Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11016A (10/08)

STATE OF WISCONSIN HFS 107.06(2), Wis. Admin. Code HFS 152.06(3)(h), 153.06(3)(g), 154.06(3)(g), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION / PHYSICIAN ATTACHMENT (PA/PA) COMPLETION INSTRUCTIONS
Complete the Prior Authorization/Physician Attachment (PA/PA), F-11016, including the Prior Authorization Request Form (PA/RF), F-11018, and submit it by fax to (608) 221-8616 or by mail to the following address: ForwardHealth Prior Authorization Ste 88 6406 Bridge Rd Madison WI 53784-0088 Providers should make duplicate copies of all paper documents mailed to ForwardHealth. Providers with questions about completing PA requests should call Provider Services at (800) 947-9627. SECTION I -- MEMBER INFORMATION Element 1 -- Name -- Member 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 -- Date of Birth -- Member Enter the member's date of birth in MM/DD/CCYY format. Element 3 -- Member Identification Number Enter the member ID. Do not enter any other numbers or letters. SECTION II -- PROVIDER INFORMATION Element 4 -- Name -- Rendering Provider Element 5 -- National Provider Identifier -- Rendering Provider Enter the National Provider Identifier of the physician rendering the service. Element 6 -- Telephone Number -- Rendering Provider Enter the telephone number, including area code, of the provider rendering the service. Element 7 -- Name -- Ordering / Prescribing Physician Enter the name of the referring/prescribing physician in this element. SECTION III -- SERVICE INFORMATION The remaining portions of this attachment are to be used to document the justification for the requested service/procedure. 1. 2. 3. Complete Elements A through C. Read the statement above Element 25 of the PA/RF before signing and dating the PA/PA. Sign and date the PA/PA (Element D).