Prior Authorization Process Improvements: Overview

REQUIREMENTS: Phase 1 - By January 1, 2026: - Billing team must obtain and begin using the revised Prior Authorization Fax Cover Sheet, F-01176 (12/2025) for all fax-submitted PA requests. All PA requests using the old form after this date will be returned. - Update PA submission procedures to ensure fax submissions follow this order: (1) Prior Authorization Fax Cover Sheet, (2) all service-specific forms, (3) necessary clinical documentation. - Train billing and clinical staff to identify urgent PA requests and ensure providers check the "Urgent" checkbox on the ForwardHealth Portal when submitting urgent PAs. - Require providers submitting urgent PAs to include attestation in the form description box stating that a delay would either: (a) put the member's life, health, or ability to regain maximum function at serious risk, OR (b) cause the member severe pain that cannot be managed without the requested care. - Update internal PA tracking to recognize the new "inactive – PA void" status for situations where: PA is submitted but not required, provider requests rescission, or PA submitted in error. - Billing team should contact Provider Services (800-947-9627) to understand clarified denial messaging for more efficient resubmissions. Phase 2 - By January 1, 2027: - Establish internal process to track and monitor that ForwardHealth processes all urgent PA requests within 72 hours and all non-urgent requests within 7 calendar days from receipt. - Review and confirm documentation retention compliance per Wisconsin Administrative Code § DHS 106.02(9) and Wisconsin Statute § 49.45(3)(f) to avoid claim denials, recoupment, or program termination. Consequences of Inaction: PA requests submitted with old forms will be returned; failure to obtain proper prior authorization will result in claim denials; refusal to produce documentation may result in claim denials, recoupment of paid claims, intermediate sanctions, or Medicaid program termination.