Medicine and Surgery Section - Wisconsin.gov

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PRIOR AUTHORIZATION / “J” CODE ATTACHMENT (PA/JCA) COMPLETION INSTRUCTIONS Page 2 of 2 HCF 11034A (Rev. 06/03) Element 16 — Use (check one) Any of the compendium standards may be used. If an intended use is not in the drug package insert, providers may want to check the United States Pharmacopeia-Drug Information (USP-DI) for the most inclusive reference for diagnosis. Drugs not listed in compendium standards may be covered by Wisconsin Medicaid; therefore, the PA/JCA must be submitted for processing and denied before the recipient is told a particular drug is not covered by Wisconsin Medicaid. Element 17 — Dose (check one) Any of the compendium standards may be used. If a prescribed dosage is not in the drug package insert, providers may want to check the USP-DI (the most inclusive reference for diagnosis). Drugs not listed in compendium standards may be covered by Wisconsin Medicaid; therefore, the PA/JCA must be submitted for processing and denied before the recipient is told a particular drug is not covered by Wisconsin Medicaid. Elements 18 and 19 — Signature — Prescriber and Date Signed The prescriber is required to review the information, verifying that the information is accurate to the best of his or her knowledge, and sign and date the PA/JCA. Check the appropriate box indicating how the provider would like to be notified of an approved or denied PA request. Indicate a fax or telephone number if selecting either of these options.
Appendix 22 Prior Authorization / “J” Code Attachment (for photocopying) (A copy of the Prior Authorization/“J” Code Attachment [PA/JCA] is located on the following pages.) Physician Services Handbook — Medicine and Surgery December 2005 139 Appendix
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Physician Services Medicine and Sur
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T Table of Contents Preface .......
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Telemedicine ......................
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Health Professional Shortage Areas
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Legal Framework The following laws
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General Information Treatment (EPSD
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General Information Category III Co
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General Information collecting the
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General Information • The current
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Evaluation and Management reimburse
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Evaluation and Management in an out
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Evaluation and Management 22 Wiscon
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Medicine Services System [HCPCS] co
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Medicine Services In cases where mo
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Medicine Services documentation in
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Medicine Services Providers of ment
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Medicine Services Substance Abuse S
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Surgery Services Appendix 10 of thi
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Surgery Services Cataract Surgery W
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Surgery Services and the insertion
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Surgery Services Note: A telephone
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Surgery Services • Sterilization.
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Surgery Services live with her sinc
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Surgery Services by a multi-discipl
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Prescription Requirements Prescribe
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Prescription Requirements Approval
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Prescription Requirements prescribe
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Prescription Requirements 54 Wiscon
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Claims Submission adjustment reques
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Claims Submission 58 Wisconsin Medi
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Reimbursement • Confirming or rev
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Reimbursement about whether a speci
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Reimbursement 64 Wisconsin Medicaid
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Appendix 66 Wisconsin Medicaid and
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Appendix Surgery Services Appendix
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Appendix Medicine Services (Continu
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Appendix Other Services Appendix 1
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Appendix Appendix 4 (Continued) If
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Appendix Appendix 4 (Continued) Ele
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Appendix Appendix 4 (Continued) Ele
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Page 90 and 91: Appendix 88 Wisconsin Medicaid and
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Page 98 and 99: ABORTION CERTIFICATION STATEMENTS P
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Page 116 and 117: Appendix Category Musculoskeletal S
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Page 122 and 123: Appendix SECTION II — RECIPIENT I
Page 132 and 133: Appendix PRIOR AUTHORIZATION / PHYS
Page 136 and 137: PRIOR AUTHORIZATION / PHYSICIAN ATT
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Page 152 and 153: Appendix Health Professional Shorta
Page 154 and 155: Appendix HPSA Name County ZIP Codes
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Page 160 and 161: Appendix The following table lists
Page 172 and 173: DECLARATION OF SUPERVISION FOR NONB
Page 176 and 177: Appendix HCPCS Code* Drug Name Diag
Page 178: Index Organ Transplants, 44 Provide
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