New Prior Authorization Requirements for Advanced Imaging Services

ased on current ForwardHealth policy can continue torender these services.Submitting Prior Authorization RequestsProviders may submit PA requests using any of the followingmethods: MedSolutions Portal at www.medsolutionsonline.com/ at anytime. Providers are required to establish an accountprior to submitting PA requests using the MedSolutionsPortal. The MedSolutions Portal offers the mostconvenient method of submitting PA and allowsproviders to easily submit multiple PA requests.Providers are frequently able to obtain instant PAapproval when using the MedSolutions Portal. Telephone at (888) 693-3211, Monday through Friday(excluding holidays) from 7:00 a.m. to 8:00 p.m. CentralTime. MedSolutions is frequently able to make a PAdetermination during the telephone call. Fax at (888) 693-3210 at any time. Providers arerequired to use MedSolutions forms to submit PArequests via fax. Faxes received of any other forms willbe returned to the provider unprocessed. MedSolutionsforms are available through the MedSolutions Portal orby calling MedSolutions at (888) 693-3211.MedSolutions is open Monday through Friday, 7:00 a.m. to8:00 p.m. Central Time. MedSolutions will process PArequests received after hours on the next business day.Information Required When RequestingPrior AuthorizationProviders should have the following member and clinicalinformation on hand when submitting a PA request toMedSolutions on the MedSolutions Portal, on the telephone,or via fax: Member’s full name, date of birth, and address. Member’s ForwardHealth member identificationnumber. Member’s working or differential diagnosis. Prior tests, lab work, and/or imaging performed relatedto the member’s diagnosis.Type and duration of treatment performed to date forthe diagnosis.Requested imaging service (e.g., “MRI of the brain”) orrequested procedure code if known. Providers shouldnote that PA requests for advanced imaging services donot require modifiers even if the procedure code isbilled with a modifier.A Medicaid-certified rendering facility. Providers shouldnote that members may choose a different Medicaidcertifiedrendering facility than the one submitted toMedSolutions with the PA request. Amendments to thePA request are not required for a change in therendering facility.Having complete member and clinical information ready willexpedite the PA determination process.Prior Authorization Requests withInsufficient Clinical DataIf the provider submits a PA request with insufficient clinicaldata, MedSolutions will take the following actions: Suspend the PA request without adjudication. Contact the provider via fax up to three times over aperiod of five business days to request the additionalinformation.If the provider does not respond within 30 calendar days,MedSolutions will adjudicate the request based on allavailable information.Prior Authorization Requests for MedicallyUrgent SituationsMedSolutions defines a PA request for a medically urgentsituation as any request for medical care or treatment withrespect to which the application of the time periods formaking non-urgent care determinations could have thefollowing impact: Seriously jeopardize the life or health of the member orthe member's ability to regain maximum function, basedon a prudent layperson's judgment. In the opinion of a practitioner with knowledge of themember's medical condition, would subject the memberForwardHealth Provider Information • October 2010 • No. 2010-92 4

to severe pain that cannot be adequately managedwithout the care or treatment that is the subject of therequest.Requesting Prior Authorization Before Rendering theServiceFor medically urgent situations, providers are encouraged toobtain PA prior to rendering the service when possible.Providers are required to call MedSolutions at (888) 693-3211 to obtain PA for urgent situations in cases where theservice has not yet been rendered. MedSolutions will make aPA decision within 72 hours of receipt of all necessaryinformation when the PA request is for an urgent situation.Providers should indicate clearly that the PA is for amedically urgent situation.Note: MedSolutions does not accept PA requests viaMedSolutions Portal or fax for medically urgent situations incases where the service has not yet been rendered.Requesting Prior Authorization After Rendering theServiceAlthough providers are encouraged to obtain PA formedically urgent situations prior to rendering the servicewhen possible, MedSolutions will allow backdating for PArequests for advanced imaging services for medically urgentsituations. Backdating for an urgent situation is allowed up toand including 14 calendar days after the service has beenrendered.A request for backdating may be approved if all of thefollowing conditions are met: The provider specifically requests backdating in the PArequest. The request includes clinical justification for beginningthe service before PA was granted. The request is received by MedSolutions within 14calendar days of the DOS. The request is submitted via telephone call at(888) 693-3211, via MedSolutions Portal, or via fax. Ifthe provider submits a backdated PA request via fax, heor she is required to clearly indicate the DOS on the PAform.Prior authorization may be denied if the PA request isreceived more than 14 calendar days after the DOS, does notmeet the criteria for medical necessity, or does not meet thecriteria for medically urgent situations. If the PA request isdenied in this case, the provider cannot require paymentfrom the member.Communicating Prior AuthorizationDecisionsMedSolutions notifies the provider who submitted the PArequest by fax whether a PA request is approved, approvedwith modifications, or denied. Providers should note that allPA communication is sent via fax from MedSolutions.Providers will not receive PA communications for PArequests for advanced imaging services in the mail unlessMedSolutions is unable to send a fax (e.g., fax number isdisconnected).The provider who submitted the PA request receives a PAconfirmation fax (in place of the ForwardHealth PA decisionnotice letter) when a PA request is approved. The PAconfirmation fax includes information about the procedurecodes that are approved for the member and the grant(effective) and expiration dates for the PA. Refer toAttachment 2 for a sample PA confirmation fax.The provider who submitted the PA request receives a PAdecision notice letter via fax when a PA request is denied.Prior authorization decision notice letters will be sent via fax.Refer to Attachment 3 for a sample PA decision notice letter.The provider who submitted the PA request receives a PAdecision notice letter when a PA request is approved withmodifications. The PA decision notice letter includesinformation on both the approved and denied procedures.Ordering providers are strongly encouraged to contact theprovider who is rendering the service with information aboutthe PA determination. The provider who renders the serviceForwardHealth Provider Information • October 2010 • No. 2010-92 5

is strongly encouraged to verify which services andprocedure codes are authorized for the member by using theMedSolutions Portal or by contacting the ordering providerprior to rendering services.The provider who renders the service will not automaticallyreceive separate notification from MedSolutions regardingPA approvals, modifications, or denials, except in caseswhere the provider who renders the service submitted theoriginal PA request.Prior Authorization NumbersMedSolutions assigns a PA number to each PA request. ThePA number consists of 10 digits, containing valuableinformation about the PA (e.g., the date the PA request wasreceived by MedSolutions). Refer to Attachment 4 forinformation about interpreting PA numbers.Prior Authorization Grant and ExpirationDatesGrant DateThe grant date (also known as the start or effective date) ofan approved PA request is the first date for which theapproved services are prior authorized and may bereimbursed. The grant date for PA requests for advancedimaging services is determined by the date that MedSolutionsenters the PA request into their system. The grant date isusually the date that the provider submitted the PA requestunless the PA request is received after normal businesshours. The PA confirmation fax will indicate the grant oreffective date of the PA.Expiration DateThe expiration date (also known as the end date) of anapproved PA request is the date through which the approvedservices are prior authorized. Prior authorization requestsapproved by MedSolutions are valid for 60 calendar daysfrom the grant date. MedSolutions will not grant requests toextend the authorization period. To extend a PAauthorization period, providers are required to submit a newPA request.Prior Authorization Adjudication ProcessMedSolutions will make a decision regarding a provider’s PArequest within 20 business days of the receipt of all thenecessary information; however, MedSolutions is frequentlyable to make a PA determination immediately. IfMedSolutions is unable to immediately approve a PArequest, the PA request will be elevated to a nurse consultantfor additional review. If the nurse consultant is unable toapprove the PA request, the PA request will be elevated to aphysician consultant. Only a physician consultant can deny aPA request based on his or her determination that therequest does not meet clinical guidelines.Approved Prior Authorization RequestsPrior authorization requests are approved for a period of 60calendar days from the grant date. The provider whosubmitted the PA request receives a copy of a PAconfirmation fax (in place of the ForwardHealth PA decisionnotice letter) when a PA request for a service is approved.Ordering providers are encouraged to share the informationon the PA confirmation fax with the provider who rendersthe service. Providers may render the approved servicesbeginning on the grant date.The PA confirmation fax identifies the specific procedurecodes that are approved. The provider who renders theservice may substitute and perform a service defined by adifferent procedure code without contacting MedSolutionsonly when the substituted procedure code is considered a“downcode,” as in the following situations: The provider renders a service without contrast whenthe approved service included contrast or included scansboth with and without contrast. The provider renders a service with contrast when theapproved service included scans both with and withoutcontrast.For example, if the PA confirmation fax authorizesprocedure code 70470 (Computed tomography, head orbrain; without contrast material, followed by contrastmaterial[s] and further sections), the provider rendering theservice may substitute and render procedure code 70450ForwardHealth Provider Information • October 2010 • No. 2010-92 6

(Computed tomography, head or brain; without contrastmaterial) or 70460 (Computed tomography, head or brain;with contrast material[s]). This would be considered“downcoding.”Providers should refer to Attachment 1 for a list of allowabledowncodes for each advanced imaging service that requiresPA.If other changes in procedure codes are necessary, such as an“upcode” or change in imaging modality, the provider whorenders the service is required to contact MedSolutions toamend the PA request. Providers should be aware that PAamendments require approval from MedSolutions. Providersare strongly encouraged to obtain approval for a PAamendment prior to rendering services when possible.Providers are encouraged to review approved PA requestsbefore rendering the service to confirm the procedurecode(s) authorized and confirm the assigned grant andexpiration dates.Prior Authorization Requests Approvedwith ModificationsModification is a change in the services originally requestedon a PA request. Modifications include a partial approval(part of the service is approved and part of the service isdenied) or the authorization of a procedure code(s) differentthan the one(s) originally requested. Prior to modifying thePA request to authorize a different procedure code,MedSolutions contacts the provider who submitted the PArequest by telephone. The provider must agree to the changein procedure code before the PA request can be approved. Ifthe provider does not agree to the change, the PA request isdenied.When a PA request is modified, both the provider whosubmitted the PA request and the member are notified. Theprovider will be sent a PA decision notice letter via fax thatincludes information on both the approved and deniedprocedures and the reason the PA was modified. Orderingproviders are encouraged to share the information on the PAdecision notice letter with the provider who renders theservice. The member receives a Notice of Appeal Rightsletter that includes a brief statement of the reason the PAwas modified and information on his or her right to a fairhearing. Only the member, or authorized person acting on behalf ofthe member, can appeal the modification.Providers may call MedSolutions for clarification of why aPA request was modified.The provider who requested the PA is required to discusswith the member the reason a PA request was modified andis encouraged to help the member understand the reason thePA request was modified.Providers have the following options when a PA request isapproved with modification: The provider who submitted the PA request maycontact MedSolutions and request a reconsideration forthe denied service(s). (This is only an option for PArequests for advanced imaging services and not forother services that require PA under ForwardHealthpolicy.) The provider who renders the service may provide theservice as authorized. The provider who was to render the service may chooseto not provide the service. The provider who renders the service may provide theservice as originally requested as a noncovered service.If the member does not appeal the decision to modify thePA request or appeals the decision but the decision tomodify the PA request is upheld, the member may choose toreceive the service(s) originally requested as a noncoveredservice and be responsible for payment.Denied Prior Authorization RequestsWhen a PA request is denied, both the provider whosubmitted the PA request and the member are notified. Theprovider receives a PA decision notice letter via fax thatincludes the reason for PA denial. The member receives aNotice of Appeal Rights letter that includes a brief statementof the reason PA was denied and information about his orForwardHealth Provider Information • October 2010 • No. 2010-92 7

her right to a fair hearing. Only the member, or authorized personacting on behalf of the member, can appeal the denial.Providers may call MedSolutions for clarification of why aPA request was denied.The provider who requested the PA is required to discuss adenied PA request with the member and is encouraged tohelp the member understand the reason the PA request wasdenied.Providers have the following options when a PA request isdenied: The provider who submitted the PA request maycontact MedSolutions and request a reconsideration forthe denied service(s). (This is only an option for PArequests for advanced imaging services and not forother services that require PA under ForwardHealthpolicy.) The ordering provider or the provider who is to renderthe service may submit a new PA request. The provider who was to render the service may chooseto not provide the service. The provider who renders the service may provide theservice as a noncovered service.The reconsideration must be requested within 14 calendardays of the PA denial or modification. Reconsiderationsrequested beyond 14 calendar days will not be processed. Torequest a reconsideration of a denied or modified PArequest, providers should follow these steps: Call MedSolutions at (888) 693-3211. MedSolutions schedules a telephone conversation (a“peer-to-peer review”) with either the MedSolutionsphysician consultant on duty or the physician consultantwho made the PA determination. The provider shouldspecify if he or she wants to talk to the physicianconsultant who made the PA determination. During the peer-to-peer review, the MedSolutionsphysician consultant may either reverse the decisionbased on additional clinical information and approve thePA request or uphold the original decision to deny ormodify the PA request.When a PA request is approved after reconsideration, theprovider who submitted the PA request receives a PAconfirmation fax. Ordering providers are encouraged toshare the information on the PA confirmation fax with theprovider who will render the service. It is the responsibilityof the provider who submitted the PA request to notify themember if a PA request is approved after reconsideration.If the member does not appeal the decision to deny the PArequest or appeals the decision but the decision to deny thePA request is upheld, the member may choose to receive theoriginally requested service(s) as a noncovered service and tobe responsible for payment.Reconsideration RequestsThe provider who submitted the PA request may contactMedSolutions to request a reconsideration of a denied ormodified PA request for advanced imaging services.Reconsideration is an informal review of the denied ormodified services conducted by a MedSolutions physicianconsultant. Providers should note that reconsideration is notan appeal. Only a member may appeal a PA determinationafter a PA request has been denied or modified.Amendments to Approved PriorAuthorization RequestsThe provider rendering the service is required to contactMedSolutions to amend an approved PA request if, based onhis or her medical judgment, it is more appropriate to rendera different or more involved service than the one originallyapproved. Providers are strongly encouraged to request a PAamendment prior to rendering services when possible.Prior authorization amendments will be required in thefollowing circumstances: The provider renders a service with contrast when theapproved service did not include contrast (i.e.,“upcodes”). For example, the provider renders a serviceindicated by procedure code 70460 (Computedtomography, head or brain; with contrast material[s])ForwardHealth Provider Information • October 2010 • No. 2010-92 8

when the PA confirmation fax authorized procedurecode 70450 (Computed tomography, head or brain;without contrast material).The provider renders a service with scans both with andwithout contrast when the approved services did notinclude contrast or only included scans with contrast(i.e., “upcodes”). For example, the provider renders aservice indicated by procedure code 70470 (Computedtomography, head or brain; without contrast material,followed by contrast material[s] and further sections)when the PA confirmation fax authorized procedurecode 70450 (Computed tomography, head or brain;without contrast material) or 70460 (Computedtomography, head or brain; with contrast material[s]).The provider images a different body part thanoriginally approved. For example, the PA confirmationfax authorized procedure code 72192 (Computedtomography, pelvis; without contrast material) but theprovider renders a service indicated by procedure code72131 (Computed tomography, lumbar spine; withoutcontrast material).The provider uses a different imaging modality thanoriginally approved. For example, the PA confirmationfax authorized procedure code 70450 (Computedtomography, head or brain; without contrast material)but the provider renders a service indicated byprocedure code 70551 (Magnetic resonance [eg, proton]imaging, brain [including brain stem]; without contrastmaterial).MedSolutions will make a decision regarding a provider’samendment request within 20 business days from the receiptof all necessary information.The provider who submitted the PA amendment requestshould request a copy of the PA notification and provide avalid fax number to MedSolutions After adjudicating the PAamendment request, MedSolutions will notify the providerby fax whether the PA amendment request was approved,approved with modifications, or denied.Appealing Prior Authorization DecisionsIf a PA request is denied or modified by MedSolutions, onlya member, or authorized person acting on behalf of themember, may file an appeal with the Division of Hearingsand Appeals (DHA). Decisions that may be appealed includedenial or modification of a PA request.The member is required to file an appeal within 45 days ofthe date of the Notice of Appeal Rights letter.To file an appeal, members may complete and submit aRequest for Fair Hearing form, DHA-28 (08/09).Though providers cannot file an appeal, they are encouragedto remain in contact with the member during the appealprocess. Providers may offer the member informationnecessary to file an appeal and help present his or her caseduring a fair hearing.The provider rendering the service is not required to contactMedSolutions to “downcode” an approved service.Providers have up to 14 calendar days after the DOS toamend an approved PA request. Amendment requests aresubject to additional medical review and may be denied if thePA amendment request is not deemed medically necessary. Ifthe amendment request is denied in this case, the providercannot request payment from the member since the memberwas not notified in advance that the service was noncovered.Fair Hearing Upholds ForwardHealth’sDecisionIf the hearing decision upholds the decision to deny ormodify a PA request, the DHA notifies the member andForwardHealth in writing. The member may choose toreceive the denied service (or in the case of a modified PArequest, the originally requested service) as a noncoveredservice, not receive the service at all, or appeal the decision.If the member chooses to receive noncovered services, themember is responsible for payment of the services.ForwardHealth Provider Information • October 2010 • No. 2010-92 9

Fair Hearing Overturns ForwardHealth’sDecisionIf the hearing decision overturns the decision to deny ormodify the PA request, the DHA notifies ForwardHealthand the member. The letter includes instructions for theprovider and for ForwardHealth.If the DHA letter instructs the provider to submit a claim forthe service, the provider should submit the following toForwardHealth after the service(s) has been performed: A paper claim with "HEARING DECISIONATTACHED" written in red ink at the top of the claim. A copy of the hearing decision. A copy of the denied PA request.Providers are required to submit claims with hearingdecisions to the following address:ForwardHealthSpecialized ResearchSte 506406 Bridge RdMadison WI 53784-0050Claims with hearing decisions sent to any other address maynot be processed appropriately.If the DHA letter instructs the provider to submit a new PArequest, the provider is required to submit the new PArequest to MedSolutions via fax with a copy of the hearingdecision. Providers should clearly indicate that the PArequest is for a fair hearing decision and should indicate therequested authorization date. If the service has already beenperformed, the requested authorization date should be theDOS. If the service has not been performed, the requestedauthorization date should be the earliest date that the servicemay be performed. MedSolutions does not accept PArequests for overturned hearing decisions via telephone orMedSolutions Portal.MedSolutions will then approve the PA request for theoverturned hearing decision. When a PA request is approvedafter an appeal, the provider who submitted the PA requestreceives a PA confirmation fax. Ordering providers areencouraged to share the information on the PA confirmationfax with the provider who rendered or will render theservice. The provider rendering the service may then submita claim following the usual claims submission proceduresafter providing the service(s).Submitting Claims for Advanced ImagingServicesClaims for advanced imaging services should be submitted toForwardHealth using normal procedures and claimcompletion instructions. Providers should always wait twofull business days from the date on which MedSolutionsapproved the PA request before submitting a claim for anadvanced imaging service that requires PA. This will ensurethat ForwardHealth has the PA on file when the claim isreceived.Procedure codes for advanced imaging services that requirePA and do not have a valid PA on file will deny on bothprofessional and institutional claims. Providers who submitinstitutional claims are reminded that effective for dates ofreceipt on and after July 1, 2010, institutional claims requireprocedure codes with revenue codes. Institutional claimssubmitted for advanced imaging services without aprocedure code will be denied. Refer to the March 2010Update (2010-22), titled “ForwardHealth Now RequiringOutpatient Hospitals to Include HCPCS or CPT Codes withMost Revenue Codes on Claims,” and the July 2010 Update(2010-59), titled “Additional Revenue Codes Exempt fromRequirement to Include HCPCS or CPT Codes onOutpatient Hospital Claims,” for more information.Billing for Technical and ProfessionalComponentsOnly one approved PA is required for both the technical andprofessional components of the service, even when billed bydifferent providers. Providers should continue to submitclaims for advanced imaging services with the appropriatemodifier for the technical and professional component,when applicable.ForwardHealth Provider Information • October 2010 • No. 2010-92 10

Claims for Medicare Dual EligiblesCrossover claims for members who are also enrolled inMedicare (dual eligibles) are not subject to PA requirements;however, if Medicare denies the service or does not cover theservice and the provider bills the service on a straightMedicaid claim, the provider is required to have obtained PAin order for the procedure code to be reimbursable.Submitting Claims for Advanced ImagingServices That Do Not Require PriorAuthorizationIn the following situations, PA is not required for advancedimaging services: The service is provided during a member’s inpatienthospital stay. The service is provided when a member is inobservation status at a hospital. The service is provided as part of an emergency roomvisit. The service is provided as an emergency service.Service Provided During an Inpatient StayAdvanced imaging services provided during a member’sinpatient hospital stay are exempt from PA requirements.Institutional claims for advanced imaging services providedduring a member’s inpatient hospital stay are automaticallyexempt from PA requirements. Providers submitting aprofessional claim for advanced imaging services providedduring a member’s inpatient hospital stay should indicateplace of service (POS) code “21” (“Inpatient Hospital”) onthe claim.Service Provided for Observation StatusAdvanced imaging services provided when a member is inobservation status at a hospital are exempt from PArequirements.Providers using a paper institutional claim form shouldinclude modifier “UA” in Form Locator 44(HCPCS/Rate/HIPPS Code) with the procedure code forthe advanced imaging service. To indicate a modifier on aninstitutional claim, enter the appropriate five-digit procedurecode in Form Locator 44, followed by the two-digit modifier.Providers submitting claims electronically using the 837Health Care Claim: Institutional (837I) should refer to theappropriate companion document for instructions onincluding a modifier.Providers using a professional claim form should indicatemodifier “UA” with the advanced imaging procedure code.Service Provided as Part of Emergency Room VisitAdvanced imaging services provided as part of an emergencyroom visit are exempt from the PA requirements.Providers using an institutional claim form should includemodifier “UA” in Form Locator 44 with the procedure codefor the advanced imaging service. Providers submittingclaims electronically using the 837I should refer to theappropriate companion document for instructions onincluding a modifier.Providers using a professional claim form should indicatePOS code “23” (“Emergency Room—Hospital”) on theclaim.Service Provided as Emergency ServiceAdvanced imaging services provided as emergency servicesare exempt from the PA requirements.Providers using an institutional claim form should includemodifier “UA” in Form Locator 44 with the procedure codefor the advanced imaging service. Providers submittingclaims electronically using the 837I should refer to theappropriate companion document for instructions onincluding a modifier.Providers using a professional claim form should submit aclaim with an emergency indicator.Training Sessions AvailableIn November and December 2010, MedSolutions andForwardHealth will be conducting Web-based orientationForwardHealth Provider Information • October 2010 • No. 2010-92 11

training sessions for providers on PA procedures foradvanced imaging services. All attendees are required toregister prior to attending any of the scheduled trainingsessions; however, there is not a fee for attending. Separateregistration is required for each training.The following topics will be covered in the training sessions: Prior authorization requirements for advanced imagingservices. Using the MedSolutions Portal to submit PA requests. Types of services and procedure codes requiring PA. Members for whom PA is required.Refer to Attachment 5 for specific training session dates andtimes. The same information will be covered at all of thesessions.Training RegistrationProviders are required to register online or by telephoneprior to attending any of the scheduled training sessions.Providers with Internet access are strongly encouraged to useonline registration.Online RegistrationProviders may register online using the following steps: Go to the MedSolutions Portal at medsolutions.webex.com/. Click on the “Training Center” tab at the top of thepage. Click on the “Upcoming” tab and select the date andtime of the training session the provider plans to attend.Training sessions for Wisconsin Medicaid are titled“Wisconsin Medicaid Provider Orientation Session.” Click “Register.” Enter all required registration information.After registering for a training session, the provider willreceive an e-mail containing the following information: The toll-free telephone number and passcode neededfor the audio portion of the training session. A link to the Web-based portion of the training session. The password for the training session.Providers should keep the registration e-mail because thetelephone number, Web address, and password are neededto participate in the training session.Telephone RegistrationProviders who do not have Internet access can register bycalling MedSolutions at (615) 468-4029 or by e-mailingMedSolutions at andrew.cline@medsolutions.com. The providerwill be given the following information: The toll-free telephone number and passcode neededfor the audio portion of the training session. A link to the Web-based portion of the training session. The password for the training session.Providers should write down this information because thetelephone number, Web address, and password are neededto participate in the training session.Questions Regarding RegistrationProviders who have questions about registration or areunable to attend a training session for which registration hasbeen confirmed should call MedSolutions at (615) 468-4029.Training Session PowerPointProviders who are unable to participate in any of the trainingsessions may request a copy of the presentation by e-mailingMedSolutions at andrew.cline@medsolutions.com. MedSolutionswill e-mail a copy of the Microsoft® PowerPoint of thetraining session in Portable Document Format (PDF).Information Regarding Managed CareOrganizationsThis Update contains fee-for-service policy and applies toadvanced imaging services members receive on a fee-forservicebasis only. For policy regarding advanced imagingservices covered by an MCO, contact the appropriate MCO.Managed care organizations are required to provide at leastthe same benefits as those provided under fee-for-servicearrangements.ForwardHealth Provider Information • October 2010 • No. 2010-92 12

The ForwardHealth Update is the first source of programpolicy and billing information for providers.Wisconsin Medicaid, BadgerCare Plus, SeniorCare, andWisconsin Chronic Disease Program are administered bythe Division of Health Care Access and Accountability,Wisconsin Department of Health Services (DHS). TheWisconsin Well Woman Program is administered by theDivision of Public Health, Wisconsin DHS.For questions, call Provider Services at (800) 947-9627or visit our Web site at www.forwardhealth.wi.gov/.P-1250ForwardHealth Provider Information • October 2010 • No. 2010-92 13

Computed Tomographic Imaging Procedure Codes Requiring Prior Authorization (Continued)ProcedureCodeDescription71275 Computed tomographic angiography, chest (noncoronary), with contrastmaterial(s), including noncontrast images, if performed, and imagepostprocessing72125 Computed tomography, cervical spine; without contrast material N/A72126 with contrast material 7212572127 without contrast material, followed by contrast material(s) and furthersections72128 Computed tomography, thoracic spine; without contrast material N/A72129 with contrast material 7212872130 without contrast material, followed by contrast material(s) and furthersections72131 Computed tomography, lumbar spine; without contrast material N/A72132 with contrast material 7213172133 without contrast material, followed by contrast material(s) and furthersections72191 Computed tomographic angiography, pelvis, with contrast material(s),including noncontrast images, if performed, and image postprocessing72192 Computed tomography, pelvis; without contrast material N/A72193 with contrast material(s) 7219272194 without contrast material, followed by contrast material(s) and furthersections73200 Computed tomography, upper extremity; without contrast material N/A73201 with contrast material(s) 7320073202 without contrast material, followed by contrast material(s) and furthersections73206 Computed tomographic angiography, upper extremity, with contrastmaterial(s), including noncontrast images, if performed, and imagepostprocessing73700 Computed tomography, lower extremity; without contrast material N/A73701 with contrast material(s) 7370073702 without contrast material, followed by contrast material(s) and furthersections73706 Computed tomographic angiography, lower extremity, with contrastmaterial(s), including noncontrast images, if performed, and imagepostprocessingAllowableProcedure Codesfor Downcoding*N/A72125, 7212672128, 7212972131, 72132N/A72192, 7219373200, 73201N/A73700, 73701N/AForwardHealth Provider Information • October 2010 • No. 2010-92 15

Computed Tomographic Imaging Procedure Codes Requiring Prior Authorization (Continued)ProcedureCodeDescription74150 Computed tomography, abdomen; without contrast material N/A74160 with contrast material(s) 7415074170 without contrast material, followed by contrast material(s) andfurther sections74175 Computed tomographic angiography, abdomen, with contrastmaterial(s), including noncontrast images, if performed, and imagepostprocessing74261 Computed tomographic (CT) colonography, diagnostic, includingimage postprocessing; without contrast material74262 with contrast material(s) including non-contrast images, ifperformed74263 Computed tomographic (CT) colonography, screening, includingimage postprocessing75571 Computed tomography, heart, without contrast material, withquantitative evaluation of coronary calcium75572 Computed tomography, heart, with contrast material, for evaluationof cardiac structure and morphology (including 3D imagepostprocessing, assessment of cardiac function, and evaluation ofvenous structures, if performed)75573 Computed tomography, heart, with contrast material, for evaluationof cardiac structure and morphology in the setting of congenitalheart disease (including 3D image postprocessing, assessment of LVcardiac function, RV structure and function and evaluation of venousstructures, if performed)75574 Computed tomographic angiography, heart, coronary arteries andbypass grafts (when present), with contrast material, including 3Dimage post processing (including evaluation of cardiac structure andmorphology, assessment of cardiac function, and evaluation ofvenous structures, if performed)75635 Computed tomographic angiography, abdominal aorta and bilateraliliofemoral lower extremity runoff, with contrast material(s), includingnoncontrast images, if performed, and image postprocessingAllowableProcedure Codesfor Downcoding*74150, 74160N/AN/A74261N/AN/AN/AN/AN/AN/AForwardHealth Provider Information • October 2010 • No. 2010-92 16

Computed Tomographic Imaging Procedure Codes Requiring Prior Authorization (Continued)ProcedureCodeDescription76376 3D rendering with interpretation and reporting of computed tomography,magnetic resonance imaging, ultrasound, or other tomographic modality;not requiring image postprocessing on an independent workstation76377 requiring image postprocessing on an independent workstation N/A76380 Computed tomography, limited or localized follow-up study N/A76497 Unlisted computed tomography procedure (eg, diagnostic, interventional) N/A77078 Computed tomography, bone mineral density study, 1 or more sites; axialskeleton (eg, hips, pelvis, spine)77079 appendicular skeleton (peripheral) (eg, radius, wrist, heel) N/AS8092 Electron beam computed tomography (also known as ultrafast CT, cine CT) N/AAllowableProcedure Codesfor Downcoding** If an allowable procedure code for downcoding is substituted for the approved procedure code, providers do not need tocontact MedSolutions to amend the PA request.N/AN/AProcedureCodeMagnetic Resonance Imaging Procedure Codes Requiring Prior AuthorizationDescription70336 Magnetic resonance (eg, proton) imaging, temporomandibular joint(s) N/A70540 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without N/Acontrast material(s)70542 with contrast material(s) 7054070543 without contrast material(s), followed by contrast material(s) and furthersequences70544 Magnetic resonance angiography, head; without contrast material(s) N/A70545 with contrast material(s) 7054470546 without contrast material(s), followed by contrast material(s) and furthersequences70547 Magnetic resonance angiography, neck; without contrast material(s) N/A70548 with contrast material(s) 7054770549 without contrast material(s), followed by contrast material(s) and furthersequences70551 Magnetic resonance (eg, proton) imaging, brain (including brain stem);without contrast material70552 with contrast material(s) 7055170553 without contrast material, followed by contrast material(s) and furthersequencesAllowableProcedure Codesfor Downcoding *70540, 7054270544, 7054570547, 70548N/A70551, 70552ForwardHealth Provider Information • October 2010 • No. 2010-92 17

Magnetic Resonance Imaging Procedure Codes Requiring Prior Authorization (Continued)AllowableProcedureDescriptionProcedure CodesCodefor Downcoding *70554 Magnetic resonance imaging, brain, functional MRI; including testselection and administration of repetitive body part movement and/orvisual stimulation, not requiring physician or psychologist administration70555 requiring physician or psychologist administration of entireneurofunctional testing71550 Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilarand mediastinal lymphadenopathy); without contrast material(s)71551 with contrast material(s) 7155071552 without contrast material(s), followed by contrast material(s) and furthersequences71555 Magnetic resonance angiography, chest (excluding myocardium), with orwithout contrast material(s)72141 Magnetic resonance (eg, proton) imaging, spinal canal and contents,cervical; without contrast material72142 with contrast material(s) 7214172146 Magnetic resonance (eg, proton) imaging, spinal canal and contents,thoracic; without contrast material72147 with contrast material(s) 7214672148 Magnetic resonance (eg, proton) imaging, spinal canal and contents,lumbar; without contrast material72149 with contrast material(s) 7214872156 Magnetic resonance (eg, proton) imaging, spinal canal and contents,without contrast material, followed by contrast material(s) and furthersequences; cervicalN/AN/AN/A71550, 71551N/AN/AN/AN/A72141, 7214272157 thoracic 72146, 7214772158 lumbar 72148, 7214972159 Magnetic resonance angiography, spinal canal and contents, with orwithout contrast material(s)72195 Magnetic resonance (eg, proton) imaging, pelvis; without contrastmaterial(s)72196 with contrast material(s) 7219572197 without contrast material(s), followed by contrast material(s) and furthersequences72198 Magnetic resonance angiography, pelvis, with or without contrastmaterial(s)N/AN/A72195, 72196N/AForwardHealth Provider Information • October 2010 • No. 2010-92 18

Magnetic Resonance Imaging Procedure Codes Requiring Prior Authorization (Continued)AllowableProcedureDescriptionProcedure CodesCodefor Downcoding *73218 Magnetic resonance (eg, proton) imaging, upper extremity, other thanjoint; without contrast material(s)73219 with contrast material(s) 7321873220 without contrast material(s), followed by contrast material(s) and furthersequences73221 Magnetic resonance (eg, proton) imaging, any joint of upper extremity;without contrast material(s)73222 with contrast material(s) 7322173223 without contrast material(s), followed by contrast material(s) and furthersequences73225 Magnetic resonance angiography, upper extremity, with or without contrastmaterial(s)73718 Magnetic resonance (eg, proton) imaging, lower extremity other than joint;without contrast material(s)73719 with contrast material(s) 7371873720 without contrast material(s), followed by contrast material(s) and furthersequences73721 Magnetic resonance (eg, proton) imaging, any joint of lower extremity;without contrast material73722 with contrast material(s) 7372173723 without contrast material(s), followed by contrast material(s) and furthersequences73725 Magnetic resonance angiography, lower extremity, with or without contrastmaterial(s)74181 Magnetic resonance (eg, proton) imaging, abdomen; without contrastmaterial(s)74182 with contrast material(s) 7418174183 without contrast material(s), followed by with contrast material(s) andfurther sequences74185 Magnetic resonance angiography, abdomen, with or without contrastmaterial(s)75557 Cardiac magnetic resonance imaging for morphology and function withoutcontrast material;75559 with stress imaging 7555775561 Cardiac magnetic resonance imaging for morphology and function withoutcontrast material(s), followed by contrast material(s) and further sequences;N/A73218, 73219N/A73221, 73222N/AN/A73718, 73719N/A73721, 73722N/AN/A74181, 74182N/AN/A75557ForwardHealth Provider Information • October 2010 • No. 2010-92 19

Magnetic Resonance Imaging Procedure Codes Requiring Prior Authorization (Continued)AllowableProcedureDescriptionProcedure CodesCodefor Downcoding *75563 with stress imaging 75557, 75559,7556175565 Cardiac magnetic resonance imaging for velocity flow mapping (Listseparately in addition to code for primary procedure)N/A76376 3D rendering with interpretation and reporting of computed tomography,magnetic resonance imaging, ultrasound, or other tomographic modality;not requiring image postprocessing on an independent workstation76377 requiring image postprocessing on an independent workstation N/A76390 Magnetic resonance spectroscopy N/A76498 Unlisted magnetic resonance procedure (eg, diagnostic, interventional) N/A77058 Magnetic resonance imaging, breast, without and/or with contrastmaterial(s); unilateral77059 bilateral N/A77084 Magnetic resonance (eg, proton) imaging, bone marrow blood supply N/AS8035 Magnetic source imaging N/AS8037 Magnetic resonance cholangiopancreatography (MRCP) N/A* If an allowable procedure code for downcoding is substituted for the approved procedure code, providers do not need tocontact MedSolutions to amend the PA request.N/AN/AForwardHealth Provider Information • October 2010 • No. 2010-92 20

Positron Emission Tomographic Imaging Procedure Codes Requiring Prior AuthorizationProcedureCodeDescription78459 Myocardial imaging, positron emission tomography (PET), metabolicevaluation78491 Myocardial imaging, positron emission tomography (PET), perfusion; singlestudy at rest or stress78492 multiple studies at rest and/or stress 7849178608 Brain imaging, positron emission tomography (PET); metabolic evaluation N/A78609 perfusion evaluation N/A78811 Positron emission tomography (PET) imaging; limited area (eg, chest,head/neck)78812 skull base to mid-thigh N/A78813 whole body N/A78814 Positron emission tomography (PET) with concurrently acquired computedtomography (CT) for attenuation correction and anatomical localizationimaging; limited area (eg, chest, head/neck)78815 skull base to mid-thigh N/A78816 whole body N/AAllowableProcedure Codesfor Downcoding ** If an allowable procedure code for downcoding is substituted for the approved procedure code, providers do not need tocontact MedSolutions to amend the PA request.N/AN/AN/AN/AForwardHealth Provider Information • October 2010 • No. 2010-92 21

ATTACHMENT 2Sample Prior Authorization Confirmation Fax(A sample “Prior Authorization Confirmation Fax” is located on the following page.)ForwardHealth Provider Information • October 2010 • No. 2010-92 22

Case ID : 7777777Auth ID: A12121212Status : ApprovedMedSolutions has been recognized for providing "An Outstanding CustomerService Experience" under the esteemed J.D. Power and AssociatesCertified Call Center Program. For J.D. Power and Associates Certified CallCenter Program SM information, visit jdpower.com730 Cool Springs Boulevard, Suite 800, Franklin, TN 37067Fax:888-693-3210/ Phone: 888-693-3211Prior Authorization Confirmation FaxPatient InformationName : DOE, JOHNHP MemberID : 0000000001Address : 123 ANY STREET ANYCITY, ST, 99999Performing Provider InformationAuthorized Facility : ANYNAME RADIOLOGYAddress : 456 ANY STREET, ANYCITY, ST 99999Referring Physician InformationProcedure Requested by: DOE, JANEAddress : 1234 ANY STREET ANYCITY, ST 99999Specialty : GENERAL SURGERYClinical InformationICD9 Procedure784.0 Headache; Other symptoms involving the head or neck.CPT Unit Status Procedure70551 1 Approved MRI Brain or Head; without contrast materialCase Type : PhoneEffective : Mon, Oct 05, 09Expires : Thurs, Dec 03, 09DOB : Dec 20, 1900HealthPlan :Sample Health PlanHealthPlan Id :00000000XXXXPhone : 800/555-1212Fax :HealthPlan Id :Phone : 800/555-1213Fax :MedSolutions is an independent company selected to manage high-tech radiology services. The authorization isfor medical necessity and does not guarantee claims payment, which is based on member benefits.If you have questions please contact Customer Service at 1-888-693-3211.Confidentiality Notice: This information is intended for the use of the person or entity to which it is addressed andmay contain information that is privileged and confidential, the disclosure of which is governed by applicable law.If the reader of this message is not the intended recipient, or the employee or agent responsible to deliver it to theintended recipient, you are hereby notified that any dissemination, distribution, or copying of this information isSTRICTLY PROHIBITED.If you have received this message by error, please notify MedSolutions sender at the address shown immediatelyand delete the related message from your files.Fax sent to 5555551212 on Mon, Oct 05, 09 2:33 PM

ATTACHMENT 3Sample Prior Authorization Decision Notice Letter(A sample “Prior Authorization Decision Notice Letter” is located on the followingpage.)ForwardHealth Provider Information • October 2010 • No. 2010-92 24

December 20, 2010Dr. IMA DOCTOR PA Number: 9103540123123 MAPLE STREET PA Status: DENIEDANYTOWN, WI 55555IM A MEMBERDear Dr. IMA DOCTOR:Your request for prior authorization (PA) has been finalized based on criteria established by theDepartment of Health Services and as stated in DHS 106.03 (4), Wis. Admin. Code. Refer to theadjudication detail on the enclosed attachment for the service specific authorization.An authorized PA does not guarantee payment. Reimbursement is contingent upon enrollmentof the member and provider at the time the service is provided and the completeness of theclaim information. Payment will not be made for services initiated prior to the approval or afterthe authorization expiration date. Reimbursement will be in accordance with ForwardHealthpayment methodology and policy. If the member is enrolled in a BadgerCare Plus or MedicaidManaged Care Program at the time a prior authorized service is provided, ForwardHealthreimbursement will be allowed only if the service is not covered by the Managed Care Program.A “Notice of Appeal Rights” letter has been sent to the member. Only the member, or authorizedperson acting on behalf of the member, may file an appeal with the Division Hearings andAppeals. Providers are encouraged to remain in contact with the member during the appealprocess. Providers may offer the member information necessary to file an appeal and helppresent his or her case during a fair hearing.If you have any questions regarding the decisions made on this PA, please contactMedSolutions at (888) 693-3211.Sincerely,Gregg Allen, MDChief Medical OfficerMedSolutions, Inc.MedSolutionsOnline.com

Member Name: IM A MEMBERMember Identification Number: 123456789Provider Name: Dr. IMA DOCTORProvider Address: 123 MAPLE STREETANYTOWN, WI 55555|Provider Identification Number: 987654321PA Number: 9103540123PA Status: DENIED78816 POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIREDCOMPUTED TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICALLOCALIZATION IMAGING; WHOLE BODY0178 - THE SERVICE REQUESTED IS NOT MEDICALLY NECESSARY.MedSolutionsOnline.com

ATTACHMENT 4Interpreting Prior Authorization NumbersEach prior authorization (PA) request is assigned a unique PA number. This number identifies valuable information about thePA. The following diagram and table provide detailed information about interpreting the PA number.Type of Number and DescriptionMedia — One digit indicates media type.Year — Two digits indicate the year MedSolutionsreceived the PA request.Julian date — Three digits indicate the day of the year, byJulian date, that MedSolutions received the PA request.Sequence number — Four digits indicate the sequencenumber.Applicable Numbers and DescriptionPrior authorization requests received by MedSolutions foradvanced imaging services are always identified with mediatype “9.”For example, the year 2010 would appear as 10.For example, February 3 would appear as 034.The sequence number is used internally by MedSolutions.ForwardHealth Provider Information • October 2010 • No. 2010-92 27

ATTACHMENT 5Web-Based Orientation Sessions for PriorAuthorization for Advanced Imaging ServicesTraining ScheduleDateNovember 16, 2010November 18, 2010November 23, 2010November 24, 2010November 30, 2010December 2, 2010December 7, 2010December 8, 2010Time9:00 a.m.11:00 a.m.11:00 a.m.1:00 p.m.12:00 p.m.9:00 a.m.4:00 p.m.9:00 a.m.ForwardHealth Provider Information • October 2010 • No. 2010-92 28