Form F-11018 - Prior Authorization Request Form (Pa/rf)

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DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

ForwardHealth

DHS 106.03(4), Wis. Admin. Code

F-11018 (05/13)

DHS 152.06(3)(h), 153.06(3)(g), 154.06(3)(g), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION REQUEST FORM (PA/RF)

Providers may submit prior authorization (PA) requests by fax to ForwardHealth at (608) 221-8616 or by mail to: ForwardHealth, Prior Authorization, Suite

88, 313 Blettner Boulevard, Madison, WI 53784. Instructions: Type or print clearly. Before completing this form, read the service-specific Prior Authorization

Request Form (PA/RF) Completion Instructions.

SECTION I — PROVIDER INFORMATION

3. Telephone Number ― Billing Provider

1. Check only if applicable

2. Process Type



HealthCheck “Other Services”



Wisconsin Chronic Disease Program (WCDP)

4. Name and Address — Billing Provider (Street, City, State, ZIP+4 Code)

5a. Billing Provider Number

5b. Billing Provider Taxonomy Code

6a. Name — Prescribing / Referring / Ordering Provider

6b. National Provider Identifier — Prescribing / Referring /

Ordering Provider

SECTION II — MEMBER INFORMATION

7. Member Identification Number

8. Date of Birth — Member

9. Address — Member (Street, City, State, ZIP Code)

10. Name — Member (Last, First, Middle Initial)

11. Gender — Member



Male

Female

SECTION III — DIAGNOSIS / TREATMENT INFORMATION

12. Diagnosis — Primary Code and Description

13. Start Date — SOI

14. First Date of Treatment — SOI

15. Diagnosis — Secondary Code and Description

16. Requested PA Start Date

17. Rendering

18. Rendering

19. Service

20. Modifiers

21.

22. Description of Service

23. QR

24. Charge

Provider

Code

POS

Provider

Number

Taxonomy

Code

An approved authorization does not guarantee payment. Reimbursement is contingent upon enrollment of the member and provider at the time the service is

provided and the completeness of the claim information. Payment will not be made for services initiated prior to approval or after the authorization expiration

25. Total

date. Reimbursement will be in accordance with ForwardHealth payment methodology and policy. If the member is enrolled in a BadgerCare Plus Managed

Charges

Care Program at the time a prior authorized service is provided, ForwardHealth reimbursement will be allowed only if the service is not covered by the

Managed Care Program.

26. SIGNATURE — Requesting Provider

27. Date Signed

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