Medicine and Surgery Section - Wisconsin.gov

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Appendix (This page was intentionally left blank.) 140 Wisconsin Medicaid and BadgerCare dhfs.wisconsin.gov/medicaid/ December 2005
DEPARTMENT OF HEALTH AND FAMILY SERVICES STATE OF WISCONSIN Division of Health Care Financing HCF 11034 (Rev. 06/03) WISCONSIN MEDICAID PRIOR AUTHORIZATION / “J” CODE ATTACHMENT (PA/JCA) Providers may submit prior authorization (PA) requests by fax to Wisconsin Medicaid at (608) 221-8616 or by mail to: Wisconsin Medicaid, Prior Authorization, Suite 88, 6406 Bridge Road, Madison, WI 53784-0088. Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/"J" Code Attachment (PA/JCA) Completion Instructions, HCF 11034A. SECTION I — RECIPIENT INFORMATION 1. Name — Recipient (Last, First, Middle Initial) 2. Date of Birth — Recipient 3. Recipient Medicaid Identification Number SECTION II — DRUG ORDER INFORMATION 4. Drug Name 5. Strength 6. National Drug Code 7. HCPCS “J” Code 8. Quantity Ordered 9. Date Order Issued 10. Daily Dose 11. Name — Prescriber 12. Drug Enforcement Agency Number 13. “Brand Medically Necessary” SECTION III — CLINICAL INFORMATION 14. Diagnosis 15. Changes to Previous Prior Authorization (If Applicable) # Yes # No Continued
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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 92 and 93: Appendix 90 Wisconsin Medicaid and
Page 96 and 97: Appendix (This page was intentional
Page 98 and 99: ABORTION CERTIFICATION STATEMENTS P
Page 102 and 103: STERILIZATION INFORMED CONSENT FORM
Page 104 and 105: DEPARTMENT OF HEALTH AND FAMILY SER
Page 114 and 115: Appendix Appendix 15 (Continued) Pe
Page 116 and 117: Appendix Category Musculoskeletal S
Page 118 and 119: Appendix Category Musculoskeletal S
Page 120 and 121: Appendix Category Female Genital Sy
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
Page 140 and 141: PRIOR AUTHORIZATION / “J” CODE
Page 144 and 145: PRIOR AUTHORIZATION / “J” CODE
Page 148 and 149: PRIOR AUTHORIZATION / PHYSICIAN OTO
Page 152 and 153: Appendix Health Professional Shorta
Page 154 and 155: Appendix HPSA Name County ZIP Codes
Page 158 and 159: Appendix Appendix 26 (Continued) ma
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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