Department of health services state of wisconsin



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DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN


Division of Health Care Access and Accountability DHS 107.07(2), Wis. Admin. Code

F-11014 (07/12)



Forwardhealth

PRIOR AUTHORIZATION / DENTAL ATTACHMENT 2 (PA/DA2)

ORAL SURGERY, ORTHODONTIC, AND FIXED PROSTHETIC SERVICES
Instructions: Complete Section I for all orthodontics, oral surgery, and fixed prosthetic services. Complete Section II when anesthesia or a professional visit is necessary. Complete Section III for orthodontic services only. The requested identifying information will only be used to process the prior authorization (PA) request. If necessary, attach additional pages for provider responses. Refer to the dental publications for service restrictions and additional documentation requirements. Provide enough information for ForwardHealth to make a determination about the request. The use of this form is mandatory when requesting PA for certain procedures.


Member Identification Number

     


Billing Provider’s National Provider Identifier (NPI)

     


Rendering Provider’s NPI

     


SECTION I — ORAL SURGERY, ORTHODONTIC, AND FIXED PROSTHETIC SERVICES

Diagnosis

     

Treatment Plan

     

Treatment Prognosis (Check one. If “poor,” explain the reason for the requested treatment.)

 Excellent  Good  Fair  Poor      




Indicate if the member is physically, psychologically, or otherwise indefinitely disabled, or has a medical condition that impacts the treatment requested.

     

SECTION II — ANESTHESIA

PROCEDURE CODES
(Check All That Apply)


TREATMENT PLAN JUSTIFICATION
(Check All That Apply)


REQUIRED DOCUMENTATION

 D9220

 D9241


 D9248

(Prior authorization not required for the following:



  • Services performed in a hospital or ambulatory surgery center.

  • Services for members ages 0-20 when performed by a pediatric dentist or oral surgeon.)

 Behavior

 Disability (describe)      

 Geriatric

 Physician consult

 Complicated medical history     

 Extensive restoration



 Maxillofacial surgery (describe)      

 Three or more extractions in more than one quadrant

Submit medical documentation to support special circumstances.

SECTION III — ORTHODONTIC SERVICES ONLY

Anticipated Number of Monthly Adjustments

     


HealthCheck referral for orthodontic treatment.

Continued

PRIOR AUTHORIZATION / DENTAL ATTACHMENT 2 (PA/DA2) ORAL SURGERY, ORTHODONTIC, AND FIXED Page 2 of 2

PROSTHETIC SERVICES

F-11014 (07/12)


Submitting Prior Authorization Requests

ForwardHealth requires certain information to enable the programs to authorize and pay for dental services provided to eligible members.


Members of ForwardHealth are required to give providers full, correct, and truthful information for the submission of correct and complete claims for reimbursement. This information should include, but is not limited to, information concerning enrollment status, accurate name, address, and member identification number (DHS 104.02[4], Wis. Admin. Code).
Under s. 49.45(4), Wis. Stats., personally identifiable information about program applicants and members is confidential and is used for purposes directly related to ForwardHealth administration such as determining eligibility of the applicant, processing prior authorization (PA) requests, or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of PA or payment for the services.
Dentists may submit PA requests by fax to ForwardHealth at (608) 221-8616 if X-rays or models are not required for documentation purposes. Providers should make duplicate copies of all paper documents mailed to ForwardHealth. Dentists who wish to continue submitting PA requests by mail or who are submitting PA requests that require X-rays or models may do so by submitting them to the following address:
ForwardHealth

Prior Authorization



Ste 88

313 Blettner Blvd



Madison WI 53784





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