Medicine and Surgery Section - Wisconsin.gov

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PRIOR AUTHORIZATION / “J” CODE ATTACHMENT (PA/JCA) Page 2 of 2 HCF 11034 (Rev. 06/03) SECTION III — CLINICAL INFORMATION (Continued) 16. Use (Check One) ! Compendium standards, such as the USP-DI or drug package insert, list the intended use identified in Element 14 as an accepted or a [bracketed] indication. ! The intended use identified in Element 14 is not listed in compendium standards. Peer reviewed clinical literature is attached. 17. Dose (Check One) ! The daily dose and duration are within compendium standards of general prescribing or dosing limits for the indicated use. ! The daily dose and duration are not within compendium standards of general prescribing or dosing limits for the intended use. Attach peer-reviewed literature that indicates this dose is appropriate or document the medical necessity of this dosing difference. 18. SIGNATURE — Prescriber 19. Date Signed Notify me of approval / denial by one of the following: ! Fax — Fax Number — ___________________________________________________________________________ ! Telephone — Telephone Number — ________________________________________________________________ ! No special notice needed.
Appendix 23 Prior Authorization / Physician Otological Report (PA/POR) Completion Instructions (A copy of the Prior Authorization/Physician Otological Report [PA/POR] Completion Instructions is located on the following pages.) Physician Services Handbook — Medicine and Surgery December 2005 143 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 94 and 95: Appendix 92 Wisconsin Medicaid and
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Page 176 and 177: Appendix HCPCS Code* Drug Name Diag
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Medicine and Surgery Section - Wisconsin.gov

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