Free Wisconsin Medicaid Verbal Orders for Recertification - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Financing HCF 1017A (11/05)

STATE OF WISCONSIN

WISCONSIN MEDICAID

VERBAL ORDERS FOR RECERTIFICATION: HOME HEALTH AGENCY REQUEST FOR VARIANCE OF PHYSICIAN SIGNATURE REQUIREMENT COMPLETION INSTRUCTIONS
Wisconsin Medicaid requires certain information to enable Medicaid to authorize and pay for medical services provided to eligible recipients. The information on this voluntary form is only to be used by home health agencies for the purpose of requesting a variance of the date by which the agency must have a physician review the recipient's plan of care (POC) and obtain the physician's dated signature on the recipient's written POC for recertification periods. Plan of Care Recertification Period Physician Signature Requirements For home health services, the provision of HFS 107.11(6)(b)4, Wis. Admin. Code, states that the written POC shall be reviewed, signed, and dated by the recipient's physician as often as required by the recipient's condition but at least every 62 days. For services provided to recipients dependent on a ventilator for life support, the provision of HFS 107.113(2), Wis. Admin. Code, states that the written POC shall be reviewed, signed, and dated by the recipient's physician and renewed at least every 62 days and whenever the recipient's condition changes. For private duty nursing services, the provision of HFS 107.12(1)(d)2, Wis. Admin. Code, states that the written POC shall be reviewed and signed by the recipient's physician as often as required by the recipient's condition, but not less often than every 62 days. INSTRUCTIONS When requesting a variance from the requirements as stated in ch. HFS 107.11(6)(b)4, 107.113(2), and/or 107.12(1)(d)2, Wis. Admin. Code, the home health agency must submit the information contained in this form to Wisconsin Medicaid. Providers are required to include all information on this form. The home health agency should complete a variance request form for itself and a separate variance request form for each branch that is assigned a unique Wisconsin Medicaid provider number. Each variance granted is specific to the agency's Wisconsin Medicaid provider number. Providers may submit this form by fax to Wisconsin Medicaid at (608) 266-1096 to the attention of the Home Care Policy Analyst. Providers who wish to submit this form by mail may do so by submitting it to the following address: Home Care Policy Analyst Wisconsin Medicaid Department of Health and Family Services PO Box 309 Madison WI 53701-0309