Medicine and Surgery Section - Wisconsin.gov

More documents

Recommendations

Info

DEPARTMENT OF HEALTH AND FAMILY SERVICES STATE OF WISCONSIN Division of Health Care Financing HFS 105.02(1), Wis. Admin. Code HCF 1182 (Rev. 09/02) WISCONSIN MEDICAID DECLARATION OF SUPERVISION FOR NONBILLING PROVIDERS SECTION I — NONBILLING PROVIDER INFORMATION Name and Credentials — Nonbilling Provider Address — Nonbilling Provider Wisconsin Medicaid Provider Number Telephone Number — Nonbilling Provider I, , direct Wisconsin Medicaid to make checks payable to (Name — Provider) (Name — Clinic or Supervisor) under Wisconsin Medicaid since Wisconsin Medicaid cannot reimburse me. for all claims payments for services performed by me I understand that this payment arrangement will continue in effect until Wisconsin Medicaid receives a new Declaration of Supervision for Nonbilling Providers form from me. When my supervisor, employer, or work address changes, I will immediately send this completed form to Wisconsin Medicaid. SIGNATURE — Nonbilling Provider (required) SECTION II — SUPERVISOR INFORMATION Name — Supervisor Address — Supervisor Date Signed (required) Wisconsin Medicaid Provider Number Internal Revenue Service (IRS) Number — Employer Telephone Number — Supervisor I, , am supervising the work of . (Name — Supervisor) (Name — Provider) I began supervising the previously listed nonbilling provider on . I hereby acknowledge and (Supervisor’s Effective Starting Date) agree to the above payment arrangement. I understand that if my name is indicated in Section I above, Wisconsin Medicaid payment for services provided by the nonbilling provider will be payable to me directly and will be reported under the IRS number written above. If I discontinue supervision of the nonbilling provider, I understand that I must notify Wisconsin Medicaid at the address at the bottom of this page. SIGNATURE — Supervisor Mail to: Wisconsin Medicaid Provider Maintenance 6406 Bridge Rd Madison WI 53784-0006 For more information, contact Provider Services at (800) 947-9627 or (608) 221-9883. Date Signed
Appendix 32 Diagnosis-Restricted Provider-Administered Drugs The following table contains diagnosis-restricted provider-administered drugs and the corresponding diagnosis code and disease descriptions. When a provider-administered drug claim is submitted with a diagnosis listed in this appendix, prior authorization (PA) is not required. For uses outside the listed diagnosis, PA is required. Peer-reviewed medical literature from scientific medical or pharmaceutical publications in which original manuscripts are rejected or published only after having been reviewed by unbiased independent experts to support the proven efficacy of the requested use of the drug is also required to be submitted with the PA request. Note: This table includes Wisconsin Medicaid’s most current information and may be updated periodically. HCPCS Code* Drug Name Diagnosis Code Disease Description J0205 Alglucerase (Ceredase) 2727 Gaucher’s Disease 3336 Idiopathic dystonia 3337 Symptomatic torsion dystonia 33381 Blepharospasm 33383 Spasmodic torticollis 33384 Focal hand dystonia 34211 Spastic hemiplegia and hemiparesis affecting dominant side 34212 Spastic hemiplegia and hemiparesis affecting nondominant side J0585 Botulinum Toxin Type A (Botox) 3440-34404, 34409 Quadriplegia 3441 Paraplegia 340 Multiple Sclerosis 3430-3439 Cerebral palsy 3518 Facial spasm 3780-37887 Strabismus 70521 Hyperhidrosis 72885 Spasm of muscle 7810 Hemifacial spasm J0587 Botulinum Toxin Type B (Myobloc) 33383 Spasmodic torticollis 042, 07953 140-20491, 230- Anemia from Acquired Immune Deficiency Syndrome (AIDS) 2386, 2388- Non-myeloid malignancies or multiple myeloma J0880 and Q4054 Darbepoetin alfa in albumin solution (Aranesp) 2399, 2733 20610 2387, 2849, 2850 Chronic myelomonocytic leukemia Myelodysplastic syndrome 28521 Anemia in end-stage renal disease 28522 Anemia in neoplastic disease 585 Chronic renal failure J1440 Filgrastim (Neupogen), 300 mcg 2880 Agranulocytosis/Neutropenia J1441 Filgrastim (Neupogen), 480 mcg 2880 Agranulocytosis/Neutropenia J1595 Glatiramer acetate (Copaxone) 340 Multiple Sclerosis J1785 Imiglucerase (Cerezyme) 2727 Gaucher’s Disease J1825 Interferon Beta 1A (Avonex) 340 Multiple Sclerosis Continued Physician Services Handbook — Medicine and Surgery December 2005 173 Appendix
Page 1 and 2:
Physician Services Medicine and Sur
Page 3 and 4:
T Table of Contents Preface .......
Page 5 and 6:
Telemedicine ......................
Page 7:
Health Professional Shortage Areas
Page 10 and 11:
Legal Framework The following laws
Page 12 and 13:
General Information Treatment (EPSD
Page 14 and 15:
General Information Category III Co
Page 16 and 17:
General Information collecting the
Page 18 and 19:
General Information • The current
Page 20 and 21:
Evaluation and Management reimburse
Page 22 and 23:
Evaluation and Management in an out
Page 24 and 25:
Evaluation and Management 22 Wiscon
Page 26 and 27:
Medicine Services System [HCPCS] co
Page 28 and 29:
Medicine Services In cases where mo
Page 30 and 31:
Medicine Services documentation in
Page 32 and 33:
Medicine Services Providers of ment
Page 34 and 35:
Medicine Services Substance Abuse S
Page 36 and 37:
Surgery Services Appendix 10 of thi
Page 38 and 39:
Surgery Services Cataract Surgery W
Page 40 and 41:
Surgery Services and the insertion
Page 42 and 43:
Surgery Services Note: A telephone
Page 44 and 45:
Surgery Services • Sterilization.
Page 46 and 47:
Surgery Services live with her sinc
Page 48 and 49:
Surgery Services by a multi-discipl
Page 50 and 51:
Prescription Requirements Prescribe
Page 52 and 53:
Prescription Requirements Approval
Page 54 and 55:
Prescription Requirements prescribe
Page 56 and 57:
Prescription Requirements 54 Wiscon
Page 58 and 59:
Claims Submission adjustment reques
Page 60 and 61:
Claims Submission 58 Wisconsin Medi
Page 62 and 63:
Reimbursement • Confirming or rev
Page 64 and 65:
Reimbursement about whether a speci
Page 66 and 67:
Reimbursement 64 Wisconsin Medicaid
Page 68 and 69:
Appendix 66 Wisconsin Medicaid and
Page 70 and 71:
Appendix Surgery Services Appendix
Page 72 and 73:
Appendix Medicine Services (Continu
Page 74 and 75:
Appendix Other Services Appendix 1
Page 76 and 77:
Page 78 and 79:
Page 80 and 81:
Appendix Appendix 4 (Continued) If
Page 82 and 83:
Appendix Appendix 4 (Continued) Ele
Page 84 and 85:
Appendix Appendix 4 (Continued) Ele
Page 86 and 87:
Page 88 and 89:
Page 90 and 91:
Page 92 and 93:
Page 94 and 95:
Page 96 and 97:
Appendix (This page was intentional
Page 98 and 99:
ABORTION CERTIFICATION STATEMENTS P
Page 100 and 101:
Page 102 and 103:
STERILIZATION INFORMED CONSENT FORM
Page 104 and 105:
DEPARTMENT OF HEALTH AND FAMILY SER
Page 106 and 107:
Page 108 and 109:
Page 110 and 111:
Page 112 and 113:
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 124 and 125: Appendix 122 Wisconsin Medicaid and
Page 128 and 129: Appendix (This page was intentional
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 150 and 151: DEPARTMENT OF HEALTH AND FAMILY SER
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
show all

Medicine and Surgery Section - Wisconsin.gov

Create successful ePaper yourself

Delete template?

Save as template?