 (other drug abuse, excluding caffeine intoxication). Element 11 Describe the member's current clinical problems and relevant clinical history, including substance abuse history. (Give details of dates of abuse, substance[s] abused, amounts used, date of last use, etc.) Element 12 Indicate whether or not the member has received any substance abuse treatment in the past 12 months. If the member has received substance abuse day treatment within the past 12 months, indicate the date for each treatment episode, the type of service provided, and the treatment outcomes. Element 13 If the member received any inpatient substance abuse care, intensive outpatient substance abuse services, or substance abuse day treatment in the past 12 months, give rationale for appropriateness and medical necessity of the current request. Discuss projected outcome of additional treatment requested. Element 14 Describe the member's severity of illness using the indicators in a-f. Refer to the substance abuse day treatment criteria on the Substance Abuse Day Treatment page of the ForwardHealth Online Handbook. Element 15 Describe the member's treatment plan and attach a copy of the plan. Element 16 Signature Member or Representative Signature of the member or representative indicates the signer has read the attached request for PA of substance abuse and agrees that it will be sent to ForwardHealth for review. Element 17 -- Date Signed Enter the month, day, and year the PA/SADTA was signed by the member or the member's representative (in MM/DD/CCYY format). Element 18 -- Relationship (if representative) Include relationship to member (if a representative signs). Element 19 -- Signature Rendering Provider Enter the signature of the rendering provider. Element 20 -- Date Signed Enter the month, day, and year the PA/SADTA was signed by the rendering provider (in MM/DD/CCYY format). Element 21 -- Discipline of Rendering Provider Enter the discipline of the rendering provider. Element 22 -- Signature Supervising Physician or Psychologist Enter the signature of the supervising physician or psychologist. Element 23 -- Date Signed Enter the month, day, and year the PA/SADTA was signed by the supervising physician or psychologist (in MM/DD/CCYY format). Element 24 -- Supervising Physician or Psychologist's NPI Enter the supervising physician or psychologist's NPI.