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  • System Availability Notice: Due to extended maintenance, the ForwardHealth Portal will be unavailable between midnight and 9 a.m. on December 15, 2019.
 
Provider Enrollment Information
 
Information for Specific Provider Types

open content close content Ambulance

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.38.
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement Ambulance Terms of Reimbursement, P-01642
Risk Level
  • At enrollment: Moderate
  • Upon revalidation: Moderate
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Other Important Information
  • Ambulance providers who operate an air ambulance or specialized medical vehicle (SMV) are required to be separately enrolled for these services to be eligible for reimbursement.
  • Wisconsin Medicaid requires an air ambulance provider to be licensed by the Department of Health Services under Wis. Stat. § DHS 105.38.
  • If a provider makes more than 12 transports a year in Wisconsin, a Wisconsin license is required.
Application Fee Yes

open content close content Ambulatory Surgery Centers

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.49.
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement Ambulatory Surgical Centers Terms of Reimbursement, P-01643
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Application Fee Yes

open content close content Anesthetist

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.055.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Anesthetist Terms of Reimbursement, P-01644
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Application Fee No

open content close content Audiologist

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.31.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Audiologist Terms of Reimbursement, P-01645
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Application Fee No

open content close content Behavioral Treatment

open content close contentBehavioral Treatment Licensed Supervisor

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Enrollment Criteria
  • The provider is required to meet one of the following options:
    • Option 1:
      • The provider has a license as a behavior analyst issued by the Wisconsin Department of Safety and Professional Services (DSPS).
      • The provider has at least 4,000 hours of documented experience as a supervisor of less experienced clinicians delivering the Wisconsin-approved treatment model.
    • Option 2:
      • The provider has a license as a psychiatrist, psychologist, behavior analyst, clinical social worker, professional counselor, or marriage and family therapist issued by the DSPS.
      • The provider has at least 4,000 hours of documented experience as a supervisor of less experienced clinicians delivering the Wisconsin-approved treatment model.
      • The provider has a certificate of Early Start Denver Model from the University of California, Davis program.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Behavioral Treatment Terms of Reimbursement, P-01683
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Other Important Information Providers are required to submit to ForwardHealth, via the ForwardHealth Portal, a letter or document stating their total hours of experience. This letter or document must be signed by the provider, by a current or prior employer of the provider, or by the provider's supervisor. This required format applies to both documentation of experience delivering treatment and documentation of experience supervising treatment.
Application Fee No

open content close contentBehavioral Treatment Therapist

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Enrollment Criteria The provider is required to meet one of the following options:
  • Option 1: The provider has a certificate as a Board Certified Assistant Behavior Analyst issued by the Behavior Analyst Certification Board.
  • Option 2:
    • The provider has a master's degree from an institution found on the national accreditation database.
    • The provider has, and attests to, at least 400 hours of documented supervised experience delivering a Wisconsin-approved treatment model.
  • Option 3:
    • The provider has a bachelor's degree from an institution found on the national accreditation database.
    • The provider has, and attests to, at least 2,000 hours of documented training and supervised experience delivering a Wisconsin-approved treatment model.
Terms of Reimbursement Behavioral Treatment Terms of Reimbursement, P-01683
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Rendering-only provider
Border Status Eligibility Eligible
Other Important Information
  • Provider enrollment applications for therapists must include the National Provider Identifier of the therapist's supervisor within the Declaration of Supervision area of the enrollment application on the ForwardHealth Portal. The supervisor is required to be Wisconsin Medicaid-enrolled as either a behavioral treatment licensed supervisor or focused treatment licensed supervisor before the therapist's application can be processed.
  • Providers are required to submit to ForwardHealth, via the Portal, a letter or document stating their total hours of experience. This letter or document must be signed by the provider, by a current or prior employer of the provider, or by the provider's supervisor. This required format applies to both documentation of experience delivering treatment and documentation of experience supervising treatment.
  • Therapists who are enrolling under the master's or bachelor's degree qualification are required to submit documentation of degree completion. Documentation can be either a degree or transcript.
Application Fee No

open content close contentBehavioral Treatment Technician

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Enrollment Criteria The provider is required to meet one of the following:
  • The provider has a high school diploma or a General Educational Development certificate and has 40 hours of documented training following the standard core curriculum requirements.
  • The provider has a certificate as a Registered Behavior Technician issued by the Behavior Analyst Certification Board.
Terms of Reimbursement Behavioral Treatment Terms of Reimbursement, P-01683
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Rendering-only provider
Border Status Eligibility Eligible
Other Important Information
  • Provider enrollment applications for technicians must include the National Provider Identifier of the technician's supervisor within the Declaration of Supervision area of the enrollment application on the ForwardHealth Portal. The supervisor is required to be Wisconsin Medicaid-enrolled as either a behavioral treatment licensed supervisor or focused treatment licensed supervisor before the technician's application can be processed.
  • Providers are required to attest to completion of high school or the equivalent when completing the enrollment application. Providers are required to produce documentation upon request from the Wisconsin Department of Health Services or federal auditors.
Application Fee No

open content close contentFocused Treatment Licensed Supervisor

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Enrollment Criteria
  • The provider is required to meet one of the following:
    • The provider has a license as a psychiatrist, psychologist, behavior analyst, clinical social worker, professional counselor, or marriage and family therapist issued by the Wisconsin Department of Safety and Professional Services.
    • The provider has at least 2,000 hours of documented supervised experience delivering a Wisconsin-approved focused treatment model.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Behavioral Treatment Terms of Reimbursement, P-01683
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Other Important Information Providers are required to submit to ForwardHealth, via the ForwardHealth Portal, a letter or document stating their total hours of experience. This letter or document must be signed by the provider, by a current or prior employer of the provider, or by the provider's supervisor. This required format applies to both documentation of experience delivering treatment and documentation of experience supervising treatment.
Application Fee No

open content close contentFocused Treatment Therapist

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Enrollment Criteria
  • The provider is required to meet one of the following:
    • Option 1: The provider has a certification as a Board Certified Assistant Behavior Analyst issued by the Behavior Analyst Certification Board (BACB).
    • Option 2:
      • The provider has a master's degree from an institution found on the national accreditation database.
      • The provider has, and attests to, at least 400 hours of documented training and supervised experience delivering a Wisconsin-approved treatment model.
    • Option 3:
      • The provider has a bachelor's degree from an institution found on the national accreditation database.
      • The provider has, and attests to, at least 2,000 hours of documented training and supervised experience delivering a Wisconsin-approved treatment model.
    • Option 4:
      • The provider has a certificate as a Registered Behavior Technician issued by the BACB.
      • The provider has, and attests to, at least 2,000 hours of documented training and supervised experience delivering a Wisconsin-approved treatment model.
Terms of Reimbursement Behavioral Treatment Terms of Reimbursement, P-01683
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Rendering-only provider
Border Status Eligibility Eligible
Other Important Information
  • Provider enrollment applications for therapists must include the National Provider Identifier of the therapist's supervisor within the Declaration of Supervision area of the enrollment application on the ForwardHealth Portal. The supervisor is required to be Wisconsin Medicaid-enrolled as either a behavioral treatment licensed supervisor or focused treatment licensed supervisor before the therapist's application can be processed.
  • Providers are required to submit to ForwardHealth, via the Portal, a letter or document stating their total hours of experience. This letter or document must be signed by the provider, by a current or prior employer of the provider, or by the provider's supervisor. This required format applies to both documentation of experience delivering treatment and documentation of experience supervising treatment.
  • Therapists who are enrolling under the master's or bachelor's degree qualification are required to submit documentation of degree completion. Documentation can be either a degree or transcript.
Application Fee No

open content close content Case Management

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.51.
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement Case Management Terms of Reimbursement, P-0649
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Not eligible
Other Important Information The following private, nonprofit entities are eligible for enrollment:
  • Independent Living Centers, as defined under Wis. Stat. § 46.96(1)(ah).
  • Private, nonprofit agencies funded by the Wisconsin Department of Health Services under Wis. Stat. § 252.12(2)(a)8 for purposes of providing life care services to persons diagnosed with HIV.
Application Fee Yes

open content close content Chiropractor

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.26.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Chiropractor Terms of Reimbursement, P-01650
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Application Fee No

open content close content Community Recovery Services

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Enrollment Criteria
  • The provider must be a local county or tribal agency with Division of Mental Health and Substance Abuse Services Certification.
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement Community Recovery Services, 1915(i) Home and Community-Based Services Terms of Reimbursement, P-01640.
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Not eligible
Application Fee Yes

open content close content Dental

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.06.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Dental / Dental Hygienists Terms of Reimbursement, P-01651
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Application Fee No

open content close content End-Stage Renal Disease

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.45.
  • The provider is required to have an Entity Type 2 National Provider Identifier.
  • The provider is required to be Medicare Part A and Part B-enrolled.
Terms of Reimbursement
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Not eligible
Other Important Information With the exception of a limited number of emergency dialysis treatments, hospital providers are required to be separately enrolled as a Medicaid end-stage renal disease provider with a specialty of "hospital affiliated" to receive reimbursement for renal disease-related services provided to a member enrolled in BadgerCare Plus or Medicaid.
Application Fee Yes

open content close content Family Planning Clinic

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.36
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement Family Planning Clinic Terms of Reimbursement, P-01654
Risk Level
  • At enrollment: Moderate
  • Upon revalidation: Moderate
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Not eligible
Application Fee Yes

open content close content Federally Qualified Health Center

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Enrollment Criteria
  • To qualify for Medicaid Federally Qualified Health Center (FQHC) enrollment, a clinic must provide documentation that they are either designated by the federal Department of Health and Human Services (HHS) as an FQHC or that it receives funds under the Indian Self-Determination Act (Public Law 93-638):
    • A federal HHS FQHC is a community health center (CHC), migrant health center, or health care for the homeless program that meets one of the following:
      • The HHS FQHC receives a grant under the Public Health Service Act, Section 329, 330, or 340.
      • The HHS FQHC has been designated by the Secretary of the federal HHS as a facility that meets the requirements of receiving a grant (FQHC Look Alike).
      • The HHS FQHC has been granted a temporary waiver of the grant requirements by the Secretary of the federal HHS.
    • An Indian Self-Determination Act FQHC is an outpatient health program or facility operated by a tribe or tribal organization receiving funds under the Indian Self-Determination Act.
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing-only provider
Border Status Eligibility Not eligible
Other Important Information Non-tribal FQHC providers (CHCs) must be associated to an active CHC Group Site. This relationship should be disclosed during the enrollment application flow.
Application Fee Yes

open content close content HealthCheck

open content close contentHealthCheck

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.37
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement HealthCheck Screener and Case Management Provider Terms of Reimbursement, P-01657
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Other Important Information
  • Wisconsin Medicaid-enrolled primary care physicians, certified pediatric nurses, or family nurse practitioners are automatically enrolled as HealthCheck providers.
  • Other physician specialties, physician assistants, and nurse practitioners are encouraged to request enrollment as HealthCheck providers.
  • Public health agencies and certain other providers, where physician supervision is available, may apply for enrollment as a HealthCheck agency.
Additional Documents
Application Fee
  • Organizations: Yes
  • Individuals: No

open content close contentPediatric Community Care

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Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Other Important Information State approval is required for enrollment.
Application Fee Yes

open content close contentResidential Community Care

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Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Other Important Information State approval is required for enrollment.
Application Fee Yes

open content close content Hearing Instrument Specialist

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.41.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Application Fee No

open content close content Home Health Agency / Personal Care Agency

open content close contentHome Health Agency

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.16.
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement
Risk Level
  • At enrollment: High
  • Upon revalidation: Moderate
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Other Important Information
  • Home health agencies planning to bill personal care services in addition to home health services are required to request enrollment for both service areas.
  • No separate enrollment is necessary for a Wisconsin Medicaid-enrolled home health agency to provide private duty nursing (PDN), durable medical equipment (DME), disposable medical supply (DMS), or enteral nutrition products. When providing PDN, DME, DMS, or enteral nutrition products, the home health agency is required to comply with the prior authorization, billing, and other requirements for those products.
  • Medicaid program requirements do not supersede the provisions for registration or licensure under Wis. Stat. § 50.49. Refer to the Wisconsin Department of Safety and Professional Services website and the Wisconsin Department of Health Services Certification, Licenses, and Permits website for more information about registration and licensure requirements.
  • Home health agencies are required to report additional information when enrolling in Medicaid in order to ensure appropriate licensing and to prevent waste, fraud, and abuse. Refer to the Requirements for Home Health and Personal Care Agencies to Report Personnel Information to ForwardHealth topic (#14358) in the ForwardHealth Online Handbook for more information regarding reporting requirements.
  • If a provider enrolls as a home health/personal care agency, later terminates their home health enrollment, and then only wants to perform personal care services, they are required to enroll as a free-standing agency.
Application Fee Yes

open content close contentPersonal Care Agency

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § 105.17.
  • To be eligible for Wisconsin Medicaid enrollment as a freestanding personal care agency, providers are required to have Division of Quality Assurance (DQA) provisional approval as a freestanding personal care agency. The effective date with Wisconsin Medicaid will be the date DQA approves the provider's provisional freestanding certification.
  • No National Provider Identifier (NPI) is required for providers who are only enrolled as personal care agencies. Providers enrolled as both home health and personal care agencies require an NPI of Entity Type 2.
Terms of Reimbursement Personal Care Terms of Reimbursement, P-01672
Risk Level
  • At enrollment: High
  • Upon revalidation: Moderate
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Not eligible
Other Important Information Personal care agencies are required to report additional information when enrolling in Medicaid in order to ensure appropriate licensing and to prevent waste, fraud, and abuse. Refer to the Requirements for Home Health and Personal Care Agencies to Report Personnel Information to ForwardHealth topic (#14358) in the Online Handbook for more information regarding reporting requirements.
Application Fee Yes

open content close content Hospice

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § 105.50.
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement Hospice Terms of Reimbursement, P-01659
Risk Level
  • At enrollment: Moderate
  • Upon revalidation: Moderate
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Application Fee Yes

open content close content Independent Lab

open content close contentIndependent Lab

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.43.
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement Laboratories Terms of Reimbursement, P-01662
Risk Level
  • At enrollment: Moderate
  • Upon revalidation: Moderate
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible (Note: Independent laboratories may receive border-status enrollment regardless of their location in the United States.)
Application Fee Yes

open content close contentBlood Bank

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.46.
  • The provider is not required to have a National Provider Identifier.
Terms of Reimbursement Blood Banks Terms of Reimbursement, P-01663
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Not eligible
Application Fee Yes

open content close content Individual Medical Supply

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.40(2).
  • The provider is required to have an Entity Type 1 or 2 National Provider Identifier (NPI).
Terms of Reimbursement Medical Supply and Equipment Vendor Terms of Reimbursement, P-01667
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Other Important Information If a medical supply vendor is an individual, an NPI of Entity Type 1 is required. If a medical supply vendor is an organization, an NPI of Entity Type 2 is required. Ensure that each practice location, if there is more than one, has its own unique NPI.
Application Fee
  • Organizations: Yes
  • Individuals: No

open content close content Inpatient / Outpatient Hospital

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code §§ 105.07, 105.075, and 105.21.
  • The provider is required to have an Entity Type 2 National Provider Identifier (NPI).
Terms of Reimbursement
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Other Important Information Hospitals are asked to provide ForwardHealth with all subpart NPIs they use with other payers, including Medicare. Providers are required to provide ForwardHealth with only those subpart NPIs that represent hospital units that are not separately enrolled in Wisconsin Medicaid. ForwardHealth uses subpart NPIs as additional identifiers that are linked to the hospital's enrollment.

Once a subpart NPI is on file with Wisconsin Medicaid, a hospital provider may use the subpart NPI as the billing provider on claims. On adjustments, providers are reminded that the billing provider NPI on the original claim and the billing provider NPI on the adjustment must match.

Providers may add or revise subpart NPI information on file with ForwardHealth using the demographic maintenance tool. In addition to subpart NPIs, providers may add to or revise the taxonomy codes corresponding to the subpart using the demographic maintenance tool.

Subpart NPIs on file with ForwardHealth may be used on claim transactions, prior authorization requests, WiCall, enrollment verification, provider enrollment, Provider Services inquiries, and the ForwardHealth Portal.
Application Fee Yes

open content close content Licensed Midwife

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Enrollment Criteria
  • The provider is required to be licensed by the Wisconsin Department of Safety and Professional Services under Wis. Stat. § 440.982.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Licensed Midwife Terms of Reimbursement, P-01684
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Application Fee No

open content close content Medical Equipment Vendor

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code DHS 105.40(1).
  • The provider is required to have an Entity Type 1 or 2 National Provider Identifier (NPI).
Terms of Reimbursement Medical Supply and Equipment Vendor Terms of Reimbursement, P-01667
Risk Level
  • At enrollment: High
  • Upon revalidation: Moderate
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Other Important Information If a durable medical equipment (DME) vendor is an individual, an NPI of Entity Type 1 is required. If a DME vendor is an organization, an NPI of Entity Type 2 is required. Ensure that each practice location, if there is more than one, has its own unique NPI.
Application Fee
  • Organizations: Yes
  • Individuals: No

open content close content Mental Health / Substance Abuse Agencies

open content close contentCommunity Support Program

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Enrollment Criteria
  • Agencies are required to obtain a Wisconsin Department of Health Services (DHS) certificate to provide community support program (CSP) services as authorized under Wis. Admin. Code ch. DHS 63, which meets Wisconsin Medicaid's Wis. Admin. Code ch. DHS 105 requirement. Agencies that do not meet this criteria will qualify as a billing-only provider and will be allowed to bill for CSP services.
  • An allowable Medicaid rendering provider is required to perform the service.
  • The billing agency is required to make available the nonfederal share needed to provide CSP services.
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement Mental Health / Substance Abuse Services Terms of Reimbursement, P-01668
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment
  • County/Tribal with Division of Quality Assurance (DQA) Certificate: Billing and rendering provider
  • County/Tribal without DQA Certificate: Billing-only provider
  • Not County/Tribal but with DQA Certificate: Rendering-only provider
  • Please ensure the appropriate provider type and specialty is chosen based on your DQA Certification. For further clarification, contact Provider Services before completing the enrollment process.
Border Status Eligibility Eligible
Other Important Information Only local county or tribal agencies may be Medicaid-enrolled to bill CSP services.
Application Fee Yes

open content close contentComprehensive Community Services

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Enrollment Criteria
  • There are two types of Comprehensive Community Services (CCS) program providers:
    • Regional providers are counties or tribes that operate a regional CCS program under one of the following four regional service models defined by the Division of Care and Treatment Services (DCTS):
       
      Regional Service Model Definition
      Population-Based Model A single county with a population exceeding 350,000 residents that operates a regional CCS program within its own county borders or a single tribe, regardless of population size, that operates a regional CCS program within its tribe.
      Shared Services Model Multiple counties and tribes partner together to operate a regional CCS program across their counties and tribes; no lead county or tribe is identified.
      Multi-County Model Multiple counties and tribes partner together to operate a regional CCS program across their counties and tribes; a lead county or tribe is identified.
      51.42 Model Multiple counties that have partnered together to form a separate 51.42 legal entity operate a regional CCS program through the 51.42 entity.

      ForwardHealth provides the federal and non-federal share of Wisconsin Medicaid and BadgerCare Plus program costs to regional CCS providers.

      To operate a regional CCS program, counties and tribes must first complete the following three steps in order:
       
      • DCTS Approval—Counties and tribes are required to obtain approval of their proposed regional CCS program from DCTS, which will confirm that the proposed regional CCS program meets the requirements of the regional service model under which it will operate.
      • Division of Quality Assurance (DQA) Certification—Counties and tribes are required to obtain either a single DQA certification or separate DQA certifications for each county or tribe within the region for the regional CCS program based on the regional service model approved by DCTS for the CCS program.
         
        Regional Service Model Approved by DCTS Type of DQA Certification Required for the CCS Program
        Population-Based Model Single DQA certification
        Shared Services Model Separate DQA certification for each county or tribe within the region
        Multi-County Model Single DQA certification
        51.42 Model Single DQA certification
        Through the DQA certification process, the DQA confirms that the proposed regional CCS program meets all requirements within Wis. Admin. Code ch. DHS 36.
      • Medicaid Enrollment—Following DCTS approval and DQA certification, counties and tribes are required to enroll with ForwardHealth in Wisconsin Medicaid as a regional CCS provider based on the following requirements for each regional service model:
         
        Regional Service Model Requirements
        Population-Based Model The single county or single tribe within the region must enroll.
        Shared Services Model Each county or tribe within the region must enroll separately.
        Multi-County Model Each county or tribe within the region must enroll separately.
        51.42 Model The 51.42 entity must enroll; individual counties within the 51.42 region do not need to separately enroll.

        Providers who have multiple Medicaid enrollments are required to provide a unique taxonomy on their CCS enrollment.

        Counties and tribes that are already enrolled in the Medicaid program as CCS providers do not need to re-enroll as regional CCS providers but do still need to complete DCTS approval and DQA certification. ForwardHealth is notified by the DQA of any changes to the provider's regional CCS program and automatically updates the provider's Medicaid enrollment file.

        Counties and tribes that are not already enrolled in Wisconsin Medicaid as CCS providers must complete a Medicaid enrollment application.
    • Non-regional providers are counties or tribes that operate a CCS program within their own county or tribe on a non-regional basis. ForwardHealth provides only the federal share of Medicaid and BadgerCare Plus program costs to non-regional CCS providers. Non-regional providers are required to be certified in either of the following ways:
      • The provider is required to be a local county or tribal agency with DCTS certification and DQA certification.
      • The agency is required to obtain a Wisconsin Department of Health Services certificate to provide CCS as authorized under Wis. Admin. Code ch. DHS 36, which meets Wisconsin Medicaid's Wis. Admin. Code ch. DHS 105 requirement.

        Agencies that do not meet this criteria will qualify as a billing-only provider and will be allowed to bill for CCS. An allowable Medicaid rendering provider is required to perform the service.

        The billing agency is required to have an agency resolution stating that the county or tribe agrees to make available the non-federal share needed to provide CCS.
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement Mental Health / Substance Abuse Services Terms of Reimbursement, P-01668
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment
  • Regional Providers are billing and rendering providers, with the exception of the non-lead county or tribe under the multi-county regional service model:
    • Population-Based Model—Billing and rendering provider
    • Shared Services Model—Billing and rendering provider
    • Multi-County Model:
      • Lead county or tribe—billing and rendering provider
      • Other county or tribe within the region—rendering-only provider
    • 51.42 Model—Billing and rendering provider.
  • Non-regional providers have a category of enrollment based on agency type and DQA certification:
    • County or tribal agency with DQA Certificate—Billing and rendering provider
    • County or tribal agency without DQA Certificate—Billing-only provider
    • Neither county nor tribal agency but with DQA certificate—Rendering-only provider
  • Ensure the appropriate provider type and specialty is chosen based on DQA certification. For further clarification, contact Provider Services before completing the enrollment process.
Border Status Eligibility Eligible
Other Important Information Only local county or tribal agencies may be Medicaid-enrolled to bill CCS.
Application Fee Yes

open content close contentCrisis Intervention Services

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Enrollment Criteria
  • The agency is required to obtain a Wisconsin Department of Health Services certificate to provide crisis intervention services as authorized under Wis. Admin. Code ch. DHS 34, subchapter III, which meets Wisconsin Medicaid's Wis. Admin. Code ch. DHS 105 requirement.

    Agencies that do not meet this criteria will qualify as a billing-only provider and will be allowed to bill for crisis intervention services. An allowable Medicaid rendering provider is required to perform the service.

    The agency is required to make available the non-federal share needed to provide crisis intervention services.
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement Mental Health / Substance Abuse Services Terms of Reimbursement, P-01668
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment
  • County or tribal agency with Division of Quality Assurance (DQA) certificate: Billing and rendering provider
  • County or tribal agency without DQA Certificate: Billing-only provider
  • Neither county nor tribal agency but with DQA Certificate: Rendering-only provider
  • Please ensure the appropriate provider type and specialty is chosen based on your DQA certification. For further clarification contact Provider Services before completing the enrollment process.
Border Status Eligibility Eligible
Other Important Information Only local county or tribal agencies may be Medicaid-enrolled to bill crisis intervention services.
Application Fee Yes

open content close contentDay Treatment Services

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Enrollment Criteria
  • Adult Mental Health Day Treatment Services agencies are required to obtain a Wisconsin Department of Health Services (DHS) certificate to provide mental health day treatment services as authorized under Wis. Admin. Code § DHS 61.75, which meets Wisconsin Medicaid's Wis. Admin. Code ch. DHS 105 requirement. Agencies that do not meet this requirement can be a billing-only provider for mental health day treatment services. An allowable Medicaid rendering provider is required to perform the service.
  • Substance Abuse Day Treatment Services agencies are required to obtain a DHS certificate to provide substance abuse day treatment services as authorized under Wis. Admin. Code § DHS 75.12, which meets Wisconsin Medicaid's Wis. Admin. Code ch. DHS 105 requirement. Agencies that do not meet this requirement can be a billing-only provider for substance abuse day treatment services. An allowable Medicaid rendering provider is required to perform the service.
  • Child/Adolescent Day Treatment Services (HealthCheck "Other Services") agencies are required to obtain a DHS certificate to provide child/adolescent day treatment services as authorized under Wis. Admin. Code ch. DHS 40, which meets Wisconsin Medicaid's Wis. Admin. Code ch. DHS 105 requirement. Agencies that do not meet this requirement can be a billing-only provider for child/adolescent day treatment. An allowable Medicaid rendering provider is required to perform the service.
  • The agency is required to meet the criteria per Wis. Admin. Code § DHS 105.24.
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement Mental Health / Substance Abuse Services Terms of Reimbursement, P-01668
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment
  • With Division of Quality Assurance (DQA) certificate: Billing and rendering provider
  • Without DQA certificate and a county or tribal agency: Billing-only provider
Border Status Eligibility Eligible
Application Fee Yes

open content close contentIn-Home Mental Health Substance Abuse Treatment Services for Children

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Enrollment Criteria
  • The agency is required to obtain a Wisconsin Department of Health Services (DHS) certificate to provide outpatient mental health or substance abuse services as authorized under Wis. Admin. Code ch. DHS 35 or, in situations where substance abuse counseling is the only service provided, as authorized under Wis. Admin. Code § DHS 75.13, which meets Wisconsin Medicaid's Wis. Admin. Code ch. DHS 105 requirement.

    The agency providing the service may qualify as an outpatient mental health clinic billing and rendering provider or outpatient substance abuse clinic billing and rendering provider. The agency billing for the service for an outpatient mental health clinic may qualify as a billing-only provider for an outpatient substance abuse clinic in situations where substance abuse counseling is the only service provided. An allowable Medicaid rendering provider is required to perform the service.
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.24.
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement Mental Health / Substance Abuse Services Terms of Reimbursement, P-01668
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment
  • With Division of Quality Assurance (DQA) certificate: Billing and rendering provider
  • Without DQA certificate: Billing-only provider
Border Status Eligibility Not eligible
Application Fee Yes

open content close contentOutpatient Services

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Enrollment Criteria
  • Outpatient Mental Health Services (Evaluation, Psychotherapy, Pharmacologic Management) agencies are required to obtain a Wisconsin Department of Health Services (DHS) certificate to provide outpatient mental health services as authorized under Wis. Admin. Code ch. DHS 35, which meets Wisconsin Medicaid's Wis. Admin. Code ch. DHS 105 requirement. Agencies that do not meet this requirement can be a billing-only provider for outpatient mental health services. An allowable Medicaid rendering provider is required to perform the service.

    Outpatient hospitals utilizing master's level therapists are required to be certified as a Division of Quality Assurance (DQA)-certified mental health clinic under Wis. Admin. Code ch. DHS 35. Only covered services provided by an approved hospital facility are eligible for payment under Medicaid's outpatient hospital payment formula. Medicaid defines "hospital facility" as the physical entity, surveyed and approved by the DQA under Wis. Stat. ch. 50.
  • Outpatient Substance Abuse Services agencies are required to obtain a DHS certificate to provide outpatient substance abuse services as authorized under Wis. Admin. Code § DHS 75.13, which meets Wisconsin Medicaid's Wis. Admin. Code ch. DHS 105 requirement. Agencies that do not meet this requirement can be a billing-only provider for outpatient substance abuse services. An allowable Medicaid rendering provider is required to perform the service.
  • Outpatient Mental Health and Substance Abuse Services in the Home or Community for Adults agencies are required to obtain a DHS certificate to provide outpatient mental health services as authorized under Wis. Admin. Code ch. DHS 35 or § DHS 75.13, which meets Wisconsin Medicaid's Wis. Admin. Code ch. DHS 105 requirement. Agencies that do not meet this criteria will qualify as a billing-only provider and will be allowed to bill for outpatient mental health and substance abuse services in the home or community services. An allowable Medicaid rendering provider is required to perform the service. The agency is required to have an agency resolution stating that the county or tribe agrees to make available the non-federal share needed to provide outpatient mental health and substance abuse services in the home or community.
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.24.
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement Mental Health / Substance Abuse Services Terms of Reimbursement, P-01668
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment
  • With DQA certificate: Billing and rendering provider
  • Local county or tribal agency without DQA certificate: Billing-only provider
Border Status Eligibility Not eligible
Other Important Information
  • Only local county or tribal agencies may be Medicaid-enrolled to bill outpatient mental health and substance abuse services in the home or community.
  • County or tribal agencies providing services to adults in the home or community must submit the agency resolution stating that the local county or tribal agency agrees to make available the non-federal share needed to provide Medicaid mental health and substance abuse outpatient services in a home or community setting.
  • Advanced practice nurse prescribers with a psychiatric specialty and psychiatrists are the only mental health providers who can submit claims for psychotherapy services that include a medical evaluation and management component. Additionally, advanced practice nurse prescribers with a psychiatric specialty are required to be separately enrolled in Medicaid as a nurse practitioner in order to be reimbursed for an evaluation and management service.
Additional Documents Matching Funds Resolution
Application Fee Yes

open content close content Mental Health / Substance Abuse Individual Practitioners

open content close contentAlcohol and Other Drug Abuse (AODA)-Certified Counselor Services

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Enrollment Criteria
  • The provider is required to meet the following:
    • Work in a clinic certified under Wis. Admin. Code § DHS 75.13 and meet the requirements in Wis. Admin. Code §§ DHS 75.02(84)(a) and (b), which meets Wisconsin Medicaid's Wis. Admin. Code ch. DHS 105 requirement.
    • Have a license as a Substance Abuse Counselor, Certified Substance Abuse Counselor, or a Certified Substance Abuse Counselor in-training, issued by the Wisconsin Department of Safety and Professional Services.
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.23.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Mental Health / Substance Abuse Services Terms of Reimbursement, P-01668
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Rendering-only provider
Border Status Eligibility Eligible
Application Fee No

open content close contentAdvanced Practice Nurse Prescriber with Psychiatric Specialty

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Enrollment Criteria
  • The provider is required to meet both of the following:
    • The provider is licensed as an Advanced Practice Nurse Prescriber by the Wisconsin Department of Safety and Professional Services.
    • The provider has a certificate issued by the American Nurses Credentialing Center for Psychiatric-Mental Health Nursing Certification (RN-BC).
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.22.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Mental Health / Substance Abuse Services Terms of Reimbursement ,P-01668
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Border Status Eligibility Advanced practice nurse prescribers with a psychiatric specialty and psychiatrists are the only mental health providers who can submit claims for psychotherapy services that include a medical evaluation and management component. Additionally, advanced practice nurse prescribers with a psychiatric specialty are required to be separately enrolled in Wisconsin Medicaid as a nurse practitioner in order to be reimbursed for an evaluation and management service.
Application Fee No

open content close contentCertified Psychotherapist

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Enrollment Criteria
  • The provider is required to meet the following:
    • The provider works in a certified mental health clinic as required under Wis. Admin. Code ch. DHS 35, which meets Wisconsin Medicaid's Wis. Admin. Code ch. DHS 105 requirement.
    • The provider has a certificate as an Advanced Practice Social Worker or Independent Social Worker issued by the Wisconsin Department of Safety and Professional Services (DSPS).
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.22.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Mental Health / Substance Abuse Services Terms of Reimbursement, P-01668
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Rendering-only provider
Border Status Eligibility Eligible
Other Important Information A provider whose practice address is in a state that borders Wisconsin is considered a border-status provider. To be eligible as a Certified Psychotherapist as a border-status provider with Wisconsin Medicaid, a provider is required to hold a current Wisconsin license or a license from the state in which they are rendering services.

Contact the DSPS for a streamlined licensing process for providers who are already licensed in a different state. DSPS will issue a Wisconsin license without requiring such providers to complete the full, typical license application.
Application Fee No

open content close contentCertified Psychotherapist with Substance Abuse Certification

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Enrollment Criteria
  • The provider is required to meet the following:
    • The provider works in a certified clinic and meets the requirements listed under Wis. Admin. Code § DHS 75.13 or Wis. Admin. Code ch. DHS 35, which meets Wisconsin Medicaid's Wis. Admin. Code ch. DHS 105 requirement.
    • The provider has a certificate as an Advanced Practice Social Worker, Independent Social Worker, or registered nurse with a master's degree in psychiatric mental health nursing or community mental health nursing issued by the Wisconsin Department of Safety and Professional Services (DSPS).
    • The provider has a certificate as a Substance Abuse Counselor, Certified Substance Abuse Counselor, or Substance Abuse Specialty issued by the DSPS.
  • The provider is required to meet the criteria per Wis. Admin. Code §§ DHS 105.22 and 105.23.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Mental Health / Substance Abuse Services Terms of Reimbursement, P-01668
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Rendering-only provider
Border Status Eligibility Eligible
Other Important Information A provider whose practice address is in a state that borders Wisconsin is considered a border-status provider. To be eligible as a Certified Psychotherapist/Substance Abuse Counselor as a border-status provider with Medicaid, a provider is required to hold either current Wisconsin licenses or licenses from the state in which they are rendering services for psychotherapy and substance abuse.
Application Fee No

open content close contentLicensed Psychotherapist

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Enrollment Criteria
  • The provider is required to be licensed as a Clinical Social Worker, Marriage and Family Therapist, or Professional Counselor by the Wisconsin Department of Safety and Professional Services.
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.22.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Mental Health / Substance Abuse Services Terms of Reimbursement, P-01668
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Other Important Information A provider whose practice address is in a state that borders Wisconsin is considered a border-status provider. To be eligible as a Licensed Psychotherapist as a border-status provider with Wisconsin Medicaid, a provider is required to hold a current Wisconsin license, as stated above.
Application Fee No

open content close contentLicensed Psychotherapist with Substance Abuse Certification

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Enrollment Criteria
  • The provider is required to meet both of the following:
    • The provider is licensed as a Clinical Social Worker, Marriage and Family Therapist, or Professional Counselor by the Wisconsin Department of Safety and Professional Services (DSPS).
    • The provider has a certificate as a Substance Abuse Counselor (SAC), Certified SAC, or Substance Abuse Specialty issued by the DSPS.
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.22.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Mental Health / Substance Abuse Services Terms of Reimbursement, P-01668
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Other Important Information A provider whose practice address is in a state that borders Wisconsin is considered a border-status provider. To be eligible as a Licensed Psychotherapist/Substance Abuse Counselor as a border-status provider with Wisconsin Medicaid, a provider is required to hold a current Wisconsin license and a Wisconsin SAC certification. The SAC can be attached to the psychotherapist license or be a separate license from DSPS.
Application Fee No

open content close contentMaster's Level Nurse with Psychiatric Specialty

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Enrollment Criteria
  • The provider is required to meet all of the following:
    • The provider works in a certified mental health clinic as required under Wis. Admin. Code ch. DHS 35, which meets Wisconsin Medicaid's Wis. Admin. Code ch. DHS 105 requirement.
    • The provider is licensed as a registered nurse by the Wisconsin Department of Safety and Professional Services.
    • The provider has a master's degree in psychiatric mental health nursing or community mental health nursing.
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.22.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Mental Health / Substance Abuse Services Terms of Reimbursement, P-01668
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Rendering-only provider
Border Status Eligibility Eligible
Application Fee No

open content close contentPh.D. Psychologist Services

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Enrollment Criteria
  • The provider is required to have a license to practice as a psychologist, according to Wis. Stat. ch. 455. This must be at the independent practice level, which meets Wisconsin Medicaid's Wis. Admin. Code ch. DHS 105 requirement.
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.22.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Mental Health / Substance Abuse Services Terms of Reimbursement, P-01668
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Application Fee No

open content close contentQualified Treatment Trainee

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Enrollment Criteria
  • Qualified treatment trainees (QTTs) with a graduate degree, as defined in Wis. Admin. Code § DHS 35.03(17m)(b), are required to meet both of the following criteria:
    • The provider has a graduate degree from an accredited institution with course work in psychology, counseling, marriage and family therapy, social work, nursing, or a closely related field.
    • The provider has not yet completed the applicable supervised practice requirements described under Wis. Admin. Code chs. MPSW 4, 12, or 16 or Psy 2, as applicable.
  • To qualify for enrollment in Wisconsin Medicaid, QTTs with a graduate degree are required to meet one of the following options:
    • Option 1:
      • The provider has a doctoral degree from an accredited institution.
      • The provider is working toward full Wisconsin Department of Safety and Professional Services (DSPS) licensure as a licensed psychologist.
    • Option 2: The provider is licensed by DSPS as one of the following:
      • The provider is licensed by DSPS as a professional counselor in training.
      • The provider is licensed by DSPS as a marriage and family therapist in training.
      • The provider is licensed by DSPS as an advanced practice social worker or certified independent social worker.
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.22.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Mental Health / Substance Abuse Services Terms of Reimbursement, P-01668
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Rendering-only provider
Border Status Eligibility Not eligible
Other Important Information As a QTT, the provider is working toward their 3,000 clinical hours to become licensed as a professional counselor, marriage and family therapist, or social worker. Upon completion of their 3,000 clinical hours, the provider plans to become a licensed professional counselor, marriage and family therapist, or social worker through DSPS and update their provider status using the demographic maintenance tool, which can be accessed through their secure ForwardHealth Portal account.
Application Fee No

open content close content Narcotic Treatment Services

open content close contentAgency

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Enrollment Criteria
  • The agency is required to obtain a Wisconsin Department of Health Services certificate to provider narcotic treatment services for opiate addiction as authorized under Wis. Admin. Code § DHS 75.15, which meets Wisconsin Medicaid's Wis. Admin. Code ch. DHS 105 requirement.
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement Mental Health / Substance Abuse Services Terms of Reimbursement, P-01668
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing-only provider
Border Status Eligibility Eligible
Application Fee No

open content close contentIndividual

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Enrollment Criteria
  • The provider is required to meet the following:
    • The provider works in a narcotic treatment service certified under Wis. Admin. Code § DHS 75.15, which meets Wisconsin Medicaid's Wis. Admin. Code ch. DHS 105 requirement.
    • The provider has a state of Wisconsin Registered Nurse License or a state of Wisconsin Practical Nurse License issued by the Wisconsin Department of Safety and Professional Services as required under Wis. Stat. §§ 441.06 and 441.10.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Mental Health / Substance Abuse Services Terms of Reimbursement, P-01668
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Rendering-only provider
Border Status Eligibility Eligible
Application Fee No

open content close content Nurse in Independent Practice

open content close contentNurse Midwife

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.201.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Nurse Midwife Terms of Reimbursement, P-01666
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Additional Document HealthCheck Screener Affirmation, F-11285
Application Fee No

open content close contentRegistered Nurse and Licensed Practical Nurse

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.19.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
  • A Registered Nurse license is required (not an American Psychiatric Nurses Association license).
Terms of Reimbursement
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Additional Documents
  • HealthCheck Screener Affirmation, F-11285
  • Copy of cardiopulmonary resuscitation card from the American Red Cross or the American Heart Association, if applicable
  • Copy of Adult Ventilator Certificate, if applicable
  • Copy of Pediatric Ventilation Certificate, if applicable
Application Fee No

open content close contentRespiratory Care Services

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.19.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Additional Documents
  • HealthCheck Screener Affirmation, F-11285
  • Copy of cardiopulmonary resuscitation card from the American Red Cross or the American Heart Association, if applicable
  • Copy of Adult Ventilator Certificate, if applicable
  • Copy of Pediatric Ventilation Certificate, if applicable
Application Fee No

open content close content Nurse Practitioner

open content close contentNurse Midwife

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.201.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Additional Documents
Application Fee No

open content close contentNurse Practitioner

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.20.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
  • A Registered Nurse license is required (not an American Psychiatric Nurses Association license).
Terms of Reimbursement
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Additional Documents
  • HealthCheck Screener Affirmation, F-11285
  • Copy of cardiopulmonary resuscitation card from the American Red Cross or the American Heart Association, if applicable
  • Copy of Adult Ventilator Certificate, if applicable
  • Copy of Pediatric Ventilation Certificate, if applicable
Application Fee No

open content close content Nursing Homes

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Enrollment Criteria
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Not eligible
Other Important Information
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.02(2)(b).
  • For enrollment requirements specific to nursing facilities or facilities for the developmentally disabled, contact the Office of Quality Assurance.
Application Fee Yes

open content close content Occupational Therapy Individual Practitioners

open content close contentOccupational Therapist

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.28.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Occupational Therapy Terms of Reimbursement, P-01670
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Application Fee No

open content close contentOccupational Therapist Assistant

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.28(2).
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Occupational Therapy Terms of Reimbursement, P-01670
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Rendering-only provider
Border Status Eligibility Eligible
Application Fee No

open content close content Optician

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.33.
  • The provider is required to have an Entity Type 1 or 2 National Provider Identifier.
Terms of Reimbursement Optometrist / Optician Terms of Reimbursement, P-01671
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Application Fee
  • Organizations: Yes
  • Individuals: No

open content close content Optometrist

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.32.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Optometrist / Optician Terms of Reimbursement, P-01671
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Application Fee No

open content close content Pharmacy

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.15.
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement Pharmacy Terms of Reimbursement, P-01673
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Application Fee Yes

open content close content Physical Therapy Individual Practitioners

open content close contentPhysical Therapist

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.27.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Physical Therapy Terms of Reimbursement, P-01674
Risk Level
  • At enrollment: Moderate
  • Upon revalidation: Moderate
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Application Fee No

open content close contentPhysical Therapist Assistant

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.27(2).
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Physical Therapy Terms of Reimbursement, P-01674
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Rendering-only provider
Border Status Eligibility Eligible
Application Fee No

open content close content Physician

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.05.
  • Psychiatry providers are also required to meet the criteria per Wis. Admin. Code § DHS 105.22.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Other Important Information
  • To be enrolled in Wisconsin Medicaid, physicians and residents are required to be licensed to practice medicine and surgery pursuant to Wis. Stat. §§ 448.05 and 448.07 and Wis. Admin. Code chs. Med 1, 2, 3, 4, 5 and 14.
  • Physicians are asked to identify their practice specialty at the time of Medicaid enrollment. Reimbursement for certain services is limited to physicians with specific specialties.
Additional Document HealthCheck Screener Affirmation, F-11285
Application Fee No

open content close content Physician Assistant

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.05.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Physicians and Physician Assistants Terms of Reimbursement, P-01675
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Rendering-only provider
Border Status Eligibility Eligible
Other Important Information To be Wisconsin Medicaid-enrolled, physician assistants are required to be licensed and registered pursuant to Wis. Stat. §§ 448.05 and 448.07, and Wis. Admin. Code chs. Med 8 and 14. All physician assistants are required to be individually enrolled in Wisconsin Medicaid for their services to be reimbursed.
Additional Document HealthCheck Screener Affirmation, F-11285
Application Fee No

open content close content Podiatrist

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.265.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Podiatrist Terms of Reimbursement, P-01676
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Application Fee No

open content close content Portable X-Ray

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.44.
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement Portable X-Ray Terms of Reimbursement, P-01677
Risk Level
  • At enrollment: Moderate
  • Upon revalidation: Moderate
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Application Fee Yes

open content close content Prenatal Care Coordination

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.52.
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement Prenatal Care Coordination Agency Terms of Reimbursement, P-01678
Risk Level
  • At enrollment: High
  • Upon revalidation: Moderate
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Not eligible
Additional Documents Resumes are required for all agency staff.
Application Fee Yes

open content close content Provider Groups

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Group Types Anesthetist, Audiologist, Chiropractor, Dentist, Hearing Instrument Specialist, Mental Health and Substance Abuse, Nurse Practitioner, Occupational Therapist, Optometrist, Physical Therapist, Physician, Podiatrist, Speech and Language Pathology, Therapy
Enrollment Criteria
  • Only one group practice can be enrolled per location unless there is a separate National Provider Identifier (NPI) or taxonomy to identify the location where services were performed. Provider group practices do not need to enroll every location from which they provide services. Only those locations responsible for billing are required to be enrolled.
  • A group practice must include two or more Medicaid-enrolled providers within the same provider specialty, except as noted under Other Important Information below.
  • The provider is required to have an Entity Type 2 NPI.
Terms of Reimbursement Refer to the Terms of Reimbursement for the respective individual practitioner.
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
  • Exception for physical therapy groups: Moderate risk level at both enrollment and revalidation
Disclosure Information
Category of Enrollment Billing-only provider
Border Status Eligibility Eligible
Other Important Information
  • A group of practitioners means two or more health care practitioners who practice their profession at a common location (whether or not they share common facilities, common supporting staff, or common equipment).
  • Individual providers within a physician clinic or group practice are required to be Medicaid-enrolled.
  • To be enrolled as a therapy group, there must be two or more combined physical therapists, occupational therapists, and speech-language pathologists enrolled in Wisconsin Medicaid.
  • To be enrolled in a group as a dental hygienist, at least one Medicaid-enrolled dentist must be part of the group.
  • For additional information, refer to ForwardHealth Update (2011-46), titled "Policy for Provider Group Practice Certification."
  • Provider groups are required to report all individual Medicaid-enrolled providers working for the group to ForwardHealth. This information must be reported during initial enrollment, when revalidating enrollment, and any time a change occurs.
  • Not keeping this information current could result in loss of group enrollment status.
Application Fee No

open content close content Rehabilitation Agencies

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.34.
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement Rehabilitation Agency Terms of Reimbursement, P-01679
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Application Fee Yes

open content close content Residential Facility SUD Treatment

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Enrollment Criteria
  • Clinically Managed High-Intensity Residential Services agencies are required to be certified by Division of Quality Assurance (DQA) as a medically monitored residential treatment facility according to Wis. Admin. Code § DHS 75.11.
  • Clinically Managed Low-Intensity Residential Services agencies are required to be certified by DQA as a medically monitored residential treatment facility according to Wis. Admin. Code § DHS 75.14.
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement Mental Health / Substance Abuse Services Terms of Reimbursement, P-01668
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Application Fee Yes

open content close content Rural Health Clinic

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.35.
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement Rural Health Clinic Terms of Reimbursement, P-01680
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing-only provider
Border Status Eligibility Eligible
Application Fee Yes

open content close content School-Based Services

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.53.
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement School-Based Services Terms of Reimbursement, P-01681
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Not eligible
Other Important Information
  • Because the Wisconsin Department of Public Instruction (DPI) licenses individual providers in Wisconsin schools only, out-of-state schools are ineligible to apply for Wisconsin Medicaid school-based services (SBS) enrollment.
  • Medicaid requires individual rendering providers to be licensed by DPI for reimbursement under the SBS benefit, with the exception of nurses. Nurses are not required to obtain a DPI license but are encouraged to do so.
Application Fee Yes

open content close content Specialized Medical Vehicle

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.39.
  • The provider is not required to have a National Provider Identifier.
Terms of Reimbursement Specialized Medical Vehicle Terms of Reimbursement, P-01682
Risk Level
  • At enrollment: High
  • Upon revalidation: Moderate
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Other Important Information All new specialized medical vehicle (SMV) providers who are enrolled or re-enrolled after a one-year lapse and providers who have a change in ownership will be approved for provisional enrollment, during which time an audit will be scheduled. No electronic billing will be approved before the audit is conducted and completed and the provider is granted approval to bill electronically. Provisional enrollment and audit applies to the new owner(s) from a change of ownership. Provisional enrollment varies from temporary enrollment, which is approved for any SMV provider when they send an insurance binder to ForwardHealth before sending the actual insurance policy.
Additional Documents
  • Specialized Medical Vehicle Providers Affidavit, F-11237
  • Letter of payment receipt for current vehicle insurance
  • Workers' compensation certificate of insurance
  • One of the following:
    • Copy of current vehicle commercial insurance policy
    • Certificate of insurance with schedule of vehicles
  • Copy of current cardiopulmonary resuscitation training completion card or digital certificate from the American Heart Association or the American Red Cross for each driver
Application Fee Yes

open content close content Speech and Hearing Clinic

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.29.
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing-only provider
Border Status Eligibility Eligible
Additional Document American Speech-Language-Hearing Association Certificate
Application Fee Yes

open content close content Speech-Language Pathologist

open content close contentBachelor's Level

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.30.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement Speech-Language Pathology Therapy Terms of Reimbursement, P-01648
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Rendering-only provider
Border Status Eligibility Eligible
Other Important Information
  • Individuals with a bachelor's degree (B.A. or B.S.) in speech and language pathology (SLP) may become enrolled as an SLP nonbilling rendering provider. SLP nonbilling providers, also referred to as SLP provider assistants, are required to submit a copy of their degree transcript.
  • SLP provider assistants are required to be under the direct, immediate, on-premises supervision of an American Speech-Language-Hearing Association-certified and Medicaid-enrolled supervisor who is responsible and liable for performance of services delivered in accordance with Wis. Admin. Code § DHS 107.18(1)(a)."Direct, immediate, on-premises supervision" is defined as face-to-face contact between the supervisor and the person being supervised, as necessary, with the supervisor being physically present in the same building when the service is being performed by the person being supervised.
  • SLP provider assistants are required to notify Medicaid immediately using the demographic maintenance tool when they have a change in supervisor, employer, or work address.
Application Fee No

open content close contentMaster's Level

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Enrollment Criteria
  • The provider is required to meet the criteria per Wis. Admin. Code § DHS 105.30.
  • The provider is required to have an Entity Type 1 National Provider Identifier.
Terms of Reimbursement
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Eligible
Application Fee No

open content close content Wisconsin Medicaid Cost Reporting (WIMCR) Regionalization

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Enrollment Criteria
  • Wisconsin Medicaid Cost Reporting (WIMCR) regionalization enrollment is based on the type of service:
    • Case Management providers are required to meet the criteria per Wis. Admin. Code § DHS 105.51.
    • Community Support Program (CSP) agencies are required to obtain a Division of Quality Assurance (DQA) certificate to provide CSP services as authorized under Wis. Admin Code ch. DHS 63, which meets Wisconsin Medicaid's Wis. Admin. Code ch. DHS 105 requirements.

      The agency is required to make available the nonfederal share needed to provide CSP services.

    • Crisis Intervention Services agencies are required to obtain a DQA certificate to provide crisis intervention services as authorized under Wis. Admin. Code § DHS 34, Subchapter III, which meets Wisconsin Medicaid's Wis. Admin. Code ch. DHS 105 requirements.

      The agency is required to make available the nonfederal share needed to provide crisis intervention services.

    • Outpatient Substance Abuse Services agencies are required to obtain a DQA certificate to provide outpatient substance abuse services as authorized under Wis. Admin. Code § DHS 75.13, which meets Wisconsin Medicaid's requirements under Wis. Admin. Code ch. DHS 105.
  • The provider is required to have an Entity Type 2 National Provider Identifier..
Terms of Reimbursement Mental Health / Substance Abuse Services Terms of Reimbursement, P-01668
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment The lead county will be the billing and rendering provider. The other county or counties within the region will be the rendering-only provider(s).
Border Status Eligibility Not eligible
Other Important Information Only local county agencies may be Medicaid-enrolled to become WIMCR regions with approval from the Wisconsin Department of Health Services.
Application Fee Yes

open content close content Women, Infants, and Children Agencies (WIC)

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Enrollment Criteria
  • Special Supplemental Nutrition Program for Women, Infants, and Children agencies must be contracted with the Wisconsin Division of Public Health.
  • The provider is required to have an Entity Type 2 National Provider Identifier.
Terms of Reimbursement
Risk Level
  • At enrollment: Limited
  • Upon revalidation: Limited
Disclosure Information
Category of Enrollment Billing and rendering provider
Border Status Eligibility Not eligible
Application Fee Yes
 
 
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