Free ForwardHealth Prior Authorization Amendment Request, F11042 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11042A (10/08)

STATE OF WISCONSIN HFS 106.03(4), Wis. Admin. Code HFS 152.06(3)(h), 153.06(3)(g), 154.06(3)(g), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION AMENDMENT REQUEST 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 service. Providers are required to use the Prior Authorization Amendment Request, F-11042, to request an amendment to a PA. The use of this form is mandatory when requesting an amendment to a PA. 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 medical consultants to make a reasonable judgment about the case. Attach the completed Prior Authorization Amendment Request to the PA Decision Notice of the PA to be amended along with physician's orders, if applicable, (within 90 days of the dated signature) and send it to ForwardHealth. Providers may submit the Prior Authorization Amendment Request to ForwardHealth by fax 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 -- Original PA Number Enter the unique PA number from the original PA to be amended. Element 2 -- Process Type Enter the process type as indicated on the PA to be amended. Element 3 -- Member Identification Number Enter the member ID as indicated on the PA to be amended. Element 4 -- Name -- Member Enter the name of the member as indicated on the PA to be amended. SECTION II -- PROVIDER INFORMATION Element 5 -- Billing Provider Number Enter the billing provider number as indicated on the PA to be amended. Element 6 -- Name -- Billing Provider Enter the name of the billing provider as indicated on the PA to be amended.

PRIOR AUTHORIZATION AMENDMENT REQUEST COMPLETION INSTRUCTIONS F-11042A (10/08)

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SECTION III -- AMENDMENT INFORMATION Element 7 -- Address -- Billing Provider Enter the address of the billing provider (include street, city, state, and ZIP+4 code) as indicated on the PA to be amended. Element 8 -- Requested Start Date Enter the requested start date for the amendment in MM/DD/CCYY format if a specific start date is required. Element 9 -- Requested End Date (If Different from Expiration Date of Current PA) Enter the requested end date for the amendment in MM/DD/CCYY format if the end date is different that the current expiration date. Element 10 -- Reasons for Amendment Request Enter an "X" in the box next to each reason for the amendment request. Check all that apply. Element 11 -- Description and Justification for Requested Change Enter the specifics and supporting rationale of the amendment request related to each reason indicated in Element 10. Element 12 -- Are Attachments Included? Enter an "X" in the appropriate box to indicate if attachments are or are not included with the amendment request. If Yes, specify all attachments that are included. Element 13 -- Signature -- Requesting Provider Enter the signature of the provider that requested the original PA. Element 14 -- Date Signed -- Requesting Provider Enter the date the amendment request was signed by the requesting provider in MM/DD/CCYY format.