Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11008 (10/08)

STATE OF WISCONSIN HFS 107.18(2), Wis. Admin. Code HFS 152.06(3)(h), 153.06(3)(g), 154.06(3)(g), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION / THERAPY ATTACHMENT (PA/TA)
Providers may submit prior authorization (PA) requests with 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/Therapy Attachment (PA/TA) Completion Instructions, F-11008A. SECTION I -- MEMBER / PROVIDER INFORMATION 1. Name -- Member (Last, First, Middle Initial) 2. Member Identification Number 3. Age -- Member

4. Name and Credentials -- Therapist

5. Therapist's National Provider Identifier

6. Telephone No. -- Therapist

7. Name -- Referring / Prescribing Physician

8. Requesting PA for Physical Therapy Occupational Therapy Speech and Language Pathology 10. Total Sessions Per Week Requested

9. Total Time Per Day Requested

11. Total Number of Weeks Requested

12. Requested Start Date

SECTION II -- PERTINENT DIAGNOSES / PROBLEMS TO BE TREATED 13. Provide a description of the member's current treatment diagnosis, any underlying conditions, and problem(s) to be treated, including dates of onset.

SECTION III -- BRIEF PERTINENT MEDICAL / SOCIAL INFORMATION 14. Include referral information, living situation, previous level of function, any change in medical status since previous PA request(s), and any other pertinent information.

SECTION IV -- PERTINENT THERAPY INFORMATION 15. Document the chronological history of treatment provided for the diagnoses (identified under Section II), dates of those treatments, and the member's functional status following those treatments. Provider Type (e.g., occupational therapy, physical therapy, speech and language pathology) Dates of Treatment Functional Status After Treatment

Continued

PRIOR AUTHORIZATION / THERAPY ATTACHMENT (PA/TA) F-11008 (10/08)

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SECTION IV -- PERTINENT THERAPY INFORMATION (Continued) 16. List other service providers that are currently accessed by the member for those treatment diagnoses identified under Section II (i.e., home health, school, behavior management, home program, dietary services, therapies). Briefly document the coordination of the therapy treatment plan with these other service providers. Documentation may include telephone logs, summarization of conversations or written communication, copies of plans of care, staffing reports, or received written reports.

17. Check the appropriate box and circle the appropriate form, if applicable. The current Individualized Education Program (IEP) / Individualized Family Service Plan (IFSP) / Individual Program Plan (IPP) is attached to this PA request. The current IEP / IFSP / IPP is attached to PA number ________________________________________________. There is no IEP / IFSP / IPP because______________________________________________________________ __________________________________________________________________________________________. Cotreatment with another therapy provider is within the plan of care. Referenced report(s) is attached (list any report[s]) ________________________________________________. SECTION V -- EVALUATION (COMPREHENSIVE RESULTS OF FORMAL / INFORMAL TESTS AND MEASUREMENTS THAT PROVIDE A BASELINE FOR THE MEMBER'S FUNCTIONAL LIMITATIONS) 18. Attach a copy of the initial evaluation or the most recent evaluation or re-evaluation, or indicate with which PA number this information was previously submitted. Comprehensive initial evaluation attached. Date of initial comprehensive evaluation ___________. Comprehensive initial evaluation submitted with PA number ___________________. Current re-evaluation attached. Date of most current evaluation or re-evaluation(s) _____________. Current re-evaluation submitted with PA number ___________________. SECTION VI -- PROGRESS 19. Describe progress in specific, measurable, objective, and functional terms (using consistent units of measurement) that are related to the goals / limitations, since treatment was initiated or last authorized. Goal / Limitation Previous Status / Date Status as of Date of PA Request / Date

(If this information is concisely written in other documentation prepared for the provider's/therapist's records, attach and write "see attached" in the space above.) Continued

PRIOR AUTHORIZATION / THERAPY ATTACHMENT (PA/TA) F-11008 (10/08)

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SECTION VII -- PLAN OF CARE 20. Identify the specific, measurable, objective, and functional goals for the member (to be met by the end of this PA request) and both of the following: (1) Indicate the therapist-required skills / treatment techniques that will be used to meet each goal. (2) Designate (with an asterisk [*]) which goals are reinforced in a carry-over program.

(If the plan of care is concisely written in other documentation prepared for the member's records, attach and write "see attached" in the space above.)

SECTION VIII -- REHABILITATION POTENTIAL 21. Complete the following sentences based upon the professional assessment. (1) Upon discharge from this episode of care, the member will be able to

(2) Upon discharge from this episode of care, the member may continue to (list supportive services)

(3) The member / member's caregivers support the therapy plan of care by the following activities and frequency of carryover

(4) It is estimated this episode of care will end (provide approximate end time)

22. SIGNATURE -- Providing Therapist

23. Date Signed

24. SIGNATURE -- Member or Member Caregiver (optional)

25. Date Signed

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