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Pharmacy, Prior Authorization

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1. l 61 17 Human Growth Hormone Serostim Serono Somatropin rDNA Origin centers erus rada cives t Gomes eti e dv Fue es HUN 65 GOSS AY Sue TS 69 Preface The Wisconsin Medicaid and BadgerCare Pharmacy Handbookis issued to pharmacy providers who are Wisconsin Medicaid certified It contains information that applies tofee for service Medicaid providers The Medicaid information in the handbookapplies to both Medicaid and BadgerCare Wisconsin Medicaid and BadgerCare are administered by the Department of Health and Family Services DHFS W ithin the DHFS the Division of Health Care Financing DHCF is directly responsible for managing Wisconsin Medicaid and BadgerCare BadgerCare extends Medicaid coverage to uninsured children and parents with incomes at orbelow 185 as of January 2001 of the federal poverty leveland who meet other program requirements BadgerCare recipients receive the same health benefits as Wisconsin Medicaid recipients and their health care is administered through the same delivery system Medicaid and BadgerCare recipients enrolled in state contracted HMOs are entitled to at least the same benefits as fee for service recipients however HMOs may establish theirown requirements regarding prior authorization billing etc If you are an HMO network provider contact yourmanaged care organization regarding its requirements Information
2. x The patienthas informed you through patient consultation In most cases itis possible to learn the necessary information fromthe patient b Thephysician wrote the diagnosis orreason foruse on this formoronapriorprescription orderforthis drug The physician orpersonnelin the physician s officeinformed you by telephone eithernow oron aprevious occasion Assigned Prior Authorization Number Grant Date Expiration Date NumberofDays Approved This is a New Prior Authorization Request This is a Renewed Prior Authorization Request Diagnosis Code Description Choosethe mostappropriate ICD 9 CM diagnosis Ifthediagnosis is nota Food and Drug Administration approved diagnosis fora particulardrug you mustsubmitthe PA requestonapaperPA RequestForm Appendix 6 STAT PA Drug Worksheet Angiotensin Converting Enzyme Inhibitors for photocopying See the next page forthe optionalSTAT PA drug worksheet forangiotensin converting enzyme ACE inhibitors This page was intentionally left blank x pu ddy Pharmacy Handbook Prior Authorization Sectiow July 2001 35 Appendix This page was intentionally left blank 36 Wisconsin Medicaid and BadgerCaree J uly 2001 STAT PA Drug Worksheet Brand Name ACE Inhibitors This vorksheetis to be used by pharmacists or dispensing physicians only NOTREQUIREDFOR PRES CRIBINGPHYSICIANS Generic angiotensin converting enzyme ACE inhibitors have NO RESTRICTIONS a
3. uoezuoy ny Joud SululeqO 5 Lus 2 je Q i S pel o lt lt Fe lt When the STAT PA request isreturned e A PA numberis assigned at the end of the transaction The STAT PA system indicates the reason for the return e The STAT PA system indicates that more clinical documentation is required and the provider may submit a paper PA request using the same PA number for reconsideration Forreconsideration please submit on paper The Prior Authorization Request Form PA RF List the PA number assigned to the returned STAT PA on the front of the PA RF in the description field e ThePriorAuthorization Drug Attachment PA DGA for legend drugs This must include additional clinical information either on the form or accompanying it e g copies of peer reviewed medical literature to substantiate the physician s reason for requesting a particular drug for the given diagnosis A faxnumber if available Special STAT PA Circumstances Dispensing STAT PA Drugs VVhen the STAT PA System is Unavailable If the STAT PA systemis down orunavailable a provider may stilldispense STAT PA approvable drugs Ifa providerdispenses a new prescription forthese drugs the following steps mustbetaken 1 Askto see the recipient s Forward temporary or Presumptive Eligibility card and verify eligibility This may be done by submitting a real time claim forthe drug or by
4. Copy the STATEXTD EXE file to yourSTAT PA directory AttheDOS command prompt type the name ofthe file without the EXE extension STATEXTD ENTER STATSOFT EXE Copy the STATSOFT EXE file to your STAT PA directory e Atthe DOS command prompt type the name ofthe file without the EXE extension STATSOFT ENTER STA TUPDT EXE Copy the STATUPDT EXE file to your STAT PA directory Atthe DOS command prompt type the name ofthe file without the EXE extension STATUPDT ENTER The files with the DOC extension are your manuals These files are ASCII DOS text files To print these files use the DOS Print command PRINT filename The file will be printed on the device you specify Ifyou have any questions about the EDS EPIX bulletin board please contact the electronic media claims unit at 608 221 4746 ext 3037 or 3041 18 Wisconsin Medicaid and BadgerCaree July 2001 Appendix 2 STAT PA Drug Worksheet Ulcer Treatment Drug Histamine 2 Antagonist for photocopying See the next page forthe optionalSTAT PA drug worksheet forthe ulcer treatment drug x pu ddy This page was intentionally left blank Pharmacy Handbook Prior Authorization Sectioe July 2001 19 Appendix This page was intentionally left blank 20 Wisconsin Medicaid and BadgerCaree J uly 2001 STAT PA Drug Worksheet Ulcer Treatment Drug Histamine 2 Antagonist This vorksheetis to be used by pharmacis
5. Department of Health and Family Services E id Medicaid sand BadgerCare Waran Pki acd bagalan YTP for Prove Pharmacy Quick Reference Page Pharmacy Point of Sale POS Correspondents For questions regarding Medicaid policies and billing please call 800 947 9627 or 608 221 9883 select 2 when prompted Hours available 8 30 a m to 6 00 p m Monday Wednesday Thursday and Friday 9 30 a m to 6 00 p m Tuesday Not available on Sunday or holidays Clearinghouse Switch or Value Added Network VAN Vendors For transmission problems call your switch VAN or clearinghouse vendor e Healtheon W ebMD switching services 800 433 4893 Envoy switching services 800 333 6869 e National Data Corporation switching services 800 388 2316 Electronic Media Claims EMC Help Desk For any questions regarding EMC tape modem and interactive software please call 608 221 4746 Ext 3037 or 3041 Hours available 8 30 a m to 4 30 p m Monday through Friday Not available on weekends or holidays Wisconsin Medicaid Web Site www dhfs state wi us medicaid Pharmacy handbook replacement pages and Wisconsin Medicaid and BadgerCare Updates on line and available for viewing and downloading Pharmacy POS information Fax Number for Prior Authorization PA 608 221 8616 Paper PA requests may be submitted by fax Specialized Transmission Approval Technology PA STAT PA System Numbers For
6. W hen resubmitting a faxed PA request providers are required to resubmit the faxed copy of the PA request including attachments which includes Wisconsin Medicaid s 15 digit internalcontrolnumb r located on the top half of the PA RF This will allow the providerto obtain the earliest possible grant flate forthe PA request apart from backdating for retroactive eligibility If any attachments or additional information that was requested is received without the rest of the PA request the information willbe returned to the provider When faxing information to Wisconsin Medicaid providslreuld notreduce the size of the PA RF to fit on the bottom half of the cover page This makes the PA request difficult to read and leaves no spdce for consultants to write a response if needed orto sign the request Ifa photocopy ofthe original PA request and attachments is faxed the provider should make sure thdse copies are clear and legible If the information is not clear it will be returned to the provider Refaxing a PA request before the previous PA request has been returned will create duplicate PA requests and may result in delays If the provider does not indicate his or her faxnumber Wisconsin Medicaid will mail the decision back to the provider Wisconsin Medicaid willattempt to faxa PA request to a provider three times Ifunsuccess ful the PA request will be mailed to the provider Pharmacy Handbook Prior Authorization Sectioe Jul
7. s telephone number including the area code ofthe office clinic facility orplace ofbusiness Element 9 Billing Provider s Wisconsin Medicaid Provider Number Enter the billing provider s eight digit Medicaid provider number Pharmacy Handbook Prior Authorization Sectiow July 2001 39 Appendix Appendix 7 continued Element 10 Dx Primary Enter the appropriate nternational Classification of Diseases Ninth Revision Clinical ModificatiotiCD 0 CM diagnosis code and description most relevant to the service procedure requested forthe recipient Note Pharmacists need only provide a written description Element 11 Dx Secondary Enterthe appropriate ICD 9 CM diagnosis code and description additionally descriptive ofthe recipient s clinical condition Note Pharmacists need only provide a written description Element 12 Start Date of SOI not required Element 13 First Date Rx not required Element 14 Procedure Code s Enter the appropriate 11 digit National Drug Code NDC or Wisconsin Medicaid assigned 5 digit procedure code foreach service procedure item requested For Enteral Nutrition Products enterthe appropriate HCFA Common Procedure Coding System HCPCS code Note Leave this element blank for HealthCheck Other Services Element 15 MOD Enter the modifier corresponding to the procedure code ifa modifier is required by Wisconsin Medicaid policy and the coding structure used fore
8. Prior Authorization Sectiow July 2001 41 Appendix 42 Wisconsin Medicaid and BadgerCaree July 2001 Appendix 8 Sample Prior Authorization Request Form MAIL IG PRR AU ELZA UM OLSI F HN AZ M TY HE FGA FFDE IL il 2X eC E PRIES AUTHORIZATION M T mul EAM EI BHILE HLIALI IZN 0 131 SUITE MADISCN 53714 0035 FA 1234567 SNT SERR IRTRFF T CTY TE TIS CEE REGIAM We Aiia AKEE Vi H T H 1234567890 609 Willow LAME Lae FAST OILE H T Recipient Ima A Anytown WI 55555 29 6 SLING FRASER TELEFI IHE HLMGCA TEL Gr miri i e XXX XXX XXXX DD YYYY TS FK PRADET WAM 22 GODE BELLES AGIOS Be 12345678 7 10 Dx LM Provider i AIDS related Kaposi s Sarcoma 1 W Williams in DX DECOR DARY Anytown WI 55555 m p 712 SIARKI LINES DE I2 DL Ix prseesunecapr se r r zil Lael K N OF SERMCE ME m Cl IARGEE 64365050101 XX XX XX XX Bemba samant js continent ups GILL liy gif Ite reciplert ax prawklur dib thie ive Ung ama viz de prawie b x lin analea eme cU d chain ir Pay rent wl mol bc macs ter initietac oier te npprowald c aftar mutbnriglar expiration caku Pairribaureg reanl will be in accordance with Wiscorsin Wacdical 4sgistacns Phacrnm payment methndaleay and Pilicy IF khe muxipiuiril ie unrolled in a Meca Qeqelance HMO at t s ima 5 inr authorize aerea is providan WMAP
9. 88 2 6406 Bridge Road Madison WI 53784 0088 Covered Rebated Drug Categories That Require Paper Prior Authorization Requests By fax Drug PA requests may also be submitted by Wisconsin Medicaid requires paper PA for faxto Wisconsin Medicaid at the following certain drug categories produced by number 608 221 8616 To avoid delayed manufacturers who signed drug rebate adjudication do not Tax and mailduplicate agreements with the Health Care Financing copies ofthe same PA requestforms Further Administration HCFA in order to determine guidelines forrequesting PA by faxcan be medicalnecessity A list of these drug found in Appendix 12 of this section categories requiring PA can be found in the Covered Services and Reimbursement section of this handbook Pharmacy Handbook Prior Authorization Sectioe July 2001 7 8 Lus 2 je C Q i S pel o lt lt Fe lt Request PA for covered rebated drug categories by submitting a paper PA RF and a PA DGA forlegend drugs The prescription documentation must be valid on the grant date of the PA request Refer to Appendices 8 10 and 11 ofthis section fora sample PA RF and for PA DGA forms for photocopying Covered Non Rebated Drugs That Require Paper Prior Authorization Requests Certain drugs require paper PA because their manufacturer did not sign a rebate agreement with HCFA Refer to the Covered Services and Reimbursement sec
10. M W F Provider Certification 9 30 a m 6 00 p m T Recipient Eligibilit y Direct Information Checkwrite Info Call 608 221 4746 7 00 a m 6 00 p m M F ULL ie with Claim Status for more information 75 Prior Authorization Dial Up Status Software Recipient Eligibilit y communications package and modem Recipient Services Recipient Eligibility 800 362 3002 7 00 a m 9 00 p m M F Recipients or persons Medicaid Certifie d 608 221 5720 7 30 a m 4 00 p m Sat caling on behalf of Providers recipients ony General Medicaid Information Please use the information exactly as it appears on the recipient s ID card or EVS to complete the patient information section on claims and other documentation Recipient eligibility information available through EVS includes Dates of eligibility Medicaid managed care program name and telephone number Privately purchased managed care or other commercial health insurance coverage Medicare coverage Lock In Program status Limited benefit information Table of Contents PRTC a m A E CUR a acct RAH 3 Obtaining Prior Authorization jit css eee RR RR e 5 The Wis onsn ST AT PA LOIRE FEY acri eodd TRT TC Ta 5 Folowslg to a STAT PA Request oso apogr m e lale pueden dh lanua ak 5 Special STAT PA CIrCHETSE ANCES cuo ie iie eee 6 Dispensing STAT PA Drugs When the STAT PA System is Unavailable 6 Change From One
11. PA requestforup to 365days 2 Ifno then ask a Has therecipienttried captopril enalapril trandolapril ormoexipriland had an adverse drug reaction 1 Ifyes approve PA requestup to 365 days 2 Ifno returnthe PA with the following message Yourpriorauthorization request requires additional information Please submit yourrequest on paper with complete clinicaldocumentation OVER Asthe pharmacist you have learned ofthis diagnosis orreason foruse when a The patienthas informed you through patient consultation In most cases itis possible to learn the necessary information fromthe patient b Thephysician wrote the diagnosis orreason foruse on this formoronapriorprescription orderforthis drug The physician orpersonnelin the physician s officeinformed you by telephone eithernovv oron aprevious occasion Assigned Prior Authorization Number Grant Date Expiration Date NumberofDays Approved This is a New Prior Authorization Request This is aRenewed Prior Authorization Request Diagnosis Code Description Choose the mostappropriate ICD 9 CM diagnosis Ifthe diagnosis is nota Food and Drug Administration approved diagnosis fora particulardrug you mustsubmitthe PA requestonapaperPA RequestForm Appendix 7 Prior Authorization Request Form Completion Instructions Element 1 Processing Type Enterthe appropriate three digit processing type fromthe list below The processing type is athree digit code used
12. Rights and Responsibilities e Recipient Rights and Responsibilities Legal Framework of Wisconsin Medicaid and BadgerCare The following laws and regulations provide the legal framework for W isconsin Medicaid and BadgerCare Federal Law and Regulation e Law United States Social Security Act Title XIX 42 US Code ss 1396 and following and Title XXI e Regulation Title 42 CFR Parts 430 456 Public Health Pharmacy Handbook Prior Authorization Sectiow July 2001 3 Wisconsin Law and Regulation Law Wisconsin Statutes Sections 49 43 49 497 and 49 665 e Regulation Wisconsin Administrative Code Chapters HFS 101 108 Handbooks andWisconsin Medicaid and BadgerCare Updatesfurther interpret and implement these laws and regulations Handbooks andUpdates maximum allowable fee schedules helpfultelephone numbers and addresses and much more information about Wisconsin 4 Wisconsin Medicaid and BadgerCaree July 2001 Medicaid and BadgerCare are available at the following Web sites www dhfs state wi us medicaid www dhfs state wi us badgercare Medicaid Fiscal Agent The DHFS contracts with a fiscalagent which is currently EDS to provide health claims processing communications and otherrelated services Forsome drugs that do require PA providers may submit PA requests through the Wisconsin Specialzed Transmission Approval Technology Prior Authorization STAT PA system Other drugs require
13. Ulcer Treatment Drug or Angiotensin Converting Enzyme ihhibitor to AIO EON eran aaa cues NE gp Uum 6 7 Obtalnino 7 Submitting Forms by Mail Ot Fax xci Hat tort E de deae EON 7 Follow Up to a Paper Prior Authorization Request sse eee e e 7 Covered Rebated Drug Categories That Require Paper Prior Authorization Requests 7 Covered Non Rebated Drugs That Require Paper Prior Authorization Requests 8 Documentation of Medical Necessity and Cost Effectiveness 8 Other Services Requiring Paper Prior Authorization 8 Prior Authorization for HealthCheck Other Services see e 8 Diagnosis Restricted 9 Prior Authorization Response Time z z S d y a a 10 Z24 HOLUTBEesponse m estates aa Da a dove 10 Weekend and Holiday Processing ee ee 10 Exceptions to the 24 Hour Response 10 Bac kd ating Prior Authorizations see 10 MER 11 1 STAT PA System ve 13 2 STAT PA Drug Worksheet Ulcer Treatment Drug Histamine 2 Antagonist for DIOL COD VING aaa a nds vine tace civ suadeo auct qoute Phu alios cds 19 3 STAT PA Drug Worksheet Non
14. carci 2339 Renal ce 07811 Co 1729 Malignant 1760 1769 Kaposi s sarcom Interferon Intron A 2024 Hairy cell leu kemi a Alfa 28 PEG Intron 2028 Non Hodgkin s 2030 Multiple myelom 2337 Bladder carcinom OVER 2339 Renal cell carci Interferon Alfa 2A Pharmacy Handbook Prior Authorization Sectiow July 2001 57 Appendix Drug Name Brand Name Disease Description i or Category Code Interferon Alfa N3 Alferon N 07811 Condylomataacuminata 2881 Chronic granulomatous disease Gamma 1B Interferon is Alfacon 1 07054 Chronic hepatitis C w o hepatic coma Interferon Alfa 2B Rebitron 07054 Chronic hepatitis C w o hepatic coma Ribavirin Interferon Beta 1A Avonex 340 Mutipleselerosis 00 sclerosis Interferon 2880 A granulocytosiNeutropenia Heo xum Mupirocin Bactroban Bactroban 2 684 mpetigo OO Oo o o o o OKT3 9968 Organ transplant rejection Bupropion 3051 Nicotine dependence treatment 3051 Nicotine dependence treatment Legend V22 V229 Normal pregnancy Prenatal V23 V239 Supervisi ion risk pregnancy ita min 4 58 Wisconsin Medicaid and BadgerCaree J uly 2001 Appendix 15 Drug Products Requiring Paper Submission For Prior Authorization Approval Approval Criteria Indicated forthe self treatment of cutaneous lesions of acquired immune deficiency syndrotge AIDS related Kaposi s Sarcoma KS Specific No
15. days supply is indicated resubmitted on a T new PA RF with Wisconsin Medicaid When a PA request is returned additional 7 7 6406 Bridge Road The return boxis checked documentation that Madison WI 53784 0003 e An explanation for the return is given justifies the need for reconsideration Please specify the form being requested and A PA request is returned because additional of the PA request the numberof forms desired Reorder forms information is needed orbecause information are included in the mailing ofeach request for on the PA request must be corrected A forms returned PA request is not the same as a denied request Providers should correct or Providers can either photocopy the PA DGA the missing information to the original PA forms located in Appendices 10 4 11ofthis request and resubmit it to Wisconsin Medicaid section or download the forms fromthe Wisconsin Medicaid Web site Go to When the PA request is denied www dhfs state wi us medicaidAnd click on Provider Handbooks then Pharmacy The denied boxis checked and an explanation is given Submitting Forms by Mail or Fax Asignature and date signed are indicated By mail Requests forservices which have been previously denied must be resubmitted on a new PA RF with additional documentation that justifies the need forreconsideration ofthe PA Send allcompleted paper PA forms to Wisconsin Medicaid Prior Authorization Suite
16. eim ssim wil bo lket voy il Le saree is mob covered Ev ne H g MM DD YYYY Si L AA Tn n v z cx m TEULE AG UOC RTT EA H C RA YB TE IN THIS SPACE PUL IOHLURTIDH ROGZOUREIT MUT IOnIZE2 LAPD ALP PS EE kato ETT EXT AT DN EAE HOBIFIEE SEASON CEBICE EASON DET IM TIEA ze DATE SEAHATL SE 25 qas 100 Pharmacy Handbook Prior Authorization Sectiow July 2001 43 x ipu ddy Appendix 44 Wisconsin Medicaid and BadgerCaree July 2001 Appendix 9 Prior Authorization Drug Attachment Completion I nstructions For Legend Drugs and Enteral Nutrition Products Timely determination of prior authorization PA is significantly increased by submitting thorough documentation Carefully complete the appropriate Prior Authorization Drug Attachment PA DGA form attach it to the Prior Authorization Request Form PA RF and submit it to Wisconsin Medicaid PriorAuthorization Unit Suite 88 6406 Bridge Road Madison WI53784 0088 x ipu ddy Wisconsin Medicaid s Policy Billing Correspondence Unit can answerquestions about completing the PA RF orthe PA DGA Contact Provider Services at 800 947 9627 or 608 221 9883 Pharmacy staff may complete the PA DGA form however the pharmacist must review the information and sign the PA DGA form verifying that the information is accurate Recipient Information Element 1 Recipient s Last Name Indicate the recipie
17. past Days Supply Requested STAT PA Request Checklist ALL information must be checked within each category in orderto be processed electronically COX 2 A Isthe NSAID being prescribed fora chronic non acute condition 1 Ifyes then ask a Does therecipienthave any ofthe following riskfactors age over65 a history ofulcerorGlbleedin g currently takin g anti coagulants orglucocorticoids 1 Ifyes approve PA requestforup to 365days 2 Ifno then ask a Has the recipient tried and failed a generic NSAID orhad an adverse drug reaction i Ifyes approvePA requestforup to 365days i 1fno you willreceive the following message Yourpriorauthorization requestrequires additional information Please submit yourrequest on paper with complete clinicaldocumentation 2 Ifno then ask a Has the recipient tried and failed a generic NSAID orhad an adverse drug reaction 1 Ifyes approve PA requestup to 365 days 2 Ifno you willreceive the following message Yourpriorauthorization requestrequires additionalinformation Please submit yourrequeston paperwith complete clinicaldocumentation OVER Non COX 2 A Has the recipient tried and failed a generic NSAID drug orhad an adverse drug reaction 1 Ifyes approve PA request up to 365 days 2 Ifno return the PA with the following message Yourpriorauthorization request requires additionalinformation Please submit yourrequest on paper with complete clinicaldocumentation As the ph
18. response e A prescriber s documentation showing how some unique characteristic e g dosage form pharmaceutical formulation therapeutic indication ofthe drug prescribed is essentialto assure the recipient receives specific medically necessary and costeffective treatment The following sample prescriber statements are notsufficient by themselves as documentation of medicalnecessity and cost effectiveness The recipient becomes illon the generic drug e The recipient is convinced thatonly the brand name drug will work for him Only the brand name drug is effective e Therecipientinsists that the generic drug is ineffective e Itis my professional opinion that this recipient requires the brand name drug for his condition Generic versions are unacceptable in the patient s treatment as they provide no benefit to him Other Services Requiring Paper Prior Authorization Prior Authorization for HealthCheck Other Services Medically necessary services that are not otherwise covered by Wisconsin Medicaid may be covered if the following conditions are met e The recipient is under 21 years ofage e The provider verifies that a comprehensive HealthCheck screening has been performed within the previous 365 days e service is allowed under the Social Security Act as a medical service 8 Wisconsin Medicaid and BadgerCaree J uly 2001 The statement of medical necessity required for
19. software by calling the STAT PA Help Desk at 800 947 1197 or 608 221 2096 Once alldata have been entered the provider trans mits the electronic request to Wisconsin Medicaid by using a modem and telephone line The telephone numberto use is 800 947 4947 or 608 221 1233 Referto the STAT PA UserManualfor more information on how to transmit the electronic request STAT PA processes the information and in minutes generates an electronic confirmation transaction that displays directly on the provider s personalcomputer screen The transaction shows e What he providerrequested e The procedure code that was authorized e The assigned PA number e Grantandexpiration dates Helpful Hints For PC Users 1 Once the provideris connected to STA T PA the provideris given 40 seconds to respond to requested data If the provider is making changes to a field the provider is then given 90 seconds to respond before being disconnected 2 The provideris limited to 25 transactions per connection 3 When entering the requested date of service of the PA the date of service may be up to 31 calendar days in the future This allows recipients to have PA requests processed so there are no lapses in their medication 4 The decimal point for diagnosis codes is not required when entering a STAT PA request 5 Inthe event the STAT PA systemis unavailable at the time the prescription order is filled the PA request may be backdated up to fourca
20. using one of the other eligibility verification methods 2 Determine that the diagnosis is appropriate 3 Determine that the recipient is not taking any other legend drug in the same category The prospective Drug Utilization Review system may identify therapeutic duplications at other pharmacies 4 Dispense up to a 14 day supply ofthe drug product 5 Request PA fromthe STAT PA system when it is available A PA request may be backdated up to fourdays 6 Ifthe STAT PA request is returned submit a paper PA request within 14 days of dispensing along with documentation supporting what was done in steps 2 5 of this process A provider who uses a billing service may find that claims for these situations are denied when PA has been granted after the dispensing date but the PA number was not included on that original claim In these situations the If the STAT PA system is down or provider mustresubmit the claim and include a i the PA numberforreimbursement provi er may sti dispense STAT PA approvable drugs In an emergency i e a situation where services necessary to prevent the death or serious impairment ofthe health of the individualare required PA is never required to provide medically necessary services When drugs are dispensed in an emergency situation providers must submit a paperclaim includes attached Special Handling documentation indicating the nature of the emergency However PA must b
21. Data Bits 8 TerminalEmulation ANSI Note These settings are standard for most communication software packages 3 Dial mto EDS EPIX Before your initial login you will be asked if you have a color screen Select Y N Disable whicheveris appropriate foryoursystem 4 Next you willbe asked yourname You may enter yourname and register as a new user or you may login as follows Enter your name or type NEW or GUEST 5 Press ENTER to continue through EDS EPIX news and review new user help information until you reach the Main Menu 6 Atthe EDS EPIX Main Menu choose Files Download Upload Files by typing F to continue to the EDS EPIX Files SystemMenu 7 Next select 6 Files STAT PA Software by typing 6 ENTER Press ENTER again when prompted to list filenames available for downloading Select N when asked to display long file descriptions Pharmacy Handbook Prior Authorization Sectioe July 2001 17 Appendix Appendix 1 continued To tag a file for downloading select Tag ENTER At the next screen type the letter indicated under the TAG column that corresponds to the file you want to receive When done press ENTER You will be returned to the Files SystemMenu Use the following guideline to decide which files you need to download A STATEXTD EXE Ifyou have already installed STAT PA on yourcomputer but are getting memory related error messages you might need this file B STATSOFT
22. EXE Ifyou have neverinstalled STAT PA on yourcomputer you willneed this file C STATUPDT EXE If you have already installed STAT PA on yourcomputer but you need the latest version ofthe software you will need this file Atthis point you may select Xpronto Changer Xfer Protocol to choose yourdownload protocolif you haven tdone so already We recommend that you select Zmodem as your protocol Choose Download Receive Files from BBS Bulletin Board System by typing D ENTER When asked if you wish to select the tagged file s choose Y You will be asked if you want to automatically disconnect after your download Choose Yes No or Quit accordingly The bulletin board is now ready to send the file Next you will need to tell your PC to receive a file If you are unsure of how to do this please refer to the user manual that came with yourcommunication software package When you have downloaded your file s and disconnected from EDS EPIX either by automatically disconnecting or choosing G Good bye fromthe Menu quit yourcommunication software Exit to your DOS prompt Go to the subdirectory you specified as yourdownload path to find the downloaded file If you did not specify a subdirectory the file willgo to yourcommunications software default directory most likely your C drive Follow the appropriate step s indicated below to installthe downloaded file s STATEXTD EXE
23. In mostcases itis possible to learn thenecessary information fromthe patient b Thephysician wrote the diagnosis orreason foruse on this formoronapriorprescription orderforthis drug The physician orpersonnelin the physician s officeinformed you by telephone eithernow oron aprevious occasion Assigned Prior Authorization Number Grant Date Expiration Date NumberofDays Approved This is a New Prior Authorization Request This is a Renewed Prior Authorization Request Diagnosis Code Description Choose the mostappropriate ICD 9 CM diagnosis Ifthe diagnosis is nota Food and Drug Administration approved diagnosis fora particulardrug you mustsubmitthe PA requestonapaperPA RequestForm Appendix 5 STAT PA Drug Worksheet 111 and C IV Stimulants and Anti Obesity Drugs for photocopying See the next page for the optional STAT PA drug worksheet for C III and C IV stimulants and anti obesity drugs This page was intentionally left blank x pu ddy Pharmacy Handbook Prior Authorization Sectiow July 2001 31 Appendix This page was intentionally left blank 32 Wisconsin Medicaid and BadgerCaree J uly 2001 STAT PA Drug Worksheet C III and C IV Stimulants and Anti Obesity Drugs This worksheetis to be usedby pharmacists or dis pensing physicians only NOTREQUIREDFOR PRES CRIBINGPHYSICIANS REMINDER The Specialized Transmission Approval Technology PriorAuthorization STAT PA Drug Work sheeojstiona
24. PA requests for non rebated drugs must include the prescriber s conclusion that the non rebated drug is the only available and medically appropriate product for treating the recipient e The service is medically necessary and Reter to the Covered Services and reasonable to correct or improve a Reimbursement section of this handbook for condition ordefect further information on HealthCheck Other The service is noncovered underthe Services current Medicaid State Plan e A service currently Medicaid covered is Diagnosis Restricted Drugs not appropriate to treat the identified d Prior authorization is required fordiagnosis condition restricted drugs when the uses areutsideof Prior authorization 5 m approved diagnoses For these drugs 5 required for EEE reune pharmacies are required to list diagnoses on diagnosis restricted PA To request PA the claim Diagnosis restricted drugs do not drugs when the Submit leted PA RF PA DGA and require PA if being used to treat certain uses are outside of 25 i and diagnoses approved verification that a HealthCheck screen i was completed within the last 365 days diagnoses e Indicate at the top ofthe PA RF that the request is for HealthCheck Other Services Do not indicate a procedure code on the PA RF uonezuouijny Joud The table in Appendix 14 of this section lists diagnosis restricted drug categories and the cor
25. PCs For touch tone telephones For the Help Desk 800 947 4947 800 947 1197 800 947 1197 608 221 1233 608 221 2096 608 221 2096 Available from 8 00 a m to 11 45 p m Available from 8 00 a m to 11 45 p m Available from 8 00 a m to 6 00 p m seven days a week seven days a week Monday through Friday excluding holidays Important Telephone Numbers Wisconsin Medicaid s Eligibility Verification System EVS is available through the following resources to verify checkwrite information claim status prior authorization status provider certification and or recipient eligibility Information Service available Telephone number Hours Automated Voice Checkwrite Info 800 947 3544 24 hours a day 57 AVR Claim Status 608 221 4247 7 days a week i mirdi voice Prior Authorization Madison area response to provider Status inquiries Recipient Eligib lit y Personal Computer Recipient Eligibilit y Refer to Provider 24 hours a day Software Resources section of 7 days a week and All Provider Magnetic Stripe Handbook for a list of Card Readers commercial eligibility verification vendors Provider Services Checkwrite Info 800 947 9627 Policy Billing and Eligibility Correspondents assist Claim Stat 8 30 a m 4 30 p m M W F with questions ju 608 221 9883 9 30 a m 4 30 p m T Prior Authorization Status Pharmacy DUR fficati 8 30 a m 6 00 p m
26. REMINDER The Specialized Transmission Approval Technology PriorAuthorization STAT PA Drug Work sheeojstional This formisnot required butis provided asa guideline only to access STAT PA oras provider documentation The STAT PA system willask forthe following items in the orderlisted below Provider Number Recipient Medicaid Identification Number Recipient Name National Drug Code NDC Procedure Code of Product Requested Type ofService D s Drug Enforcement Administration DEA Number Diagnosis Code 1 Use the recipient sInternational Classification ofDiseases Ninth Revision Clinical Modification ICD 9 CM diagnosis code The decimalis not necessary Place of Service Date ofService ___ The date ofservice may be up to 31 days in the future orup to fourdays in the past Days Supply Requested STAT PA Request Checklist ALL information must be checked within each category in orderto be processed electronically A Does therecipienthave clinically significant panacinaremphysemadueto congenitalA Ipha 1 Antitrypsin deficiency 1 Ifyes approve PA requestforup to 365 days 2 Ifno you willreceive the following message Yourpriorauthorization requestrequires additionalinformation Please submit yourrequestonpaperwith complete clinicaldocumentation OVER Asthe pharmacist you have learned ofthis diagnosis orreason foruse when x The patienthas informed you through patient consultation
27. Steroidal Anti Inflammatory Drugs for photocopying 23 4 STAT PA Drug Worksheet Alpha 1 Proteinase Inhibitor Prolastin for photocopying 27 5 STAT PA Drug Worksheet C III and C IV Stimulants and Anti Obesity Drugs for DMOLO COM YING Ec TT l 6 STAT PA Drug Worksheet Angiotensin Converting Enzyme Inhibitors for Photocopying ees a aa bay 35 7 Prior Authorization Request Form Completion Instructions 39 8 Sample Prior Authorization Request nnne nnn 43 9 Prior Authorization Drug Attachment Completion Instructions For Legend Drugs and 45 10 Prior Authorization Drug Attachment For Legend Drugs for photocopying 47 11 Prior Authorization Drug Attachment For Enteral Nutrition Products for DNOEO COPYING ssa masa e rer UNG ka actrice qtio eae Su des s 49 PHC 1354E 12 Prior Authorization Fax epe e pp e vage deer sapo b a ege va 53 13 Drug Categories Allow ing Prior Authorization Approval Through the STAT PA SA CR Die DA af 55 14 Diagnosis Code Table for Diagnosis Restricted Drugs and Drug Categories 57 15 Drug Products Requiring Paper Submission For Prior Authorization Approval 59 16 Food Supplement Prior Authorization Guidelines
28. ach service procedure item requested Element 16 POS Enter the appropriate Medicaid single digit place of service POS code designating where the requested service procedure item would be provided performed dis pens ed Code Description Pharmacy Doctor s Office Home Nursing Facility Skilled Nursing Facility on BW C Element 17 TOS Enter the appropriate Medicaid single digit type of service TOS code foreach service procedure item requested TOS Code Description D Drugs 40 Wisconsin Medicaid and BadgerCaree J uly 2001 Appendix 7 continued Element 18 Description of Service Entera written description corresponding to the appropriate 11 digit NDC 5 digit procedure code or 3 digit revenue code foreach service procedure item requested Note When resubmitting a STAT PA claim reference the STAT PA number in the description field on the Prior Authorization Request Form PA RF Element 19 Quantity of Service Requested Enter the quantity e g number ofunits dollar amount requested foreach service procedure item requested Drugs numberofunits ordays supply Element 20 Charges Enter yourusualand customary charge foreach service procedure itemreques ted Ifthe quantity is greaterthan 1 multiply the quantity by the charge foreach service procedure item requested Enter that total amount in this element x ipu ddy Note The charges indicated on the request form shou
29. approval indicate any changesto the clinical condition progress or known results to date Attach another sheet if additional room isneeded Source for Clinical Information check one D Thisinformation was primarily obtained from the prescriber or prescription order Thisinformation wasprimarily obtained from the recipient D Thisinformation wasprimarily obtained from some other source specify Use check one U Compendial standards such asthe USP DI or drug package insert liststhe intended use identified above asan accepted UO bracketed indication D The intended use above isnotlisted in compendial standards Peer reviewed clinical literature isattached Dose check one u The daily dose and duration are within compendial standards general prescribing or dosing limitsfor the indicated use The daily dose and duration are notwithin compendial standardsgeneral prescribing or dosing limits for the intended use Attach peer reviewed literature which indicates this dose is appropriate or document the medical necessity of this dosing difference Signature Date Check the appropriate box Please notify me of approval denial by D Fax l elephone LINo notice needed The pharmacist dispenser must review information and sign and date this form Appendix 11 Prior Authorization Drug Attachment For Enteral Nutrition Products for photocopying See the next page for the Prior Authorization Drug Attachment PA DGA for entera
30. armacist you have learned ofthis diagnosis orreason foruse when a The patienthas informed you through patient consultation In most cases itis possible to learn the necessary information fromthe patient b The physician wrote the diagnosis orreason foruse on this formoronapriorprescription orderforthis drug c The physician orpersonnelin the physician s office informed you by telephone eithernovv oron aprevious occasion Assigned Prior Authorization Number GrantDate Expiration Date NumberofDays Approved This is a New Prior Authorization Request This is a Renewed Prior Authorization Request Diagnosis Code Description Choosethe mostappropriate ICD 9 CM diagnosis Ifthediagnosis is notaFood and Drug Administration approved diagnosis fora particulardrug you mustsubmitthePA requestonapaperPA RequestForm Appendix 4 STAT PA Drug Worksheet Alpha 1 Proteinase I nhibitor Prolastin for photocopying See the next page for the optional STAT PA drug worksheet for A lpha 1 Proteinase Inhibitor Prolas tin This page was intentionally left blank x ipu ddy Pharmacy Handbook Prior Authorization Sectioe July 2001 27 Appendix This page was intentionally left blank 28 Wisconsin Medicaid and BadgerCaree July 2001 STAT PA Drug Worksheet Alpha 1 Proteinase Inhibitor Prolastin This vorksheetis to be used by pharmacists or dis pensing physicians only NOTREQUIREDFOR PRES CRIBINGPHYSICIANS
31. as intentionally left blank x pu ddy Pharmacy Handbook Prior Authorization Sectiow July 2001 23 Appendix This page was intentionally left blank 24 Wisconsin Medicaid and BadgerCaree July 2001 STAT PA Drug Worksheet Brand Name NSAIDs This worksheetis to be used by pharmacists or dis pensing physicians only NOTREQUIREDFOR PRES CRIBINGPHYSICIANS Generic non steroidalanti in flammatory drugs NSAIDs have NO RESTRICTIONS as to eitherdiagnosis codes orpriorauthorization PA As with allinnovatordrugs prescribers must write Brand Medically Necessary onallhard copies ofthe prescriptions andon each new nursing facility ordersheet REMINDER The Specialized Transmission Approval Technology PA STAT PA Drug Work sheet ptional This formisnot required butis providedasa guideline only toaccessSTAT PA orasproviderdocumentation The STAT PA systemwillask forthe following items in the orderlisted below Provider Number Recipient Medicaid Identification Number Recipient Name National Drug Code NDC Procedure Code of Product Requested TypeofService D Prescriber s Drug Enforcement Administration DEA Number Diagnosis Code Use the recipient sInternational Classification ofDiseases Ninth Revision Clinical Modification ICD 9 CM diagnosis code The decimalis notnecessary Place of Service Date of Service The date ofservice may be up to 31 days in the future orup to fourdays in the
32. ay through Friday excluding holidays Providers are allowed to submit up to 25 PA requests perconnection ifusing a personal computerand five PA requests perconnection for touchtone telephone and help desk queries Referto Appendix 1 of this section for instructions on how to use the Wisconsin STAT PA system Wisconsin STAT PA is available for the following drugs only e Certain ulcer treatment drugs Brand name non steroidal anti inflammatory drugs NSAIDs Cy clooxy genase 2 COX 2 and Non 2 e Alpha 1 Proteinase inhibitor Pro lastin 4 C IV stimulants e Anti obesity drugs Angiotensin converting enzyme ACE inhibitors Refer to A ppendix 13 of this section for drug classes that allow PA approval through STAT PA Also refer to Appendices 2 through 6 of this section fowptionaldrug s pecific worksheets which provide guidelines forusing the STAT PA system Follow Up to a STAT PA Request A STAT PA request will be approved or returned Providers willreceive a STAT PA receipt confirmation notice both during the transaction and by mail for any STAT PA requestsubmitted whetherit was approved or returned When the PA request isapproved APA numberis assigned at the end ofthe transaction e The grant and expiration dates are indicated e days supply allowed is indicated The claim may be billed immediately Pharmacy Handbook Prior Authorization Sectiow July 2001 5
33. cimetidine fora minimumofone month and therapy failed orhas the recipienthad an adverse drug reaction 1 Ifyes approve PA requestforup to 365days 2 Ifno you willreceive the following message Yourpriorauthorization requestrequires additionalinformation Please submit yourrequestonpaperwith complete clinicaldocumentation Othermis sing information may also necessitate manualprocessing OVER Asthe pharmacist you have learned ofthis diagnosis orreason foruse when a The patienthas informed you through patient consultation In most cases itis possible to learn the necessary information fromthe patient Thephysician wrote the diagnosis orreason foruse on this formoronapriorprescription orderforthis drug The physician orpersonnelin the physician s officeinformed you by telephone eithernow oron aprevious occasion Assigned Prior Authorization Number Grant Date Expiration Date NumberofDays Approved This is a New Prior Authorization Request This is aRenewed Prior Authorization Request Diagnosis Code Description Choose the mostappropriate ICD 9 CM diagnosis Ifthe diagnosis is nota Food and Drug Administration approved diagnosis fora particulardrug you mustsubmitthe PA requestonapaperPA RequestForm Appendix 3 STAT PA Drug Worksheet Non Steroidal Anti l nflammatory Drugs for photocopying See the next page forthe optional STAT PA drug worksheet fornon steroidalanti inflammatory dr SA IDs This page w
34. claim that was originally paid or allowed at least in part by Wisconsin Medicaid Allowed status A Medicaid or Medicare claim that has at least one service that is reimbursable BadgerCare BadgerCare extends Medicaid coverage through a Medicaid expansion under Titles XIX and XXI to uninsured children and parents with incomes at or below 185 ofthe federal poverty leveland who meet other program requirements The goal of BadgerCare is to fill the gap between Medicaid and private insurance without supplanting or crowding out private insurance BadgerCare benefits are identical to the benefits and services covered by Wisconsin Medicaid and recipients health care is administered through the same delivery system CPT Current Procedural TerminologyA listing of descriptive terms and codes forreporting medical surgical therapeutic and diagnostic procedures These codes are developed updated and published annually by the American Medical Association and adopted for billing purposes by the Health Care Financing Administration HCFA and Wisconsin Medicaid Crossover claim A Medicare allowed claim fora dualentitlee sent to Wisconsin Medicaid for possible additional payment of the Medicare coinsurance and deductible Daily nursing facility rate The amount that a nursing facility is reimbursed for providing each day ofroutine health care services toa recipient who is a patient in the home Days Supply The estimat
35. contained in this and other Medicaid publications is used by the DHCF to resolve disputes regarding covered benefits that cannot be handled internally by HMOs under managed care arrangements Verifying Eligibility Wisconsin Medicaid providers should always verify a recipient s eligibility before providing services both to determine eligibility for the current date and to discover any limitations to the recipient s coverage Wisconsin Medicaid s Eligibility Verification System EVS provides eligibility information that providers can access anumberofways Refer to the Important Telephone Numbers page at the beginning ofthis section for detailed information on the methods of verifying eligibility If you are billing a pharmacy claimthrough real time Point of Sale POS eligibility verification is part ofthe claims submission process Handbook Organization The Pharmacy Handbook consists ofthe following sections Claims Submission Covered Services and Reimbursement e Drug Utilization Review and Pharmaceutical Care e Pharmacy Data Tables Prior Authorization In addition to the Pharmacy Handbook each M edicaid certified provideris issued a copy ofthe All Provider Handbook The A ll ProviderHandbookincludes the following subjects s Claims Submission Coordination of Benefits Covered and Noncovered Services Prior Authorization e Provider Certification Provider Resources e Provider
36. der number e Recipient s 10 digit Medicaid identification number e 11 digit National Drug Code NDC e Type ofservice code e Prescriber s Drug Enforcement Administration DEA number nternational Classification of Diseases Ninth Revision Clinical Modificatio CD 9 CM diagnosis code e Place of service code Requested grant date or date of service e Days supply quantity Refer to Appendices 2 through 6f this section fopptionallrug specific worksheets that can be used as guidelines for the information needed to request PA forSTAT PA authorized drugs Personal Computer Users Providers enter the PA information into the STAT PA software provided by Wisconsin Medichackccess the STAT PA software and user manual from the Wisconsin Medicaid Web sitewtvw dhfs state wi us medicaid pro viders should Select Provider Publications fromthe main menu Scrolldown and select STAT PA e Follow the steps indicated to ensure proper installation ofthe STAT PA software Pharmacy Handbook Prior Authorization Sectiow July 2001 13 Appendix Appendix 1 continued This software and user manual may also be obtained electronically through Wisconsin Medicaid s Bulletin Board System EDS EPIX Searchlight Instructions fordownloading the STAT PA software and user manual from EDS EPIX can be found at the end of this appendix Providers who are unable to access the Bulletin Board through their personal computer may request
37. dicate the date of the screen which must have been performed within one year from the date of receipt of the PA request by Wisconsin Medicaid A PA request is considered for approval if the request includes a statement or indication from the screener that a comprehensive HealthCheck screen was performed Documentation that a comprehensive HealthCheck screening occurred may be Submission of peer reviewed medical literature to support the proven efficacy ofthe requested use of the drug is required for PA outside of the diagnosis restriction Additionalinformation documenting the individual s need fortheservice and the appropriateness oftheservice being delivered may be requested fromthe provider Pharmacy Handbook Prior Authorization Sectiow July 2001 9 Lus ie je io Q i S pel o lt lt ng lt Prior Authorization Response Time 24 Hour Response For most drugs Wisconsin Medicaid responds by faxor telephone to the provider s paper PA request within 24hours ofthe receipt of the request The response consists ofan acknowledgment that the PA request was received by Wisconsin Medicaid Weekend and Holiday Processing Paper PA requests received by Wisconsin Medicaid Monday through Friday except holidays are handled as follows e Ifthe request is received before 1 p m central time Wisconsin Medicaid makes an attempt to notify the provider by telephone or fax
38. ding the following information y Normal weight percentile weight and number of pounds lost in a specified time V A specific medical problem which has caused the weight loss y Specific reasons why a diet of normal or pureed food cannot suffice Failure to thrive in infants with documentation providing the following information Weight and height percentile weight and height and numberofpounds lost ifany in a specified time period A specific medical problem or condition which has caused the failure to thrive Specific reasons why a diet of formula normal or pureed food cannot suffice Conditions that are not covered by Medicare such as products given by mouth y When justified by documentation indicating why normaland pureed food is not sufficient Noncovered Wisconsin Medicaid does not grant PA for Diagnoses Food supplements used by nursing facility recipients and included in the daily rate e Products which may be purchased in a grocery store drug store or other retail outlet with food stamps or with Women Infant and Children WIC stamps Individuals who receive food stamps or WIC assistance may be able to use these for purchasing enteral nutrition products Noncovered s wallowing and eating disorders include Swallowing disorders which may lead to aspiration Swallowing disorders which are psychosomatic in nature as in anorexia or dementia Reduced appetite due to side effects of drug products as with met
39. e obtained for any subsequent refills Refer to the Covered Services section ofthis handbook for Special Handling information Change From One Ulcer Treatment Drug or Angiotensin Converting Enzyme Inhibitor to Another When a prescription for one ulcer treatment drug or ACE Inhibitoris changed to another ulcertreatment drug or ACE Inhibitor the first PA must be enddated in orderto obtain approvalofthe new drug To do this providers should callthe STAT PA Help Desk for assistance through the process The provider holding the original PA willbe notified in writing that the PA has been enddated A new PA numberand a confirmation notice willbe sent to theproviderrequesting PA 6 Wisconsin Medicaid and BadgerCaree J uly 2001 Paper Prior Authorization Follow Up to a Paper Prior Authorization Request A PA request submitted to Wisconsin Medicaid Obtaining Forms may be approved returned or denied Sample PA RFs PA DGAs for legend drugs and enteralnutrition products andcompletion When the PA request is approved amp 2 and submittalinstructions foreach form can be el m found in Appendices 7 through 11 ofthis e The approved boxis checked yo Requests for section e The grant and expiration dates are 5 4 services which indicated s have been Obtain PA RFs by calling Provider Services at e A signature and a date signed are previousiy denied 800 947 9627 or 608 221 9883 orby writing indicated must be to e A specific
40. ealth Care Financing Administration HCFA to supplement CPT codes HealthCheck Program which provides Medicaid eligible children underage 21 with regular health screenings 1 9 International Classification of Diseases Ninth Revision Clinical Modification Nomenclature for medical diagnoses required for billing Available through the American Hospital Association LOS Levelof Service Field required when billing Pharmaceutical Care services or compound drugs indicating the time associated with the service provided Maximum allowable fee schedule A listing ofallprocedure codes allowed by Wisconsin Medicaid fora providertype and Wisconsin Medicaid s maximum allowable fee foreach procedure code Medicaid Medicaid is a joint federal s tate programes tab lhs hed in 1965 under Title XIX of the SocialSecurity Act to pay formedicalservices for people with disabilities people 65 years and older children and their caretakers and pregnant women who meet the program s financial requirements The purpose of Medicaid is to provide reimbursement forand assure the availability of appropriate medical care to persons who meet the criteria for Medicaid Medicaid is also known as the MedicalAssistance Program Title XIX or T19 Medically necessary According to HFS 101 03 96m Wis Admin Code a Medicaid service that is a Required to prevent identify ortreat a recipient s illness injury or disability and b Me
41. ed days supply oftablets capsules fluids cc s etc that has been prescribed forthe recipient Days supply is not the duration of treatment but the expected number of days the drug willbe used DHCF Division of Health Care Financing The DHCF administers Wisconsin Medicaid for the Department of Health and Family Services DHFS under statutory provisions administrative rules and the state s Medicaid plan The state s Medicaid plan is a comprehensive description ofthe state s Medicaid program that provides the Health Care Financing Administration HCFA and the U S Department of Health and Human Services DHHS assurances that the programis administered in conformity with federal law and HCFA policy DHFS Wisconsin Department of Health and Family Services The DHFS administers the Wisconsin Medicaid program Its primary mission is to fosterhealthy self reliant individuals and families by promoting independence and community responsibility strengthening families encouraging healthy behaviors protecting vulnerable children adults and families preventing individualand social problems and providi services of value to taxpayers DHHS Department of Health and Human Services The United States government s principalagency for protecting the health ofall A mericans and providing essential human services especially for those who are least able to help themselves The DHHS includes more than 300 pro
42. er is advised to obtainlin approved Medicaid PA first before dispensing the service If Medicare denies the claim Wisconsin Medicaid may then reimburse back to the authorized PA date e Complete the section ofthe PA drug attachment forenteral nutrition products Use HCFA Common Procedure Coding System HCPCS codes instead of National Drug Code codes and billon the HCFA 1500 claim form Refer toAppendix 17 of this section for billing codes forenteral nutrition products Pharmacy Handbook Prior Authorization Sectiow July 2001 59 Appendix Fertility Enhancing Drugs Approval Criteria Indicated foruse forconditions otherthan the treatment of infertility Documentation must indicate the medical necessity of this product over any other product available forthe treatment in question Specific Wisconsin Medicaid may approve these drugs only fortreatments otherthan infertility Requirements Human Growth Hormone Somatrem Human Growth Hormone Somatropin Somatropin Recombinant rDNA origin Serostim Approval Criteria Indicated for growth deficiency in children Indicated forthe treatment for A IDS wasting or cachexia Specific The prescriber must be an endocrinologist Refer to the questionnaire inAppendix 17 Requirements ora pediatric endocrinologist ofthis section that mustbe completed by thi The recipient s age must be 20 years or prescribing physician under This criterion may be waived ifthe skeletal age is docu
43. escribing or dosing limits for the indicated use L The daily dose and duration are not within compendial standards general prescribing or dosing limits for the intended use Attach or reference peer reviewed literature which indicates this dose is appropriate or document the medical necessity of this dosing difference Reference include publication name date and page number Additional Information Required for Enteral Nutrition Supplements Height Percentile children only Weight Percentile children only Amount of weight loss if any and within what specific time span checkall that apply This recipient is tube fed If not tube fed number of Kcal prescribed per day Percent total calories from this supplement 96 This recipient can consume most normal table foods This recipient can consume softened mashed pureed or blenderized food This recipient has a clinical condition as indicated in Section C which prevents him her from consuming normal table and softened mashed pureed or blenderized foods Comprehensive documentation of this recipients condition is presented above in Section C Clinical Information D U U U U U This recipient is eligible for food stamps m This product or a similar product can be obtained from VVIC Signature Date Check the appropriate box Please notify me of approval denial by D Fax D Telephone CINo notice needed The pharmacist dispenser must review information and si
44. ets the following standards 1 Isconsistent with the recipient s symptoms or with prevention diagnosis ortreatment ofthe recipient s illness injury ordisability 2 Isprovided consistent with standards of acceptable quality of care applicable to type of service the type of provider and the setting in which the service is provided 3 Is appropriate with regard to generally accepted standards of medical practice 4 Is not medically contraindicated with regard to the recipient s diagnoses the recipient s symptoms or other medically necessary services being provided to the recipient 5 Is of proven medical value or usefulness and consistent with s HFS 107 035 is not experimentalin nature 6 Is not duplicative with respect to other services being provided to the recipient 7 Isnotsolely forthe convenience of the recipient the recipient s family ora provider 8 With respect to prior authorization ofa service and to other prospective coverage determinations made by the department is cost effective compared to an alternative medically necessary service which is reasonably accessible to the recipient 9 Is the most appropriate supply or level or service that can safely and effectively be provided to the recipient NCPDP National Council for Prescription Drug Programs This entity governs the telecommunication formats used to submit prescription claims electronically NDC National Drug Code An 11 digit c
45. gn and date this form Appendix 12 Prior Authorization Fax Procedures Providers may faxprior authorization PA requests to Wisconsin Medicaid at 608 221 8616 Prior authorization requests sentto any Wisconsin Medicaid faxnumber otherthan 608 221 8616 may result in processing delays When faxing PA requests to Wisconsin Medicaid providers should be aware of the following Faxing a PA request eliminates one to three days of mail time However the adjudication time ofthe P4 request hasnotchanged Allactions regarding PA requests are made within the time frames outlined 1 the Prior Authorization section of the All Provider Handbook Faxed PA requests must be received by 1 00 p m otherwise they willbe considered as received the following business day Faxed PA requests received on Saturday or Sunday willbe processed on the next business day x pu ddy After faxing a PA request providersshould notsend the original paperwork such as the carbon PA request form PA RF by mail Mailing the original paperwork after faxing the PA request will create duplicate PA requests in the system and may result in a delay of several days to process the faxed PA request Providers should not photocopy and reuse the same PF RF for otherrequests When submittiregya request for PA it must be submitted on a new PA RF so that the request is processed undemavPA number This requirement applies whether the PA request is submitted by faxorby mail
46. grams covering a wide spectrum of activities including overseeing Medicare and Medicaid medical and social science research preventing outbreak of infectious disease assuring food and drug safety and providing financial assistance for low income families DOS Date of service The calendar date on which a specific medicalservice is performed Dual entitlee A recipient who is eligible forboth Medicaid and Medicare either Medicare Part A Part B or both Pharmacy Handbook Prior Authorization Sectiow July 2001 69 Glossary EMC Electronic Media Claims Method of claims submission through a personalcomputer or mainframe system Claims can be mailed on tape or trans mitted via telephoneand modem Emergency services Those services which are necessary to prevent death or serious impairment of the health of the individual For the Medicaid managed care definition of emergency refer to the Managed Care Guide or the Medicaid managed care contract EOB Explanation of Benefits Appears on the provider s Remittance and Status R S Report and informs Medicaid providers ofthe status of or action taken on their claims EVS Eligibility Verification System Wisconsin Medicaid encourages all providers to verify eligibility before rendering services both to determine eligibility for the current date and to discover any limitations to a recipient s coverage Providers may access recipient eligibility information thro
47. gy Prior Authorization STAT PA systemis an electronic PA system that allows Medicaid certified pharmacy providers to receive PA electronically rather than by mail or fax Providers answer a series of questions and receive an immediate response of an approved orreturned PA Providers communicate with the Wisconsin STAT PA systemby entering requested information on a personalcomputer screen a touch tone telephone keypad orby calling a STAT PA help desk correspondent Providers must have their eight digit Medicaid provider number to access the Wisconsin STAT PA system The Wisconsin STAT PA systemis available to all pharmacy providers by calling one of the following telephone numbers Personal Touch tone Help Computers Telephones Desk 800 947 4947 800 947 1197 800 947 1197 608 221 1233 608 221 2096 608 221 2096 x ipu ddy Available from 8 00 a m Available from 8 00 a m Available from 8 00 a m to 11 45 p m to 11 45 p m to 6 00 p m seven days a week seven days a week Mondaythrough Friday excluding holidays How to Use Wisconsin STAT PA Wisconsin STAT PA complements the current PA process by eliminating the paperworkinvolved forseveralclasses of drugs Wisconsin STAT PA allows the provider to ans wera series of questions in order to receive an immediate response of an approved orreturned PA Providers need the following information to begin using the STAT PA software Hight digit Medicaid provi
48. hylphenidate amphetamines appetite suppressants etc Mastication problems due to dentition problems i e lack of teeth Pharmacy Handbook Prior Authorization Sectiow July 2001 61 Appendix U U U LU LU LU U LU N N N N N N N N N O o o p Appendix 16 continued Enteral Nutrition Products Billing Codes Effective August 1 1996 Units Container DHCF MAC Unit 2 ni 00 Q HCPCS B4150 B4150 B4150 Q sure High Pro B4150 ight B4150 ttain noice DM U N D m m D gt b B s ep o o KD TI lO KD 2 d D p Io 2 Bg E C LU L U N O B4150 B4150 B4150 0 L B4150 LD D v EH v 2 z 2122 E L o opt TI Q 5 6 KD S 5 D D B B 8 S jo a B G EB bo n e b i R io B m o iz KD o KD D ca E b I 2 dr 0 lt E SE E I E FU d RU 5 2e B 3 D 84 4150 D 84 4150 Nutren 1 0 fiber B4150 B4150 B4150 Osmolite B4150 B4150 Promote B4150 B4150 B4150 B4150 Promote Fiber eso ep Resource Fruit Bevrge ustacal lig Units Container o Z C E os om om om om om om os om om om om os om om om om OMpied Q HCPCS HCFA Common Procedure Coding System DHFS Department of Health and Family Services MAC Maximum allowed cost 62 W
49. ice may be up to 31 calendar days in the future This allows recipients to get prescription orders filled early so there are no lapses in their medication Pharmacy Handbook Prior Authorization Sectioe July 2001 15 Appendix Appendix 1 continued 5 Inthe event the STAT PA systemis unavailable at the time the prescription order is filled the PA request may be backdated up to four calendar days 6 Providers are assigned a PA numberforthe request at the end ofa completed transaction Use and retain the STAT PA assigned PA numberforclaims submission or if advised submit a PA requeston paperif more clinical documentation is needed Note When submitting a paper PA request please include a faxnumber if available on the request This will enable Wisconsin Medicaid to reply to that number 7 The decimal point for diagnosis codes is not required when entering a STAT PA request STAT PA Help Desk Users Providers who do not have a touch tone telephone ora personal computer may callthe STAT PA help desk The help desk correspondent has the personalcomputersoftware to access STAT PA and enters the required data requested fromthe provider Forthe help desk call 800 947 1197 or 608 221 2096 The STAT PA help desk is available to all pharmacy providers using STAT PA Providers may use the help desk to order software fora personalcomputer orto report difficulties with the system Refer to Appendices 2 through 6f this section fopptional
50. isconsin Medicaid and BadgerCaree J uly 2001 Appendix 16 continued Enteral Nutrition Products Billing Codes Effective August 1 1996 OQ RE 2 4151 Maned 2 250 1 64 B4152 0 70 B4152 Ensure Plus 0 70 B4 nsure P 60 0 70 aise liosurei amp CL an 0 70 B4152 0 70 B4152 Magnacal 0 70 B4152 NupascsPlus 00005 azi 0 70 paisa 35 0 70 B4152 0 70 B4152 0 70 B4 Reso e P 60 0 70 B4152 0 70 B4152 0 70 B4 stacal P 60 0 70 Baqa Two 0 70 xx033 1 60 1 00 xx044 Peptamin Peptamin 5 250 1 30 xx049 0 85 x ipu ddy 0 plena BR 4 80 Q xx064 MCT Oil 74 21 1 03 xx065 0 94 068 ose Par gm 4 00 0 66 0 75 Note Call Sandmerc at 877 735 1326 for product codes not listed here Pharmacy Handbook Prior Authorization Sectiow July 2001 63 Appendix 64 Wisconsin Medicaid and BadgerCaree J uly 2001 Appendix 17 Human Growth Hormone Serostim Serono Somatropin rDNA Origin Questionnaire for photocopying See the next page for the questionnaire forhuman growth hormone Seros Gmmatropin This page was intentionally left blank x ipu ddy Pharmacy Handbook Prior Authorization Sectiow July 2001 65 Appendix This page was intentionally left blank 66 Wisconsin Medicaid and BadgerCaree J uly 2001 Human Growth Hormone Serostim Serono Somatropin rDNA Origin Questionnaire Prior Authorization Request Form PA RF must be co
51. l This formisnot required butis provided asa guideline only to access STAT PA oras provider documentation The STAT PA system willask forthe following items in the orderlisted below Provider Number Recipient Medicaid Identification Number Recipient Name National Drug Code NDC Procedure Code of Product Requested Type ofService D Prescriber s Drug Enforcement Administration DEA Number Diagnosis Code Use the recipient sInternational Classification ofDiseases Ninth Revision Clinical Modification ICD 9 CM diagnosis code The decimalis notnecessary Place of Service Date of Service The date ofservice may be up to 31 days in the future orup to fourdays in the past Days Supply Requested STAT PA Request Checklist ALL information must be checked within each category in orderto be processed electronically A Entertherecipient s height in inches using atwo digit format Forexample ifthe recipient s height is 5 10 enter 70 B Entertherecipient s weight in pounds using a three digit format 1 STATPA willthen calculate the body mass index BM D using a formula a IfBMIis gt 30 the PA willbe approved fora maximumof186days b 15 lt 30 you willreceive the following message Yourpriorauthorization request requires additional information Please submit yourrequest on paperwith complete clinicaldocumentation OVER Asthe pharmacist you have learned ofthis diagnosis orreason foruse when
52. l nutrition products This formcan also be downloaded from the Wisconsin Medicaid Web site locatedhatbw dhfs state wi us medicaid x ipu ddy This page was intentionally left blank Pharmacy Handbook Prior Authorization Sectiow July 2001 49 Appendix This page was intentionally left blank 50 Wisconsin Medicaid and BadgerCaree J uly 2001 Mail To Wisconsin Medicaid PA D G A 1 Complete the PA DGA PriorAuthorization 2 Attach to the Prior i m 1 i R F dee Kd Prior Authorization ABE N equest Tom Madison WI 53784 0088 Drug DMS Attachment 3 Mail to Wisconsin Medicaid FOR ENTERAL NUTRITION PRODUCTS 15 t Last Name First Name Identification Number Recipient information Section A Type of Request Indicate start date requested date prescription filled required checkone This is an initial prior authorization request for this drug for this recipient by this provider Q Thisis a request to renew or extend previously prior authorized therapy using this drug First PA LC This is a request to change or add a new NDC number to a current valid PA PA NDC to add Section B Prescription Information complete Section B orattach a copy of the prescription order Drug Name Strength Quantity Ordered 2 s Directions for use Daily Dose Refills Prescriber Name uu DEA Number Brand Medically Necessary is hand
53. ld reflect the provider s usualand customary charge forthe procedure requested Providers are reimbursed for authorized services according to the Department of Health and Social Service s Terms of Provider Reimbursement Element 21 Total Charge Enter the anticipated totalcharge for this request Element 22 Billing Claim Payment Clarification Statement An approved authorization does not guarantee payment Reimbursement is contingent upon the recipient s and provider s eligibility at the time the service is provided and the completeness ofthe claiminformation Payment is not made for services initiated prior to approval or after authorization expiration Reimbursement is in accordance with Wisconsin Medicaid methodology and policy Ifthe recipient is enrolled in a commercial managed care programat the time a prior authorized service is provided W isconsin Medicaid reimbursement is only allowed if the service is not covered by the commercial managed care program and PA has been obtained Element 23 Date Enter the month day and year in MM DD YYYY format the PA RF was completed and signed Element 24 Requesting Provider s Signature The signature of the provider requesting performing dis pens ing the service procedure item must appear in this element DO NOT ENTER ANY INFORMATION BELOW THE SIGNATURE OF THE REQUESTING PROVIDER THIS SPACE IS USED BY WISCONSIN MEDICAID CONSULTANTS AND ANALYSTS Pharmacy Handbook
54. lendardays 6 Providers are assigned a PA number for the request at the end ofa completed transaction Providers are reminded to use and retain the STA T PA assigned PA number for claims submission or if advised to submit a PA request on paper if more clinicaldocumentation is needed Note When submitting a paper PA request please include a faxnumber if available on the request 14 Wisconsin Medicaid and BadgerCaree July 2001 Appendix 1 continued Telephone Users Call 800 947 1197 or 608 221 2096 Providers willthen be connected directly with the STAT PA system W hen the system answers it willaska series of questions that providers answer by entering the information on the telephone keypad Use the optional worksheets found ippendices 2 through 6f this section as guidelines forthe information needed to request PA forSTAT PA authorized drugs Note When using atouch tone telephone to enter the Medicaid provider number recipient identification number procedure code type ofservice code ICD 9 CM diagnosis code place ofservice code requested grant date and quantity always press the pound sign to mark the end ofthe data just entered The pound sign signals th asses systemthat the providerhas finished entering the data requested and ensures the quickest response fromthe system Providers may be asked to enter alphabetic data which can be entered by using the asterisk key Forexample a provider is asked to e
55. lrug specific worksheets that can be used as guidelines for the information needed to request PA for STAT PA authorized drugs Once alldata have been entered completely STAT PA begins to process the information and in minutes indicates the PA number and if approved the authorized LOS Helpful Hints For Help Desk Users 1 Iftheprovideris unable to provide the necessary information to the help desk correspondent the provider is asked to callback with the necessary information 2 The provideris limited to five transactions per connection 3 When asked to give the requested date of service of the PA the date of service may be up to 31 calendar days in the future This allows recipients to get prescription orders filled early so there are no lapses in their medication 4 Intheeventthe STAT PA system is unavailable at the time the prescription order is filled the PA request may be backdated up to four calendar days 5 Providers are assigned a PA numberforthe request at the end ofthe completed transaction Use and retain the STAT PA assigned PA number forclaims submission or if advised to submit a PA request on paper if more clinical documentation is needed Note When submitting a paper PA please include a faxnumber if available on the request 6 Providers needing to enddate a PA request due to a change in a prescription may do so through the help desk The help deskcorrespondent willassist the provider through this process N
56. mented to be less tha 18 years The results of growth stimulation testing must be a value of less than 12 nanogramg mlof growth hormone 60 Wisconsin Medicaid and BadgerCaree J uly 2001 Appendix 16 Food Supplement Prior Authorization Guidelines Authority HFS 107 10 2 c Wis Admin Code states that prior authorization PA is required for all fook supplement or replacement products Medically necessary specially formulated enteral nutrition products are used for the treatment b f health conditions such as pathology ofthe gastrointestinal tract or metabolic disorders Nas ogastric or gastrostomy tube feeding Malabsorption diagnoses including V Short Bowel Gut Syndrome V Crohn s Disease V Pancreatic Insufficiency Metabolic disorders including cystic fibrosis Limited volumetric tolerance requiring a concentrated source of nutrition i e athetoid cerebral palsy with high metabolic rate Severe s wallowing and eating disorders where consistency and nutritionalrequirements be metonly using commercial nutritional supplements including refer below to no covelkd swallo wing and eating disorders y Dysphagia due to excoriation oforal pharyngeal mucosa x ipu ddy y Mechanical s wallowing dysfunction secondary to a disease process suchas e Cancer or herpetic stomatitis e Oral pharyngeal trauma such as burns Otheroral pharyngealtissue injury Weightloss with documentation provi
57. mpleted and signed bya physician experienced in the diagnosis and management of acquired immune deficiency syndrome AIDS Please enclose separate sheets for answers requiring more space than is provided on this form Recipient Name Recipient Medicaid Number 10 11 12 13 Diagnosis Does this patient have human immune deficiency virus HIV with serum antibodies to HIV YES NO Isthe patient at least 18 years of age YES NO must be at least 18 years of age to qualify If the patient is a female is she pregnant or lactating YES NO Current Medical Condition of the Patient Does the patient have any signs or symptoms of AIDS or associated illnesses YES NO Does the patient have an untreated or suspected serious systemic infection or persisent fever greater than 101 degrees Fahrenheit YES NO Does the patient have an active malignancy other than Kapos s Sarcoma YES NO Is the patient receiving antiretroviral therapy concurrently with human growth homone The patient mus be on an antiretroviral therapy that is approved or available under a treatment IND and agree to continue antiretroviral medication while taking Serosim Individuals on 3TC mus also be receiving AZT YES MO Individuals with documented hypogonadisn may be on replacement therapy with gonadal steroids Is this the case with this patient YES NO Evidence of Wasting Syndrome Patient s height Patients usual weight
58. n explaining the need for the product requested Source for Clinical Information Checkthe appropriate boxindicating the primary source used to obtain yourinformation Use Any ofthe compendialstandards may be used If an intended use is not in the drug package insertmayuvant to check the United States Pharmacopeia Drug Information USP DI this reference is most inclusive for diagnoses Ifa drug use is not listed in compendial standards it may still be covered Therefore the PA RF foundppendix8 of this section and PA DGA found inAppendices 10 and11 ofthis section must be submitted for processing and denied before you tell arecipient a particular drug is not covered by Wisconsin Medicaid Dose Any ofthe compendialstandards may be used If an intended use is not in the drug package insertmaguwant to check the USP DI this reference is most inclusive for diagnosis Additional Information Required for Enteral Nutrition Supplements Use the form found inAppendix 11 of this section Check all boxes that apply Complete this section ywhen an enteral nutritional supplement is requested Signature of Pharmacist The pharmacist must review the information and sign the PA DGA form verifying that the informatioarisurate to the bestofhis orherknowledge 46 Wisconsin Medicaid and BadgerCaree J uly 2001 Appendix 10 Prior Authorization Drug Attachment For Legend Drugs for photocopying See reverse side of this page forthe Prior Authorizati
59. nt s last name fromthe recipient s Medicaid identification ID card Use the Eligibility Verification System EVS to obtain the correct spelling of the recipient s name Ifthe name orspelling ofthe name on the Medicaid ID card and the EVS do not match use the spelling from the EVS Element 2 Recipient s First Name Indicate the recipient s first name from the recipient s Medicaid ID card Use the EVS to obtain the correct spelling ofthe recipient s name If the name or spelling ofthe name on the Medicaid ID card and the EVS do not match use the spelling from the EVS Element 3 Recipient s Middle Initial Indicate the recipient s middle initial from the recipient s Medicaid ID card Element 4 Recipient s Wisconsin Medicaid Identification Number Enter the recipient s 10 digit Medicaid ID number Do not enter any other numbers or letters Element 5 Recipient s Age Indicate the age of the recipient in numerical form e g 21 45 60 Pharmacy Handbook Prior Authorization Sectiow July 2001 45 Appendix Section A Type of Request Checkthe appropriate boxindicating whetherornotthis product has been requested previously Section B Prescription I nformation If you complete this section you do not need to include a copy ofthe prescription documentation used to dispense the product requested Section C Clinical Information Include diagnostic information as wellas clinical informatio
60. ntera prescriber s DEA number The first two characters in the prescriber s DEA number are alpha characters therefore the provider presses the single asterisk followed by the two digits that indicate the letter The fir digit is the number on the keypad where the letter is located and the second digit is the position of the letter on that key For example gt o p D 2 2 x Prescriber s DEA number AB1234567entered as 21 221234567 cemere bep ew esmeesiae ue IE neri Note Referto the Claims Submission section of this handbook fbafault codes ifthe DEA number cannot be obtained Once alldata have been entered completely STAT PA begins to process the information and in minutes indicates the PA numberand if approved the authorized levelof service LOS Once familiar with the STAT PA system providers may enterthe PA information in the designated order immediately there is no need to wait forthe full voice prompt Providers may key information at any time even when the systemis relaying information The systemautomatically proceeds to the next function Helpful Hints For Telephone Users 1 Theprovideris given three attempts at each field to correctly enter the requested data 2 Failure to enterany data within three minutes ends the telephone connection 3 Theprovideris limited to five transactions perconnection 4 When entering the requested date of service ofthe PA the date of serv
61. ode assigned to each drug The first five numbers indicate the labeler code Health Care Financing Administration HCFA assigned the next fournumbers indicate the drug and strength labeler assigned and the remaining two numbers indicate the package size labeler assigned OBRA Omnibus Budget Reconciliation Act Federal legislation that defines Medicaid drug coverage requirements and drug rebate rules OTC Over the counter Drugs that non Medicaid recipients can obtain without a prescription PA Prior authorization The electronic or written authorization issued by the Department of Health and Family Services DHFS to a provider priorto the provision ofa service POS Place of service A single digit code which identifies the place where the service was performed POS Point of Sale A system that enables Medicaid providers to submit electronic pharmacy claims in an on line real time environment R S Report Remittance and Status Report A statement generated by the Medicaid fiscalagent to inform providers regarding the processing of their claims Real time processing Immediate electronic claim transaction allowing foran electronic pay ordeny response within seconds of submitting the claim Real time response Information returned to a provider fora real time claim indicating claim payment or denial Pharmacy Handbook Prior Authorization Sectiow July 2001 71 Glossary STAT PA Specialized Transmi
62. on Drug Attachment PA DGA for legend drugs This formcan also be downloaded fromthe Wisconsin Medicaid Web site locatedsatw dhfs state wi us medicaid x ipu ddy This page was intentionally left blank Pharmacy Handbook Prior Authorization Sectiow July 2001 47 Mail To Wisconsin Medicaid PA D G A 1 Complete the PA DGA 2 PriorAuthorization Attach to the Prior Suite 88 Prior Authorization Authorization Request Form 6406 Bridge Rd Drug DMS Attachment PA RF Madison WI 53784 0088 FOR LEGEND DRUGS 3 Mail to Wisconsin Medicaid Recipient Information 9 Q 9 1 11 Lag Name FirstName Ml Identification Number Age Section A Type of Request Indicate start date requested date prescription filled required D Thisprior authorization request for this drug for this recipient by thisproviderisQ New D Renewal Section B Prescription Information complete Section B or attach a copy of the prescription order Drug Name Strength 0002070000 Quantity Ordered Date order issued Directions for use Daily Dose Refills Prescriber Name DEA Number Brand Medically Necessary is handwritten by the prescriber on the prescription order Yes UNo Section C Clinical Information List the recipient scondition the prescribed drug isintended to treat Include ICD 9 CM diagnosiscodes and the expected length of need If requesting a renewal or continuation of a previous prior authorization
63. ote The provider holding the original PA is notified in writing that a PA has been enddated 16 Wisconsin Medicaid and BadgerCaree July 2001 Appendix 1 continued Documentation l nformation Providers are required to retain the assigned PA number for e Use in claims submission if approved e Submission ofa paper PA request when more clinical documentation is needed Regardless of what STA T PA method is used providers willreceive by mail a confirmation notice indicating the assigned PA number and the STA T PA decision This confirmation notice should be maintained as a permanent record of the transaction Providers must also maintain alldocumentation that supports medical necessity claim information and delivery of equipment in theirrecords fora period not less than five years Downloading STAT PA software and user manual from the EDS EPI X bulletin board 1 Ifthis is the first time you willbe installing STA T PA software on your computer we recommend that you create a directory on your hard drive specifically for your STA T PA software To do this type the following command at the C promptin DOS x pu ddy MD STAT PA ENTER 2 Setup yourcommunications software to dial EDS EPIX A long with the telephone number you may need to program your software to dial with the following settings Phone Number 608 221 8824 Stop Bits 1 Baud Rate 14 400 maximum Duplex Full Parity None Protocol ZMODEM recommended
64. paperPA requests Obtaining Prior Authorization Wisconsin Medicaid has the authority to require prior authorization PA for certain drug products under HFS 107 10 2 Wis Admin Code and the federal Omnibus Budget Reconciliation Acts of 1990and 1993 OBRA 90 and 93 Most drugs do not require PA For some drugs that do require PA providers may submit PA requests through the Wisconsin Specialized Trans mission ApprovalTechnology Prior Authorization STAT PA system Other drugs require paper PA requests Refer to Appendices 13 and 15 of this section for approval criteria for STAT PA and paper drugs and drug categories Refer to the Prior Authorization section of the All Provider Handbook for general information on obtaining PA including emergency situations appeal procedures supporting materials retroactive authorization recipient loss ofeligibility midway through treatment and PA for providers from other states The Wisconsin STAT PA System The Wisconsin STAT PA systemis a PA systemthat allows Medicaid certified pharmacy providers to request and receive PA electronically rather than on paper for certain drugs The Wisconsin STAT PA systemcan be accessed in the following ways and at the following times e Personalcomputer available 8 00 a m to 11 45 p m seven days a week e Touchtone telephone available 8 00 a m to 11 45 p m seven days a week e Help desk available 8 00 a m to 6 00 p m Mond
65. prior to diagnosis of HIV Patient s current weight Does the patient have an unintentional weight loss of at least 1096 from baseline premorbid weight YES NO Does the patient have an obstruction or malabsorption to the degree to account for the weight loss YES MOM 20 All of the Following Procedures Are to Be Tried Before Beginning a Course of Therapy with Human Growth Hormone The patient must be receiving at least 100 of estimated caloric requirement on his her current regimen Please include the type and use of enteral nutrition product s used with weight status before and after use how long the course of treatment was used and why or if the treatment was discontinued Individuals receiving assisted enteral or parenteral nutrition must be weight stable for at least two months or have persistent weight loss despite such interventions and must still meet the eligibility of criterion 12 A course of generally accepted therapy with megesterol acetate and or dronabinol for appetite stimulation must have been tried Please describe the program of treatment and how long the treatment was used and why the treatment was discontinued A course of therapy using dihydrotestosterone this has Orphan Drug Product Designation for the treatment of weight loss in HIV postive and AIDS patients must be tried for suitable patients Please describe the physician s program of treatment and how long the course of treatment wa
66. responding diagnosis codes and disease descriptions If providers use an unapproved diagnosis code for that drug the claim willbe denied and providers will get a message that Ifthe service is approved Wisconsin Medicaid paper PA request is required assigns a procedure code forthe service on the PA request These procedure codes are Note Ifthe claim was submitted through then billed on a HCFA 1500 claim form electronic media claims oron paper the message willappearin the provider s Remittance and Status Report Note Referto the Pharmacy Data Tables section of this handbook fora list of HealthCheck Other Services drugs that do not require PA butstillrequire Claims using diagnosis codes are monitored by evidence of a HealthCheck Division of Health Care Financing DHCF screening auditors A provider is expected to have reasonable readily retrievable documentation to verify the accuracy of the diagnosis for the original prescription This documentation must show the diagnosis was provided by the prescription someone in the prescriber s office orby the recipient The diagnosis should be reasonably comprehensive not just the provided by the screener through use ofthe single word definition of thinternational HealthCheck Verification Card or on the Classification of Diseases Ninth Revision prescription This documentation mustbe Clinical Modification ICD 9 CM code signed by the screenerand must in
67. s the results of the treatment and why the treatment was discontinued A course of therapy with a protease inhibitor either alone or concurently with one or more nucleosides must have been tried Please describe the program of treatment how long the course of therapy was and why the treatment was discontinued This course of therapy snould last at least 24 weeks before the planned initiation of Serostim Manufacturer s Treatment Guidelines Upon completion of two weels treatment please assess the patient s weight status If the patient has no weight loss during the two week trial continue for an additional 10 weeks therapy Initial weight Weight after two weeks of therapy Upon completion of two weeks treatment in cases where patient continues to lose weight please rule out underlying causes for weight loss If the patient is not experiencing additional condition s contributing to weight loss continue for an additional four weeks therapy Continued weight loss precludes additional use beyond the six weeks If patient s weight increases during the additional four week therapy continue for an additional six weeks therapy Weight after Sx weeks of therapy Weight after 12 weeks of therapy Efficacy of this drug beyond 12 weeks has not been established Wisconsin Medicaid may approve initial therapy only to a maximum of 12 weeks Physician s Signature Date Glossary of Common Terms Adjustment A modified orchanged
68. s to either diagnosis codes orpriorauthorization PA As with allinnovatordrugs prescribers must write Brand Medically Necessary onallhard copies ofthe prescriptions andon each new nursing facility ordersheet In addition to the generic drugs the following brand name drugs are also available without PA restrictions Captopril Enalapril Trandolapri M oexipril REMINDER The Specialized Transmission Approval Technology PA STAT PA Drug Work sheetaptional This formisnot required butis providedasa guideline only toaccessSTAT PA orasproviderdocumentation The STAT PA systemwillask forthe following items in the orderlisted below Provider Number Recipient Medicaid Identification Number Recipient Name National Drug Code NDC Procedure Code of Product Requested TypeofService D Prescriber s Drug Enforcement Administration DEA Number Diagnosis Code Use the recipient sInternational Classification ofDiseases Ninth Revision Clinical Modification ICD 9 CM diagnosis code The decimalis not necessary Place of Service Date ofService ____ The date ofservice may be up to 31 days in the future orup to fourdays in the past Days Supply Requested STAT PA Request Checklist ALL information must be checked within each category in orderto be processed electronically A Isthepatientcurrently stabilized orbeing titrated on an A CEInhibitorotherthan captopril enalapril trandolapril or moexipril 1 Ifyes approve
69. ssion Approval Technology Prior Authorization An electronic PA systemthat allows Medicaid certified pharmacy providers to request and receive PA electronically rather than by mail for certain drugs Switch transmissions System that routes real time transmissions froma pharmacy to the processor Also called Clearinghouse or Value Added Network VAN system TOS Type ofservice A single digit code which identifies the general category ofa procedure code 72 Wisconsin Medicaid and BadgerCaree J uly 2001 Index Backdating prior authorizations 10 Diagnosis restricted drugs 9 57 60 Enteral nutrition products 59 61 63 HealthCheck Other Services 8 Paper prior authorization Covered rebated drug categories 7 Covered non rebated drugs 8 Diagnosis restricted drugs 9 57 60 Enteral nutrition products 59 61 63 Faxing requests 7 53 Health Check Other Services 8 Mailing requests 7 Obtaining forms 7 Overview 7 Prior authorization request form 7 9 39 43 53 Prior authorization request form for enteral nutrition products 7 9 45 46 49 52 Prior authorization request form for legend drugs 7 9 45 48 Response time for prior authorization 10 STAT PA Dispensing drugs when system is unavailable 6 Drug worksheets 19 38 Follow up to a STAT PA request 5 Overview 5 STAT PA drugs 5 19 38 55 System instructions 13 18 Pharmacy Handbook Prior Authorization Sectioe July 2001 73
70. t indicated Requirements When systematic anti Kaposi s Sarcoma therapy is required more than 10 new lesions the prior month In the presence ofsymptomatic lymphedema In the presence ofsymptomatic pulmonary KS In the presence of symptomatic visceral involvement Drugs That May Be Used fora Condition Other Than for the Treatment of Impotence Approval Criteria Indicated foruse fora condition other than the treatment of impotence Documentation mug indicate the medicalnecessity ofthis product overany other product available forthe treatment in question x ipu ddy After March 1 1997 Wisconsin Medicaid requires prior authorization PA forthe followin drugs Alprostadil Systemic Prostin VR Pediatric Vasoprost Phentolamine Systemic Regitine Phentolamine Oral Vasomax Specific Requirements Noncovered After March 1 1997 Wisconsin Medicaid does not coverthe following impotence drugs Diagnoses AlprostadilIntracavernosal Caverject Edex UrethralSuppository Muse Phentolamine Intracavernosal Regitine Yohimbine Sildenafil Viagra Wisconsin Medicaid denies PA requests forthe above noncovered drugs ww Enteral Nutrition Products Approval Criteria See the Approval Criteria inAppendix 16 of this section Specific Bill dual Medicare M edicaid recipient s claims for tube fed recipients first to Medicare If the Requirements provider is unsure whether Medicare will pay forthe claim the provid
71. tegory Stimulants 4 C IV Approval Criteria Indicated as an appetite suppressant in the treatment ofexogenous obesity for short term Uf a few weeks in a regimen of weight reduction based on caloric reduction Specific Documentation ofrecipient s height and weight Requirements Pharmacy Handbook Prior Authorization Sectiow July 2001 55 Appendix 56 Wisconsin Medicaid and BadgerCaree J uly 2001 Appendix 14 Diagnosis Code Table for Diagnosis Restricted Drugs and Drug Categories Foruses outside ofthe following diagnoses prior authorization PA is required Submission of peer reviewed medical literature to support the proven efficacy ofthe requested use of the drug is required for PA outside of the diagnosis restriction Drug Name BrandName Diagnosis Disease Description or Category Code pa Non steroidal anti inflammatory drug Aciphex NSAID induced gastric ulcer Nexium NSAID induced duodenal ulcer Proton Pump Prevacid H Pylori infection Inhibitors Prilosec Zollinger Ellison syndrome Protonix Erosiveesophag itis Gastroesophageal reflux Gastric hypersecretory conditions Anemia fromacquired immune Epogen deficiency syndrome AIDS P rocrit Renal failure aligna gt 9 p D 2 x 07054 Chronic hepatitisC w o hepatic coma 1729 alignant melanoma 1760 1769 Kaposi s sarcoma 2024 Hairy cell leukemia 2028 Non Hodgki ymp ho ma 2030 ultple a 2051 Chronic tic leukemia 2331 Bladder
72. tion of this handbook fora list of these non rebated drugs To request PA for these drugs providers must submit a paper PA RF a PA DGA for legend drugs and astatement of medical necessity andcost effectiveness forthese specific brand drugs Documentation of Medical Necessity and Cost Effectiveness The statement of medicalnecessity required for PA requests fornon rebated drugs must include the prescriber s conclusion that the non rebated drug is the only available and medically appropriate product fortreating the recipient and the details ofthe recipient s clinicalexperience which led to that conclusion The documentation ofthe recipient s clinicalexperience may include e A copy ofthe recipient s medicalrecord documenting the dates and clinical details of therapeutic failures and the specific companies and generic products involved e A copy ofthe documentation provided by the prescriber about the recipient s experience of therapeutic failure with a generic product of one or more manufacturers e A prescriber s documentation ofthe recipient s blood levels showing that the blood levels were substantially lower when using a generic drug than when using the brand name drug e AA copy ofthe recipient s records showing that otherdrug products within the same therapeutic class of drugs have been ruled out because previous clinical trials with that recipient produced ineffective or unsafe results e g allergic
73. to identify a category of service requested 131 Drugs Enteral Nutrition Products 137 24 Hour Drug 637 Wisconsin Specialized Transmission ApprovalTechnology Prior Authorization STA T PA Element 2 Recipient s Medicaid ID Number Enterthe recipient s 10 digit Medicaid identification ID number Do notenterany othernumbers orletters x pu ddy Element 3 Recipients Name Enterthe recipient s last name first name and middle initial Use the Hligibility Verification System EVS to obtain the correct spelling ofthe recipient s name Ifthe name orspelling ofthe name on the Medicaid ID card and the EVS do not match use the spelling fromthe EVS Element 4 Recipient s Address Enter the complete address street city state and ZIP code ofthe recipient s place ofresidence If the recipient is a resident ofa nursing facility also include the name ofthe nursing facility Element 5 Recipient s Date of Birth Enterthe recipient s date ofbirth in MM DD YYYY format e g June 18 1942 would be 07 18 1942 Element 6 Sex Enter an X to specify male or female Element 7 Billing Providers Name Address and ZIP Code Enter the billing provider s name and complete address street city state and ZIP code other information should be entered into this element since it also serves as a return mailing label Element 8 Billing Provider s Telephone Number Enterthe billing provider
74. ts or dis pensing physicians only NOTREQUIREDFOR PRES CRIBINGPHYSICIANS Generic Histamine 2 antagonists have NO RESTRICTIONS as to eitherdiagnosis codes orpriorauthorization PA As with allinnovator drugs prescribers must write Brand Medically Necessary onallhard copies ofthe prescriptions and on each new nursing facility ordersheet There are also norestrictions on injectable ulcertreatment drugs Thecurrentdrugis Axid Nizatidine REMINDER The Specialized Transmission Approval Technology PA STAT PA Drug Work sheet aptional This formisnot required butis providedasa guideline only toaccessSTAT PA orasproviderdocumentation The STAT PAsystemwillask forthe following items in the orderlisted below Provider Number Recipient Medicaid Identification Number Recipient Name National Drug Code NDC Procedure Code of Product Requested TypeofService D Prescriber s Drug Enforcement Administration DEA Number Diagnosis Code Use the recipient sInternational Classification ofDiseases Ninth Revision Clinical Modification ICD 9 CM diagnosis code The decimalis notnecessary Place of Service Date ofService ___ The date ofservice may be up to 31 days in the future orup to fourdays in the past Days Supply Requested STAT PA Request Checklist ALL information must be checked within each category in orderto be processed electronically A Has the recipient been tried on prescription strength ranitidine and or
75. ugh the following methods e Automated Vice Response AVR system Magnetic stripe card readers e Personalcomputer software e Provider Services telephone correspondents e Direct Information Access Line with Updates for Providers Dial Up Fee for service The traditional health care payment system under which physicians and other providers receive a payment foreach unit of service provided rather than a capitation payment foreach recipient Fiscal agent The Department of Health and Family Services DHFS contracts with Electronic Data Systems EDS to provide health claims processing services for Wisconsin Medicaid including provider certification claims payment providerservices and recipient services The fiscalagent also issues identification 70 Wisconsin Medicaid and BadgerCaree J uly 2001 cards to recipients publishes information for providers and recipients and maintains the Wisconsin Medicaid Web site HCFA Health Care Financing Administration An agency housed within the U S Department of Health and Human Services DHHS HCFA administers Medicare Medicaid related quality assurance programs and other programs HCPCS HCFA Common Procedure Coding System A listing of services procedures and supplies offered by physicians and other providers HCPCS includesCurrent Procedural TerminologXCPT codes national alphanumeric codes and local alphanumeric codes The national codes are developed by the H
76. within 24 hours e Ifthe request is received after 1 p m central time Wisconsin Medicaid makes an attempt to notify the providerby telephone or faxon the next regular business day Exceptions to the 24 Hour Response Wisconsin Medicaid responds within 24 hours except when e The PA request contains insufficient incorrect orillegible information so that Wisconsin Medicaid cannot identify the requesting provideror determine that the requested service requires a 24 hour response e The PA request does not have the provider s telephone orfaxnumber Wisconsin Medicaid makes three unsuccessfulattempts to contactthe providerby telephone orfaxwithin 24 hours of receiving the PA request Backdating Prior Authorizations Under most circumstances PA is needed before performing services to receive Medicaid reimbursement However in the case ofrecipient retroactive eligibility authorization may be granted retroactively Referto the Prior Authorization section ofthe All Provider Handbook for more information on backdating PA 10 Wisconsin Medicaid and BadgerCaree July 2001 Formost drugs Wisconsin Medicaid responds by fax or telephone to the provider s paperPA request within 24 hours of the receipt of the request Appendix x ipu ddy Pharmacy Handbook Prior Authorization Sectiow July 2001 11 Appendix 1 STAT PA System Instructions The Wisconsin Specialized Trans mission Approval Technolo
77. written by the prescriber on the prescription order Lives No Section C Clinical Information Lis the recipient s condition the prescribed drug is intended to treat Include ICD 9 CM diagnosis for pharmaceutical care recipients Include the expected length of need If requesting a renewal or continuation of a previous prior authorization approval indicate any changes to the clinical condition progress or known results to date Attach another sheet if additional room is needed Over Source for Clinical Information checkone LI This information was primarily obtained from the prescriber or prescription order Li This information vvas primarily obtained from the recipient LI This information was primarily obtained from some other source specify Use checkone L1 Compendial standards such as the USP DI or drug package insert list the intended use identified above as an accepted indication Compendial standards such as the USP DI lis the intended use identified above as a bracketed accepted indication Compendial standards such as the USP DI or drug package insert list the intended use identified above as an unaccepted use D OL The intended use above is not listed in compendial standards Peer reviewed clinical literature is attached or referenced Reference include publication name date and page number Dose checkone The daily dose and duration are within compendial standards general pr
78. y 2001 53 Appendix 54 Wisconsin Medicaid and BadgerCaree J uly 2001 Appendix 13 Drug Categories Allowing Prior Authorization Approval Through the STAT PA System Prior authorization PA requests should be submitted through the Specialized Trans mission ApprovalTechnology PA STAT PA system forthe following drug categories e Angiotensin converting enzyme ACE inhibitors e Non steroidal anti inflammatory drugs NSAIDs that are enzyme cyclooxy genase 2 COX 2 inhibitors e NSAIDs that are not enzyme COX 2 inhibitors The following tables also list drug categories that should be submitted through STAT PA Drug Category A Ipha 1 Proteinase Inhibitor Human Systemic Approval Criteria Indicated for replacement therapy in recipients with emphysema panacinar due to congenilkl alpha 1 antitrypsin deficiency treatment gt 9 D 2 x Specific Requirements Drug Category Brand Name Histamine 2 Antagonists Approval Criteria adenoma gastric hypersecretory conditions Zollinger Ellison syndrome erosive esophagi gastroes phageal reflux disease ulcers due to H Pylori e Use for these diagnoses is available through STAT PA e Use for any other diagnosis requires paper PA Specific Requirements Drug Category Weight Loss Products Approval Criteria Indicated as adjunctive weight loss therapy to diet and exercise Specific Documentation ofrecipient s height and weight Requirements Drug Ca

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