Wisconsin Medicaid uses this one-page physician report to support prior authorization of a hearing instrument. It is mandatory when a hearing instrument specialist requests PA, and audiologists may use it in place of a physician prescription kept in the member's record. The physician documents hearing history and ear findings and refers the member for a hearing instrument evaluation.
The requesting physician completes all three sections: provider information with NPI, member information, and the documentation section covering hearing loss history, otological findings, diagnosis and recommendations. The physician signs and enters the date the request is made.
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Prior Authorization/Physician Otological Report (PA/POR)
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The F-11019A instructions say the PA/POR is mandatory when a hearing instrument specialist requires prior authorization for a hearing instrument. Audiologists may use it in place of a physician prescription, which they keep in the member's medical record. It supports the PA/HIAS2 hearing instrument request.
In Element 15 the physician refers members aged 21 or under to an audiologist for the hearing instrument evaluation, as BadgerCare Plus regulations require. The same audiologist referral applies to members who are behaviorally or cognitively impaired or have other special needs requiring specialized diagnostic tools.
The requesting physician signs at the bottom of Section III and enters the date the request is made. Above the signature, the physician records the clinical diagnosis of hearing status, describes any medical, cognitive or developmental problems, and checks the applicable recommendation boxes.