Free Wisconsin Medicaid STAT-PA Specialized Medical Vehicle Worksheet, HCF 11053 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Financing HCF 11053A (Rev. 08/03)

STATE OF WISCONSIN

WISCONSIN MEDICAID

STAT-PA SPECIALIZED MEDICAL VEHICLE WORKSHEET INSTRUCTIONS
Wisconsin Medicaid requires information to enable Medicaid to authorize and pay for medical services provided to eligible recipients. Under s. 49.45(4), Wis. Stats., personally identifiable information about Medicaid applicants and recipients is confidential and is used for purposes directly related to Medicaid administration such as determining eligibility of the applicant, processing prior authorization (PA) requests, or processing provider claims for reimbursement. The STAT-PA Specialized Medical Vehicle Worksheet is not a required worksheet for documenting the information needed to request PA for specialized medical vehicle transportation. The Wisconsin Specialized Transmission Approval Technology-PA (STAT-PA) system is an electronic PA system that allows Medicaidcertified providers to receive PA electronically rather than by mail or fax. Providers answer a series of questions and receive an immediate response of an approved or returned PA. Providers communicate with the Wisconsin STAT-PA system by entering requested information on a touch-tone telephone keypad or by calling a STAT-PA help desk correspondent. Providers must have their eight-digit Medicaid provider number to access the Wisconsin STAT-PA system. The Wisconsin STAT-PA system is available by calling one of the following telephone numbers: Touch-Tone Telephone (800) 947-1197 (608) 221-2096 Available from 8:00 a.m. to 11:45 p.m., seven days a week. · Help Desk (800) 947-1197 and press "0" (608) 221-2096 and press "0" Available from 8:00 a.m. to 6:00 p.m., Monday through Friday, excluding holidays.

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REQUIRED INFORMATION All providers using STAT-PA are required to provide the following information: · Eight-digit Medicaid provider number. · Recipient's 10-digit Medicaid identification number. · Procedure code of service requested. · Diagnosis code. · Two-digit place of service (POS) code. · Requested grant date or date of service (DOS). · Number of days allowed by prescription. Refer to the STAT-PA Specialized Medical Vehicle Worksheet for documenting the information needed to request PA for SMV transportation. HOW TO USE WISCONSIN STAT-PA 1. Complete the STAT-PA Specialized Medical Vehicle Worksheet. 2. Select mode of transmission (touch-tone telephone or help desk). TOUCH-TONE TELEPHONE REQUESTS To use a touch-tone telephone to submit a PA request: 1. Call (800) 947-1197 or (608) 221-2096. This connects the provider directly with the STAT-PA system. 2. When the system answers, it will ask a series of questions that providers answer by entering the information on the telephone keypad. The STAT-PA Specialized Medical Vehicle Worksheet gives the information needed in the order it is requested by the STAT-PA system. Note: When using a touch-tone telephone to enter the Medicaid provider number, recipient identification number, procedure code, diagnosis code, POS code, requested first DOS, and quantity, always press the pound (#) key to mark the end of the data just entered. The pound (#) key signals the system that the provider has finished entering the data requested and ensures the quickest response from the system.

STAT-PA SPECIALIZED MEDICAL VEHICLE WORKSHEET INSTRUCTIONS HCF 11053A (Rev. 08/03)

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Providers may be asked to enter alphabetic data, which can be entered by using the asterisk (*) key. For example, a provider is asked to enter a procedure code, such as S0209. The first character is an alpha character; therefore, the provider presses the single asterisk (*) followed by the two digits that indicate the letter. The first digit is the number on the keypad where the letter is located, and the second digit is the position of the letter on that key. For example: Procedure code S0209 should be entered as *73 0 2 0 9. Alphabet Key: A = *21 B = *22 C = *23 D = *31 E = *32 F = *33 3. G = *41 H = *42 I = *43 J = *51 K = *52 L = *53 M = *61 N = *62 O = *63 P = *71 Q = *11 R = *72 S = *73 T = *81 U = *82 V = *83 W = *91 X = *92 Y = *93 Z = *12

Once all data have been entered completely, STAT-PA begins to process the information and, in minutes, indicates the PA number and, if approved, the authorized level of service.

Once familiar with the STAT-PA system, providers may enter the PA information in the designated order immediately -- there is no need to wait for the full voice prompt. Providers may key information at any time, even when the system is relaying information. The system automatically proceeds to the next function. STAT-PA HELP DESK REQUESTS Providers who do not have a touch-tone telephone may call the STAT-PA help desk. The help desk correspondent accesses STAT-PA and enters the required data requested from the provider. For the help desk, call (800) 947-1197 and press option "0," or call (608) 221-2096 and press option "0." The STAT-PA help desk is available to all providers using STAT-PA. Providers may use the help desk to report difficulties with the system. DOCUMENTATION INFORMATION Providers are required to retain the assigned PA number for: · Use in claims submission, if approved. · Submission of a paper PA request when more clinical documentation is needed. Providers must maintain all documentation that supports medical necessity and claim information in their records for a period not less than five years. Wisconsin Medicaid recommends providers maintain the STAT-PA Specialized Medical Vehicle Worksheet in their files. Regardless of what STAT-PA method is used, providers will receive, by mail, a confirmation notice indicating the assigned PA number and the STAT-PA decision. This confirmation notice should be maintained as a permanent record of the transaction. Helpful Hints · In touch-tone telephone transactions, the provider is given three attempts at each field to correctly enter the requested data. Failure to enter any data within three minutes ends the telephone connection. · Providers are allowed five PA requests per connection for touch-tone telephone and help desk. · The decimal point for diagnosis codes is not required when entering a STAT-PA request by touch-tone telephone; however, all digits of the codes must be entered. · The first DOS entered by the provider may be up to 31 calendar days in the future. · In the event that the STAT-PA system is unavailable, the PA request may be backdated up to four calendar days. · Providers needing to enddate a PA request due to a change in prescription may do so through the STAT-PA help desk. The help desk correspondent will assist the provider though this process. · The help desk is available to all STAT-PA users. Providers who are experiencing difficulties with the system, may call the help desk.