F-1161 - Abortion Certification Statements printable pdf download

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Health Care Access and Accountability

s. 20.927, Wis. Stats.

F-1161 (10/08)

FORWARDHEALTH

ABORTION CERTIFICATION STATEMENTS

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.

Coverage Policy

In accordance with s. 20.927, Wis. Stats., ForwardHealth covers abortions when one of the following situations exists:

• The abortion is directly and medically necessary to save the life of the woman, provided that prior to the abortion the physician

attests in a signed, written statement, based on his or her best clinical judgment, that the abortion meets this condition.

• In a case of sexual assault or incest, provided that prior to the abortion the physician attests in a signed, written statement, to his or

her belief that sexual assault or incest has occurred and provided that the crime has been reported to the law enforcement

authorities.

• Due to a medical condition existing prior to the abortion, the physician determines that the abortion is directly and medically

necessary to prevent grave, long-lasting physical health damage to the woman, provided that prior to the abortion, the physician

attests in a signed, written statement, based on his or her best clinical judgment, that the abortion meets this condition.

INSTRUCTIONS

When filing a claim for reimbursement of an abortion with ForwardHealth, physicians are required to attach a written certification

statement attesting to one of the following circumstances. The following are sample certification statements that providers may use to

certify the medical necessity of the abortion. The use of this form is mandatory when filing a claim for reimbursement of an abortion.

SECTION I — LIFE OF THE WOMAN

I, __________________________________________________________________________________________ , certify that

(Name — Provider)

on the basis of my best clinical judgment, abortion is directly and medically necessary to save the life of

__________________________________________________________________________________________________, of

(Name — Member)

____________________________________________________________________________________________________,

(Address — Member)

for the following reasons:

____________________________________________________________________________________________________

____________________________________________________________________________________________________.

___________________________________________________________________ _____________________

SIGNATURE — Physician

Date Signed

Continued

Reset Page 1

F-1161 - Abortion Certification Statements

Related Articles

Related forms

Related Categories