Form F 11134 – Fill Out and Use This PDF

DEPARTMENT OF HEALTH SERVICES	STATE OF WISCONSIN
Division of Health Care Access and Accountability	DHS 107.112(3), Wis. Admin. Code
F-11134 (07/12)

FORWARDHEALTH

PERSONAL CARE PRIOR AUTHORIZATION PROVIDER ACKNOWLEDGEMENT

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 (DHS 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 services.

The Personal Care Prior Authorization Provider Acknowledgement, F-11134, states that the supervising registered nurse (RN) will perform each of the following tasks before personal care (PC) services are provided for the claims submitted to ForwardHealth:

•Obtain physician’s signed and dated orders.

•Conduct an assessment at the member’s place of residence.

•Develop the plan of care (POC).

The use of this form is mandatory when requesting PA.

Providers are required to submit the Personal Care Prior Authorization Provider Acknowledgement and other documents as directed by ForwardHealth PC policy to ForwardHealth when requesting PA for PC services. Providers may submit PA documents by fax to ForwardHealth at (608) 221-8616 or by mail to the following address:

ForwardHealth

Prior Authorization

Ste 88

313 Blettner Blvd

Madison WI 53784

Providers should make duplicate copies of all paper documents mailed to ForwardHealth. The provision of services that are greater than or significantly different from those authorized may result in nonpayment of the billing claim(s).

INSTRUCTIONS: Type or print clearly.

As the authorized representative of the billing provider, I will assure that the supervising RN completes the following tasks before PC services are provided for the claims submitted to ForwardHealth: the physician’s signed and dated orders for this member will be obtained, an assessment at the member’s place of residence will be conducted, and a POC will be completed for this member.