Appendix 7 — Prior Authorization Request Form (PA/RF) Completion Instructions for Chiropractic Services
Wisconsin Medicaid requires certain information to enable Medicaid to authorize and pay for medical services provided to eligible recipients.
Recipients are required to give providers full, correct, and truthful information for the submission of correct and complete claims for Medicaid reimbursement. This information should include, but is not limited to, information concerning eligibility status, accurate name, address, and Medicaid identification number (HFS 104.02[4], Wis. Admin. Code).
Under s. 49.45(4), Wis. Stats., personally identifiable information about Medicaid applicants and recipients is confidential and is used for purposes directly related to Medicaid administration such as determining eligibility of the applicant or processing provider claims for reimbursement. The Prior Authorization Request Form (PA/RF) is used by Wisconsin Medicaid and is mandatory when requesting PA. Failure to supply the information requested by the form may result in denial of Medicaid payment for the services.
Providers may submit PA requests, along with all applicable service-specific attachments, including the Prior Authorization/Chiropractic Attachment (PA/CA) (fillable PDF, 29 KB), by fax to Wisconsin Medicaid at (608) 221-8616; or, providers may send the completed form with attachments to:
Wisconsin Medicaid
Prior Authorization
Ste 88
6406 Bridge Rd
Madison WI 53784-0088
The provision of services that are greater than or significantly different from those authorized may result in nonpayment of the billing claim(s).
SECTION I — PROVIDER INFORMATION
Element 1 — Name and Address — Billing Provider
Enter the name and complete address (street, city, state, and zip code) of the
billing provider. The name listed in this element must correspond with the
Medicaid provider number listed in Element 4. No other information should be
entered in this element, since it also serves as a return mailing label.
Element 2 — Telephone Number — Billing Provider
Enter the telephone number, including the area code, of the office, clinic,
facility, or place of business of the billing provider.
Element 3 — Processing Type
Enter processing type "118" (chiropractic). The processing type is a three-digit
code used to identify a category of service requested.
Element 4 — Billing Provider’s Medicaid Provider Number
Enter the eight-digit Medicaid provider number of the billing provider. The
provider number in this element must correspond the provider name listed in Element
1.
SECTION II — RECIPIENT INFORMATION
Element 5 — Recipient Medicaid ID Number
Enter the recipient’s 10-digit Medicaid identification number. Do not enter any
other numbers or letters. Use the recipient’s Medicaid identification card or
the Eligibility Verification System (EVS) to obtain the correct identification
number.
Element 6 — Date of Birth — Recipient
Enter the recipient’s date of birth in MM/DD/YY format (e.g., September 8, 1966,
would be 09/08/66).
Element 7 — Address — Recipient
Enter the complete address of the recipient’s place of residence, including the
street, city, state, and zip code. If the recipient is a resident of a nursing
home or other facility, include the name of the nursing home or facility.
Element 8 — Name — Recipient
Enter the recipient’s last name, followed by his or her first name and middle
initial. Use the EVS to obtain the correct spelling of the recipient’s name. If
the name or spelling of the name on the Medicaid identification card and the EVS
do not match, use the spelling from the EVS.
Element 9 — Sex — Recipient
Enter an "X" in the appropriate box to specify male or female.
SECTION III — DIAGNOSIS / TREATMENT INFORMATION
Element 10 — Diagnosis — Primary Code and Description
Enter the appropriate International Classification of Diseases, Ninth
Edition, Clinical Modification (ICD-9-CM) diagnosis code and description
most relevant to the service/procedure requested. Refer to
Appendix 3 of this
handbook for a diagnosis code that is most relevant to the procedure requested.
Element 11 — Start Date — SOI (not required)
Element 12 — First Date of Treatment — SOI (not required)
Element 13 — Diagnosis — Secondary Code and Description
Enter the appropriate secondary ICD-9-CM diagnosis code and description relevant
to the service/procedure requested, if applicable. Refer to
Appendix 3 of this
handbook for a list of Medicaid-allowable diagnosis codes for chiropractic
services.
Element 14 — Requested Start Date
Enter the requested start date for the service(s) in MM/DD/YY format, if a
specific start date is requested.
Element 15 — Performing Provider Number
Enter the eight-digit Medicaid provider number of the provider who will be
providing the service only if this number is different from the billing provider
number listed in Element 4.
Element 16 — Procedure Code
Enter the appropriate procedure code for each service/procedure/item requested.
Element 17 — Modifiers (not required)
Element 18 — POS
Enter the place of service (POS) code designating where the requested
service/procedure/item would be provided/performed. Refer to
Appendix 2 of this
handbook for a list of Medicaid-allowable POS codes for chiropractic services.
Element 19 — Description of Service
Enter a written description corresponding to the appropriate procedure code for
each service/procedure/item requested.
Element 20 — QR
Enter the appropriate quantity (e.g., number of services, days’ supply)
requested for the procedure code listed.
Element 21 — Charge
Enter the usual and customary charge for each service/procedure/item requested.
If the quantity is greater than "1," multiply the quantity by the charge for
each service/procedure/item requested. Enter that total amount in this element.
| Note: | The charges indicated on the request form should reflect the provider’s usual and customary charge for the procedure requested. Providers are reimbursed for authorized services according to Terms of Provider Reimbursement issued by the Department of Health and Family Services. |
Element 22 — Total Charges
Enter the anticipated total charge for this request.
Element 23 — Signature — Requesting Provider
The original signature of the provider requesting/performing this
service/procedure/item must appear in this element.
Element 24 — Date Signed
Enter the month, day, and year the PA/RF was signed (in MM/DD/YY format).
Do not enter any information below the signature of the requesting provider — this space is reserved for Wisconsin Medicaid consultants and analysts.
Next — Appendix 8 — Sample Prior Authorization Request Form (PA/RF)
Previous — Appendix 6 — Sample CMS 1500 Claim Form (Second and Third Visits in Spell of
Illness)
Chiropractic Services Handbook
PHC 1306, October 2004