Form F 11134 PDF Details

In the realm of healthcare services, ensuring that eligible members receive the care they need while maintaining a streamlined and compliant billing process is paramount. The F-11134 form, also known as the Personal Care Prior Authorization Provider Acknowledgement, plays a critical role in this process within the State of Wisconsin's Department of Health Services. Crafted by the Division of Health Care Access and Accountability, this form serves as a required step for healthcare providers who are looking to secure prior authorization for personal care services. It outlines a series of tasks that the supervising registered nurse must complete, including obtaining physician’s orders, conducting an in-home assessment, and developing a care plan. This ensures the submission of correct and complete claims for reimbursement to ForwardHealth, a necessity for providers aiming to facilitate medical services to eligible members. Not only does the form necessitate full, correct, and truthful information from members, but it also operates under strict confidentiality guidelines to protect personal information, aligning with ForwardHealth's administration purposes such as eligibility determination, prior authorization requests, and reimbursement processing. Failure to adhere to the form's requirements could lead to the denial of authorization or payment, emphasizing its importance in the provision and billing of personal care services. Moreover, it instructs providers on the submission process, whether through fax or mail, and underscores the necessity of maintaining copies of all submitted documents. The F-11134 form thus stands as a pivotal document, intricately tied to the assurance of quality care and the efficient operation of healthcare services within Wisconsin.

QuestionAnswer
Form NameForm F 11134
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameswisconsin forward health prior auth forms, forward health addendum, HFS, pcst addendum forward health

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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.

Name — Personal Care Services Provider

Provider Number

Name — Member

Member ID

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.

SIGNATURE — Authorized Representative of the Billing Provider

Date Signed

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