Medicine and Surgery Section - Wisconsin.gov

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PRIOR AUTHORIZATION / PHYSICIAN OTOLOGICAL REPORT (PA/POR) COMPLETION INSTRUCTIONS Page 2 of 2 HCF 11019A (Rev. 06/03) Element 11 — Pertinent Otological Findings Enter an “X” in the appropriate box(es) and describe all problems. Element 12 — Describe Additional Findings Describe any additional findings not covered in Element 11. Element 13 — Clinical Diagnosis of Hearing Status Enter the diagnosis of the recipient’s hearing status. Element 14 — Medical, Cognitive, or Developmental Problems Describe any medical, cognitive, or developmental problems of the recipient. Element 15 — Physician’s Recommendations Check the appropriate box(es) to indicate the physician’s recommendations. Signature — Physician and Date Signed The requesting physician must sign the form and enter the date the request is made.
Appendix 24 Prior Authorization / Physician Otological Report (PA/POR) (for photocopying) (A copy of the Physician Otological Report (PA/POR) (for photocopying) is located on the following page.) Physician Services Handbook — Medicine and Surgery December 2005 147 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 (This page was intentional
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Page 102 and 103: STERILIZATION INFORMED CONSENT FORM
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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
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Page 140 and 141: PRIOR AUTHORIZATION / “J” CODE
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Page 152 and 153: Appendix Health Professional Shorta
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Page 160 and 161: Appendix The following table lists
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Page 176 and 177: Appendix HCPCS Code* Drug Name Diag
Page 178: Index Organ Transplants, 44 Provide
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Medicine and Surgery Section - Wisconsin.gov

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