Covered and Noncovered Services : Covered Services and Requirements

An Overview of HealthCheck Services

The purpose of EPSDT is to ensure that children receive early detection and care, so that health problems are prevented or diagnosed and treated as early as possible. HealthCheck is the term used for EPSDT in Wisconsin.

The HealthCheck benefit provides periodic, comprehensive health screening exams (also known as "well child checks"), as well as interperiodic screens, outreach and case management, and additional medically necessary services (referred to as HealthCheck "Other Services") for members under 21 years of age.

The HealthCheck benefit consists of the following service types:

• Periodic comprehensive screens
• Interperiodic screens
• Outreach and case management
• HealthCheck "Other Services"

A HealthCheck screen may be distinguished from other preventive health care under Wisconsin Medicaid because HealthCheck includes a strong anticipatory guidance and health education component, a schedule for periodic examinations (based on recommendations by the AAP).

Beyfortus Covered Through the Vaccines for Children Program

Beyfortus (nirsevimab), a monoclonal antibody, is used for the prevention of lower respiratory tract disease caused by RSV in infants or children.

The CDC's ACIP recommends the routine use of Beyfortus for the prevention of RSV for newborns and infants younger than 8 months of age born during or entering their first RSV season. The ACIP also recommends the routine use of Beyfortus for children aged 8 to 19 months who are at increased risk of severe RSV, which includes Alaska Native and American Indian children, as defined by the Indian Health Care Improvement Act, who are entering their second RSV season.

Beyfortus Supplied Through the Vaccines for Children Program

The federal VFC Program was created to provide vaccines to eligible children through enrolled public and private providers. The VFC Program is part of a national approach to improving immunization services and levels.

Although not a vaccine, the ACIP voted to include Beyfortus in the VFC Program.

ForwardHealth covers Beyfortus consistent with current policies for immunization services. Therefore, providers are required to obtain Beyfortus for children from the VFC supply. ForwardHealth reimburses only an administration code for Beyfortus supplied through the VFC Program.

Providers may refer to the Wisconsin Immunization Program for contact information about enrolling in the VFC Program.

Blood Lead Screening Test

A capillary finger stick test can be done for a blood lead screening test. A confirmatory blood test is required only if the capillary blood lead level is 3.5 mcg/dL or greater.

Providers may be reimbursed for collection of a capillary blood specimen (for example, finger, heel, ear stick) using CPT procedure code 36416 (collection of capillary blood specimen [e.g., finger, heel, ear stick]). This procedure is frequently used when doing a finger stick blood draw for blood lead testing.

Providers may be reimbursed for CPT procedure code 36416 and lab handling fee CPT procedure code 99000 when drawing a finger stick blood specimen to be mailed to the laboratory for analysis.

Providers may be reimbursed for CPT procedure code 36416 and CPT procedure code 83655 (Lead) when doing on-site blood lead testing. Providers will not be reimbursed for the lab handling fee CPT procedure code 99000 in this situation.

Blood Lead Testing at WIC Clinics

The WIC Program's role is to assess and refer participants to health care providers for blood lead testing. WIC offices that do not provide blood lead testing are encouraged to:

• Refer participants who have children ages 12 and 24 months for a blood lead test.
• Refer participants who have children between 24 and 72 months with no record of a previous blood test.

For blood lead tests completed at a WIC office, the result is uploaded to the Wisconsin Blood Lead Registry.

HealthCheck providers should ensure they follow blood lead level testing guidelines.

Wisconsin Blood Lead Registry

The Lead Registry is a web-based tool that allows providers to check a child's blood lead testing history online during an office visit. The Lead Registry is linked to the WIR and updated by WCLPPP each week with new test results done at all locations, including WIC, Head Start, and physicians' offices. The Lead Registry can help providers easily identify children who have not yet been tested or are due for another test. For information on how to access the Lead Registry, providers may contact the WCLPPP.

Office-Based Blood Lead Testing

Providers are encouraged to draw capillary (finger stick) blood lead samples within their office or clinic. Performing the finger stick in the clinic ensures the test is completed. If the child is referred to an outside area, the test may not be done.

Providers wanting to provide blood lead testing in their office should follow Clinical Laboratory Improvement Amendment requirements. CLIA requires laboratories and providers performing tests for health assessment or for the diagnosis, prevention, or treatment of disease or health impairment to comply with specific federal quality standards.

Certificate of Need for Transportation

ForwardHealth covers SMV services if the transportation is to and from a facility where the member receives Medicaid-covered services and the member meets the criteria for SMV services. The following are criteria for SMV services:

• A member must be indefinitely disabled, legally blind, or temporarily disabled.
• A member must have a medical condition that contraindicates safe travel by common carrier such as bus, taxi, or private vehicle.

If a member meets the criteria, a physician, physician assistant, nurse practitioner, or nurse midwife should complete a Certification of Need for Specialized Medical Vehicle Transportation form.

Inconvenience or lack of timely transportation are not valid justifications for the use of SMV transportation. The presence of a disability does not by itself justify SMV transportation.

The medical provider gives a copy of the completed form to the member who then gives the form to the SMV provider. The medical provider does not need to keep a copy of the completed form on file, but they are required to document the medical condition necessitating SMV transportation in the member's medical record.

Physicians are required to complete a new Certification of Need for Specialized Medical Vehicle Transportation form upon expiration. For members who are indefinitely disabled, the form is valid for three years (36 months) from the date the medical provider signed the form. For members who are temporarily disabled, the form is valid for the period indicated on the form, which must not exceed 90 days from the date the medical provider signed the form.

Medical providers must not complete the forms retroactively for SMV providers or members.

Providers may not charge members for completing the Certification of Need for Specialized Medical Vehicle Transportation form. Wisconsin Medicaid will reimburse providers at the lowest level E&M CPT procedure code if the member is in the office when the form is completed and no other medical service is provided.

Choosing Appropriate Components for a Member

Each of the required components of a comprehensive HealthCheck screen must be assessed and documented. On occasion, not every exam component needs to be performed to be a comprehensive screen, but each component must be documented. For example, a hearing test is unnecessary for a member previously referred to an audiologist via a school screening exam referral.

The periodicity schedule indicates recommended exam components for specific member ages.

Comprehensive HealthCheck Screening Components and Periodicity

Required Components for Comprehensive Screens

Comprehensive HealthCheck screens are age-appropriate medical wellness check-ups that occur on a regular basis for Medicaid members under 21 years of age, and include the following components:

• A comprehensive health and developmental history, including:
  • A health history
  • A nutritional assessment
  • A developmental-behavioral assessment
  • Health education and anticipatory guidance for the member and caregiver
• A comprehensive unclothed physical exam
• A hearing screen
• A vision screen
• An oral assessment, plus referral to a dentist beginning when the first tooth erupts or by age 1
• Appropriate immunizations (according to age and health history, per the CDC's ACIP guidelines)
• Appropriate laboratory tests (including blood lead level testing when appropriate for age)

HealthCheck provides access to comprehensive medical, vision, hearing, and dental screens according to the periodicity schedule recommended by the AAP.

As required by 42 C.F.R. § 441.58, Wisconsin Medicaid follows AAP's periodicity schedule for screening services.

Conditions identified during a HealthCheck screen may be referred for additional evaluation, which is covered by Wisconsin Medicaid. These conditions may result in recommendations for services that may be covered as HealthCheck "Other Services."

Accessing Comprehensive Screens

Comprehensive HealthCheck screens are available without PA. Primary care providers, including pediatricians, nurse practitioners, local health departments, and physician clinics, should provide the appropriate components of a HealthCheck screen, based on AAP or other best practice guidelines, as part of a comprehensive well child exam. No special forms are required.

Providers are required to maintain documentation of the HealthCheck screen and all areas that were assessed in the member's medical record. Clinics or agencies may use their own documentation system, or they may use forms available from Wisconsin Medicaid that meet the documentation requirements. These forms are available free of charge.

Note: Medicaid reimbursement is limited to Medicaid-enrolled providers.

Definition of Covered Services

Dental Sealants

ForwardHealth reimburses HealthCheck nursing agencies enrolled in Wisconsin Medicaid for providing dental sealants to BadgerCare Plus and Medicaid members under age 21 when they are provided by a dentist or a dental hygienist as a HealthCheck service. Medicaid coverage for sealants in HealthCheck nursing agencies is limited to tooth numbers 02, 03, 14, 15, 18, 19, 30, and 31. Sealants for other teeth require PA.

The dentist or dental hygienist providing sealants is not required to be Medicaid-enrolled since the HealthCheck nursing agency is Medicaid-enrolled. Dental hygienists may provide sealants at a HealthCheck nursing agency under one of the following:

• A dentist's order
• A physician's order
• An agency protocol

Submitting Claims

HealthCheck nursing agencies are required to submit claims for dental sealants using either the ADA 2006 Claim Form or the ADA 2012 Claim Form with CDT procedure code D1351 and the appropriate tooth number(s). Providers should submit claims fee-for-service, even if the member is enrolled in an HMO, including HMOs that cover dental services. Providers should use the appropriate claim form instructions for the ADA 2006 or 2012 claim forms when submitting these claims for dental sealants provided by HealthCheck nursing agencies.

There is a once-per-three-year limitation on sealants for permanent first and second molars. To exceed the once-per-three-year limitation, a narrative must be attached to the claim explaining why the limitation was exceeded. The narrative must be signed by a licensed dentist.

Prior Authorization

PA is required for tooth numbers/letters 01, 04-13, 16, 17, 20-29, 32, A-T, and supernumerary teeth (AS-TS, 51-82). For these teeth, HealthCheck providers are required to refer the member to a Medicaid-enrolled dentist to request PA and provide these services. If the PA request is approved, Wisconsin Medicaid will reimburse the dentist for the service.

Dental and Dental Hygienist Services

The following procedure codes are reimbursable for HealthCheck agencies submitting claims for services performed by dentists and dental hygienists. Dentists and dental hygienists are not required to be Medicaid-enrolled.

Dental Hygienists

Dentists

Description of Required Components of a HealthCheck Screen

Guidelines for Completing Components

Providers may use the following guidelines when documenting components of a HealthCheck screen:

1. A comprehensive health and developmental history, including:
1. A health history — A review of the member's and family's health and treatment history to identify special risk factors or prior conditions/treatments pertinent to future care.
2. A nutritional assessment — A review of the individual's eating patterns/habits should be included in order to identify persons who may require a more in-depth dietary assessment and counseling, particularly if other nutrition-related risk factors exist (for example, iron deficiency anemia, abnormal height/weight).
3. Health education and anticipatory guidance for the member and caregiver — All screening exams must include preventive health education and an explanation of screening findings. This may include discussion of:
• Proper nutrition, parenting skills, family planning concerns, alcohol and other drug abuse/mental health concerns
• Preventive health and healthy lifestyle actions (for example, use of infant car seats, poison prevention, injury prevention, hot water temperature settings, avoidance of tobacco products)
• Normal stages of growth and development
• Screening findings and explanation of any problems found and the importance of necessary follow-up care
4. Developmental-behavioral assessment — Observed behavior and attainment of developmental milestones (including emotional status) should be compared to age-specific norms to identify developmental delays or subtle indications of hidden problems. Parental concerns and observations regarding the child's development and health should be reviewed to identify possible special conditions warranting more careful examination. Adolescent health visits should involve seeing the adolescent alone, as well as with the parents whenever possible. The adolescent should be assured of the confidentiality of the interview.
5. Forms — Although optional, a number of forms are available to document details of the screen for the member's medical record, assisting with this requirement. Available forms include the following:
• HealthCheck Family History
• HealthCheck Infant's Food Record (Birth to 12 Months of Age)
• HealthCheck Child's Food Record/1-12 Years of Age
• HealthCheck Adolescent's Food Record (13 to 20 Years of Age)
2. A comprehensive unclothed physical exam
1. Unclothed physical exam and physical growth assessment — This should be a systematic examination of each body system according to accepted medical procedure. Blood pressure readings must be taken for all children beginning at 3 years of age.

   Note: The screener should be alert for any indication of physical or sexual abuse. State law requires that signs of abuse be reported immediately to Child Protection Services of the certifying agency.

2. Growth assessment — Comparison of member's height, weight, and head circumference to age-specific norms to identify growth abnormalities. This includes the calculation of the child's length to age percentile, weight to length percentile, and head circumference to age percentile.
3. Sexual development to members who have reached puberty — At the request of the member or parent, the screener is required to provide counseling on sexual development, birth control, and sexually transmitted diseases, as well as appropriate prescriptions and testing, or the screener is required to refer the member to an appropriate resource. A pelvic examination or referral for the appropriate testing should be offered to all females who have reached puberty.
3. A vision screen — All children should be observed for:
• Appropriate visual acuity
• Strabismus
• Abnormal disc reflex (under age 1)
• Response to cover test
• Amblyopia
• Color blindness
Use of vision charts must be attempted to measure visual acuity beginning at age 4.
4. A hearing screen
1. All hearing screens in infancy and early childhood should include an otoscopic exam and/or tympanometric measurements for the detection of chronic or recurrent otitis media.
2. Screen at birth through age 2 using both methods outlined in High Risk Factors for Hearing Loss in Neonates and Infants and the HealthCheck/Your Child's Speech and Hearing form. Children failing either screening method should be referred for audiological assessment.
3. Administer puretone audiometric screen as follows: annually to all children ages 3 to 8 and at four-year intervals thereafter up to age 16; and to any children older than age 8 with excessive exposure to noise, delayed speech and language development, or who are receiving a HealthCheck screen for the first time.
5. An oral assessment, plus referral to a dentist beginning when the first tooth erupts or by age 1 (This exam must be sufficient to identify children in need of early examination by a dentist. Parents with children under 3 years of age should be questioned regarding their child's problematic thumb sucking, lip biting, caries, tongue thrusting, non-erupted teeth, extra teeth, extended use of pacifier, or bottle feeding practices conducive to early dental caries or malfunction of oral cavity. All children age 1 or older (and younger where medically indicated) must be referred to a dentist if they are not already receiving such care.)

Medically necessary services, which are not otherwise covered, may be covered under HealthCheck "Other Services." The following dental services are covered only to members under age 21 to address concerns identified during a HealthCheck screen:

• Orthodontics (Once started, orthodontic services will be reimbursed to completion regardless of the member's eligibility. PA is required.)
• One additional cleaning per year with PA for children ages 13 through 20 (One cleaning is allowed per year for members between the ages of 13 and 20.)
ForwardHealth has identified criteria for effective oral assessments.
6. Appropriate immunizations (according to age and health history per the CDC's ACIP guidelines) (Federal regulations require that immunizations recommended by the ACIP are automatically covered after approval by the CDC. The majority of required childhood immunizations are available through the Wisconsin Immunization Program's VFC Program.)

ForwardHealth reimburses only the administration fee for children 18 years of age or younger when a VFC vaccine is available. For members 19 years of age or older, ForwardHealth reimburses for the vaccine component and the administration component.

Beyfortus (nirsevimab), a monoclonal antibody, is used for the prevention of lower respiratory tract disease caused by RSV in infants or children. Although not a vaccine, the CDC's ACIP voted to include Beyfortus in the VFC Program. Providers are required to obtain Beyfortus for children from the VFC supply. ForwardHealth only reimburses an administration code for Beyfortus supplied through the VFC Program.

Additional resources include the following:

• The Wisconsin Immunization Registry
• The Wisconsin Immunization Program at 608-267-9959
7. Appropriate laboratory tests (including blood lead level testing when appropriate for age)

Blood lead level test — CMS, through EPSDT guidelines, requires that all children who are enrolled in ForwardHealth receive a blood lead level test at about 12 months and again at about 24 months. In addition, children between the ages of 3 and 5 must receive a blood lead level test if they have never been tested before. Providers are responsible for assuring that children receive blood lead level tests at the required ages. Testing of all children enrolled in ForwardHealth applies regardless of the presence or absence of recognized blood lead level exposure risks. According to the AAP, a low blood lead level concentration in a 1 year old does not preclude elevation later. Therefore, providers are required to repeat blood lead level testing at about 2 years of age, regardless of the results of the 1-year test.

Additional resources include the following:

• WCLPPP
• Wisconsin Blood Lead Registry (contact the WCLPPP to request access to this registry)
HealthCheck nursing agencies should perform any additional laboratory tests indicated by their protocol. Physicians should order any additional laboratory tests they feel appropriate.

Diagnosis and Treatment

All appointments for any further diagnosis or treatment as a result of the screening should be scheduled within 60 days of the date of the HealthCheck screening. All BadgerCare Plus and Medicaid services on a HealthCheck referral should be provided within six months of the screening date.

Discussing Results

Following performance of a HealthCheck screening, test results must be explained to educate the member or parent about preventive measures that can be taken. Discuss the need for referred follow-up care (e.g., dentist) and schedule the next periodic examination when possible.

Adolescent health visits should involve seeing the adolescent alone as well as with the parents. The adolescent should be assured of the confidentiality of the interview.

Emergencies

Certain program requirements and reimbursement procedures are modified in emergency situations. Emergency services are defined in Wis. Admin. Code § DHS 101.03(52), as "those services that are necessary to prevent the death or serious impairment of the health of the individual." Emergency services are not reimbursed unless they are covered services.

Additional definitions and procedures for emergencies exist in other situations, such as dental and mental health.

Program requirements and reimbursement procedures may be modified in the following ways:

• PA or other program requirements may be waived in emergency situations.
• Non-U.S. citizens may be eligible for covered services in emergency situations.

Environmental Lead Investigation Services

ForwardHealth covers ELI services provided by the following:

• Local health departments, as defined in Wis. Stat. § 250.01(4), enrolled as HealthCheck screening providers.
• Wisconsin DHS-certified lead hazard investigators (or risk assessors) contracted with local health departments. Note: Providers are reminded that they are legally, programmatically, and fiscally responsible for the services provided by their contractors and their subcontractors' services.

ELI services include all of the following:

• An initial comprehensive environmental lead investigation, billed under HCPCS procedure code T1029 (comprehensive environmental lead investigation, not including laboratory analysis, per dwelling)
• Follow-up lead clearance investigations, billed under procedure code T1029 with modifier TS (Follow-Up Service)
• Nursing education visits related to lead poisoning, billed under procedure code T1002 (RN services, up to 15 minutes)

ELI services may be Medicaid reimbursable if the following criteria are met:

• A child 0–20 years old is shown to have lead poisoning or lead exposure as defined in Wis. Stat. § 254.11(9).
• The ELI services are provided in the child's home.
• The person (including contractors and subcontractors) doing the investigation is Wisconsin DHS-certified as a lead hazard investigator (or risk assessor).
• The person doing the lead poisoning education is a registered nurse.

Additional Coverage Criteria

The following requirements also apply to the coverage of ELI services:

• If more than one child in the home has lead poisoning or lead exposure, all ELI services must be billed under one child's Medicaid ID only.
• An initial comprehensive environmental lead investigation (T1029) is limited to one per rolling year, per provider, per residence. Add modifier TS to indicate follow-up environmental lead clearance investigations.
• Nurse education visits (T1002) are limited to four units (i.e., one hour) per date of service, per provider, per member. If a child is diagnosed with lead exposure or lead poisoning, a nurse education visit for lead poisoning is covered regardless of whether an environmental lead investigation will be conducted.

Components of a Comprehensive Lead Investigation

Environmental lead investigation of the child's home involves not only the identification of all sources of lead exposure, but also advising parents or guardians about identified and potential sources of lead and ways to reduce exposure. Once home owners or rental property owners are notified of the problem and have an opportunity to remedy the situation, a follow-up lead clearance investigation should be conducted to assure that the lead hazards are resolved. Additional information about aspects of the environmental lead investigation can be obtained from the Lead-Safe Wisconsin website.

Technical aspects of a comprehensive lead investigation must include all of the following:

• Interview with parents or guardians and property owner to determine physical characteristics and usage of dwelling
• A complete lead risk assessment of the property, including:
  • A visual assessment of the dwelling and property to determine the locations of deteriorated paint and lead paint hazards
  • Collection of samples and/or use of X-ray fluorescence analyzer to measure lead in the environment (dust, paint, soil, or water)
  • Identification and evaluation of any non-paint lead hazards
  • Provision of a complete lead risk assessment report to the property owner and parents or guardians, including findings and any work orders or recommendations for lead hazard reduction

Technical aspects of a comprehensive lead investigation must include all of the following:

• A visual assessment to determine that all identified lead hazards have been remediated, no visible dust or debris remains, and non-paint hazards have been removed
• For interior lead paint hazards, collection of clearance dust-wipe samples to verify safe completion and clean-up of the work
• Provision of a written clearance report to the contractor, property owner, and parents or guardians

Education Home Visits by a Registered Nurse

An education home visit involves advising parents or guardians of the child's blood lead level and what it means, the impact of lead poisoning on children, risk factors and possible sources of lead exposure, steps parents or guardians can take to decrease their child's lead exposure, the importance of a well-balanced diet, and follow-up blood lead testing recommendations. Additional information about lead poisoning prevention education can be obtained from Lead-Safe Wisconsin.

Claim Submission

Local health departments that are enrolled as HealthCheck providers may submit claims for ELI services even if a comprehensive HealthCheck screen has not previously been done.

The following applies to claims submitted for ELI services:

• POS code must be 12 (home).
• Member must have a diagnosis of lead poisoning or lead exposure.
• For procedure code T1002 (RN services, up to 15 minutes), the claim must include diagnosis code Z77.011 (Contact with and [suspected] exposure to lead).
• The service must have the HealthCheck service modifier EP submitted in the primary modifier position.
• If procedure code T1029 is billed and the service represents a follow-up lead clearance investigation, modifier TS must also be submitted in the second modifier position.

If a member is enrolled in a managed care program, providers are required to submit claims to Wisconsin Medicaid fee-for-service for ELI services. Providers should not submit claims to the member's MCO because ELI services are covered on a fee-for-service basis for all members and, thus, will not be reimbursed by the member's managed care organization.

Fluoride — Topical Applications

Topical application of fluoride to a child's teeth is a safe and effective way to prevent tooth decay as part of a comprehensive oral health program.

It is recommended that children under age 5 who have erupted teeth receive topical fluoride treatment. Children at low or moderate risk of early childhood caries should receive one or two applications per year; children at higher risk should receive three or four applications per year.

The most accepted mode of fluoride delivery in children under age 5 is a fluoride varnish. OTC mouth rinses are not covered.

Allowable Providers

Topical applications of fluoride may be provided by nurses and dental hygienists employed at Medicaid-enrolled HealthCheck nursing agencies. Nurses may provide topical fluoride applications at a HealthCheck nursing agency under one of the following:

• A physician's order
• An agency protocol

Dental hygienists may provide topical fluoride applications at a HealthCheck nursing agency under one of the following:

• A dentist's order
• A physician's order
• An agency protocol

Submitting Claims

When submitting claims for topical fluoride treatment, indicate procedure code D1208 (Topical application of fluoride). Providers may also submit claims with HealthCheck and office visit procedure codes for these services.

In cases where more than two fluoride treatments per year are medically necessary, providers are required to retain supporting clinical documentation in the member's file indicating the need for additional treatments.

Ancillary staff (e.g., physician assistants, nurse practitioners) are required to follow certain billing procedures.

Wisconsin Medicaid will separately reimburse providers for the appropriate level office visit or preventive visit at which the fluoride application was performed.

Training Materials

An Oral Health Provider Training guide describing how providers may perform lift-the-lip oral screenings, apply fluoride varnish to a small child's teeth, and provide basic oral health guidance to parents is available.

Immunizations

Providers are required to indicate the procedure code of the actual vaccine administered, not the administration code, on claims for all immunizations. Reimbursement for both the vaccine, when appropriate, and the administration are included in the reimbursement for the vaccine procedure code, so providers should not separately bill the administration code. Providers are required to indicate their usual and customary charge for the service with the procedure code.

The immunizations identified by CPT subsections "Immune Globulins" (procedure codes 90281-90399) and "Vaccines, Toxoids" (procedure codes 90476-90749) are covered.

Immune globulin procedure codes and the unlisted vaccine/toxoid procedure code are manually priced by ForwardHealth's pharmacy consultant. To be reimbursed for these codes, physicians are required to attach the following information to a paper claim:

• Name of drug
• NDC
• Dosage
• Quantity (for example, vials, milliliters, milligrams)

Medicaid reimbursement for immune globulins, vaccines, toxoid immunizations, and the unlisted vaccine/toxoid procedure codes includes reimbursement for the administration component of the immunization, contrary to CPT's description of the procedure codes. Procedure codes for administration are not separately reimbursable.

Vaccines for Children 18 Years of Age or Younger

Most vaccines provided to members 18 years of age or younger are available through the federal VFC Program at no cost to the provider. If a vaccine is available through the VFC Program, providers are required to use vaccines from VFC supply for members 18 years of age or younger. ForwardHealth reimburses only the administration fee for vaccines supplied by the VFC Program.

For vaccines that are not supplied by the VFC Program, providers may use a vaccine from a private stock. In these cases, ForwardHealth reimburses for the vaccine and the administration fee.

The Wisconsin Immunization Program has more information about the VFC Program. Providers may also call the VFC Program at 608-267-9959 or email VFC@dhs.wisconsin.gov.

Vaccines that are commonly combined, such as MMR or DTaP, are not separately reimbursable unless the medical necessity for separate administration of the vaccine is documented in the member's medical record.

If a patient encounter occurs in addition to the administration of the injection, physicians may receive reimbursement for the appropriate E&M procedure code that reflects the level of service provided at the time of the vaccination. If an immunization is the only service provided, the lowest level E&M office or other outpatient service procedure code may be reimbursed, in addition to the appropriate vaccine procedure code(s).

Vaccines for Members 19 Years of Age or Older

For vaccines from a provider's private stock that are administered to members 19 years of age or older, ForwardHealth reimburses for the vaccine and the administration fee.

Interperiodic Visits

Wisconsin Medicaid covers medically necessary interperiodic screens to follow up on detected problems or conditions.

Interperiodic screens are visits with qualified providers that occur outside the AAP periodicity schedule. They may be recommended by any professional who comes into contact with the child, such as physicians, dentists, health officials, or educators.

An interperiodic screen can be problem-focused or may include any or all components of the comprehensive screen. These visits may be required to diagnose a new illness or condition or to determine whether a previously diagnosed illness or condition requires additional services. Interperiodic screens ensure that access to a necessary service is not delayed by waiting until the next scheduled wellness check-up. Examples of interperiodic screens include the following:

• Immunizations
• Retesting for an elevated blood lead level
• Retesting for a low hematocrit
• Addressing nutrition concerns

Like comprehensive HealthCheck screens, conditions identified during an interperiodic screen may result in recommendations for further evaluation or services which may be covered.

Accessing Interperiodic Screens

Interperiodic HealthCheck screens are available without PA, and any Medicaid-enrolled provider, within the scope of their license, may provide these screens. No special forms are required.

Documentation of Guidelines for Evaluation and Management Services

BadgerCare Plus has adopted the federal CMS 2021 and 2023 Documentation Guidelines for Evaluation and Management Services in combination with BadgerCare Plus policy for E&M services. Providers are required to present documentation upon request indicating which of the guidelines or BadgerCare Plus policies were utilized for the E&M procedure code that was billed.

The documentation in the member's medical record for each service must justify the level of the E&M code billed. Providers may access the CMS documentation guidelines on the CMS website. BadgerCare Plus policy information can be found in service-specific areas of the Online Handbook or on the ForwardHealth Portal.

Interpretive Services

ForwardHealth reimburses interpretive services provided to BadgerCare Plus and Medicaid members who are deaf or hard of hearing or who have LEP. A member with LEP is someone who does not speak English as their primary language and who has a limited ability to read, speak, write, or understand English.

Interpretive services are defined as the provision of spoken or signed language communication by an interpreter to convey a message from the language of the original speaker into the language of the listener in real time (synchronous) with the member present. This task requires the language interpreter to reflect both the tone and the meaning of the message.

Only services provided by interpreters of the spoken word or sign language will be covered with the HCPCS procedure code T1013 (Sign language or oral interpretive services, per 15 minutes). Translation services for written language are not reimbursable with T1013, including services provided by professionals trained to interpret written text.

Covered Interpretive Services

ForwardHealth covers interpretive services for deaf or hard of hearing members or members with LEP when the interpretive service and the medical service are provided to the member on the same DOS and during the same time as the medical service. A Medicaid-enrolled provider must submit for interpretive services on the same claim as the medical service, and the DOS they are provided to the member must match. Interpretive services cannot be billed by HMOs and MCOs. Providers should follow CPT and HCPCS coding guidance to appropriately document and report procedure codes related to interpretive and medical services on the applicable claim form. Time billed for interpretive services should reflect time spent providing interpretation to the member. At least three people must be present for the services to be covered: the provider, the member, and the interpreter.

Interpreters may provide services either in-person or via telehealth. Services provided via telehealth must be functionally equivalent to an in-person visit, meaning that the transmission of information must be of sufficient quality as to be the same level of service as an in-person visit. Transmission of voices, images, data, or video must be clear and understandable. Both the distant and originating sites must have the requisite equipment and staffing necessary to provide the telehealth service.

Billing time for documentation of interpretive services will be considered part of the service performed. BadgerCare Plus and Wisconsin Medicaid have adopted the federal "Documentation Guidelines for Evaluation and Management Services" (CMS 2021 and 2023) in combination with BadgerCare Plus and Medicaid policy for E&M Services.

Most Medicaid-enrolled providers, including border-status or out-of-state providers, are able to submit claims for interpretive services.

Standard ForwardHealth policy applies to the reimbursement for interpretive services for out-of-state providers, including PA requirements.

Interpretive Services Provided Via Telehealth for Out-of-State Providers

ForwardHealth requirements for services provided via telehealth by out-of-state providers are the same as the ForwardHealth policy for services provided in-person by out-of-state providers. Requirements for out-of-state providers for interpretive services are the same whether the service is provided via telehealth or in-person. Out-of-state providers who are not enrolled as either border-status or telehealth-only border-status providers are required to obtain PA before providing services via telehealth to BadgerCare Plus or Medicaid members. The PA would indicate that interpretive services are needed.

Documentation

While not required for submitting a claim for interpretive services, providers must include the following information in the member's file:

• The interpreter's name and/or company
• The date and time of interpretation
• The duration of the interpretive service (time in and time out or total duration)
• The amount submitted by the medical provider for interpretive services reimbursement
• The type of interpretive service provided (foreign language or sign language)
• The type of covered service(s) the provider is billing for

Third-Party Vendors and In-House Interpreters

Providers may be reimbursed for the use of third-party vendors or in-house interpreters supplying interpretive services.

Providers are reminded that HIPAA confidentiality requirements apply to interpretive services. When a covered entity or provider utilizes interpretive services that involve PHI, the entity or provider will need to conduct an accurate and thorough assessment of the potential risks and vulnerabilities to PHI confidentiality, integrity, and availability. Each entity or provider must assess what are reasonable and appropriate measures for their situation.

Limitations

There are no limitations for how often members may utilize interpretive services when the interpretive service is tied to another billable medical service for the member for the same DOS.

Claims Submission

To receive reimbursement, providers may bill for interpretive services on one of the following claim forms:

• 1500 Health Insurance Claim Form (for dental, professional, and professional crossover claims)
• Institutional UB-04 (CMS 1450) claim form (for outpatient crossover claims and home health/personal care claims)

Noncovered Services

The following will not be eligible for reimbursement with procedure code T1013:

• Interpretive services provided in conjunction with a noncovered, non-reimbursable, or excluded service
• Interpretive services provided by the member's family member, such as a parent, spouse, sibling, or child
• The interpreter's waiting time and transportation costs, including travel time and mileage reimbursement, for interpreters to get to or from appointments
• The technology and equipment needed to conduct interpretive services
• Interpretive services provided directly by the HMOs and MCOs are not billable to ForwardHealth for reimbursement via procedure code T1013

Cancellations or No Shows

Providers cannot submit a claim for interpretive services if an appointment is cancelled, the member or the interpreter is a no-show (is not present), or the interpreter is unable to perform the interpretation needed to complete the appointment successfully.

Procedure Code and Modifiers

Providers must submit claims for interpretive services and the medical service provided to the member on separate details on the same claim.

Procedure code T1013 is a time-based code, with 15-minute increments. Rounding up to the 15-minute mark is allowable if at least eight minutes of interpretation were provided.

Providers should use the following rounding guidelines for procedure code T1013.

Claims for interpretive services must include HCPCS procedure code T1013 and the appropriate modifier(s):

• U1 (Spoken language)
• U3 (Sign Language)
• GT (Via interactive audio and video telecommunication systems)
• 93 (Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system)

Providers should refer to the interactive maximum allowable fee schedules for the reimbursement rate, covered provider types and specialties, modifiers, and the allowable POS codes for procedure code T1013.

*Any telehealth service must be provided using HIPAA-compliant software or delivered via an app or service that includes all the necessary privacy and security safeguards to meet the requirements of HIPAA.

Dental Providers

Dental providers submitting claims for interpretive services are not required to include a modifier with procedure code T1013. Dental providers should retain documentation of the interpretive service in the member's records.

Allowable Places of Service

Claims for interpretive services must include a valid POS code where the interpretive services are being provided.

Federally Qualified Health Centers

Non-tribal FQHCs, also known as CHCs, (POS code 50), will not receive direct reimbursement for interpretive services as these are indirect services assumed to be already included in the FQHC's bundled PPS rate. However, CHCs can still bill the T1013 code as an indirect procedure code when providing interpretive services. This billing process is similar to that of other indirect services provided by non-tribal FQHCs. This will enable DHS to better track how FQHCs provide these services and process any future change in scope adjustment to increase their PPS rate that includes providing interpretive services.

Rural Health Clinics

RHCs (POS code 72) receives direct reimbursement for interpretive services. Procedure code T1013 should be billed when providing interpretive services.

Interpreter Qualifications

The two types of allowable interpreters include:

• Sign language interpreters—Professionals who facilitate the communication between a hearing individual and a person who is deaf or hard of hearing and uses sign language to communicate
• Foreign language interpreters—Professionals who are fluent in both English and another language and listen to a communication in one language and convert it to another language while retaining the same meaning.

Qualifications for Sign Language Interpreters

For Medicaid-enrolled providers to receive reimbursement, sign language interpreters must be licensed in Wisconsin under Wis. Stat. § 440.032 and must follow the specific requirements regarding education, training, and locations where they are able to interpret. The billing provider is responsible for determining the sign language interpreter's licensure and must retain all documentation supporting it.

Qualifications for Foreign Language Interpreters

There is not a licensing process in Wisconsin for foreign language interpreters. However, Wisconsin Medicaid strongly recommends that providers work through professional agencies that can verify the qualifications and skills of their foreign language interpreters.

A competent foreign language interpreter should:

• Be at least 18 years of age.
• Be able to interpret effectively, accurately, and impartially, both receptively and expressively, using necessary specialized vocabulary.
• Demonstrate proficiency in English and another language and have knowledge of the relevant specialized terms and concepts in both languages.
• Be guided by the standards developed by the National Council on Interpreting Health Care.
• Demonstrate cultural responsiveness regarding the LEP language group being served including values, beliefs, practices, languages, and terminology.

Laboratory Test Preparation and Handling Fees

The laboratory provider who performed the clinical diagnostic laboratory test is reimbursed, and the provider who collected the specimen is reimbursed a handling fee.

The independent laboratory or a physician's office is reimbursed a handling fee when the independent laboratory or physician's office sends specimens to an outside laboratory for analysis or interpretation. The handling fee covers the collection, preparation, forwarding, and handling of obtained specimen(s).

When forwarding a specimen from a physician's office to an outside laboratory, providers should submit claims for preparation and handling fees using procedure code 99000. When forwarding a specimen from a location other than a physician's office (e.g., an independent laboratory) to an outside laboratory, submit claims using procedure code 99001. It is not necessary to indicate the specific laboratory test performed on the claim.

A handling fee is not reimbursable if the physician or independent laboratory is reimbursed for the professional and/or technical component of the laboratory test.

Additional Limitations

Additional limitations on reimbursement for handling fees include the following:

• One lab handling fee is reimbursed to a physician or independent laboratory per member, per outside laboratory, or per DOS, regardless of the number of specimens sent to the laboratory.
• More than one handling fee is reimbursed when specimens are sent to two or more laboratories for one member on the same DOS. Indicate the number of laboratories and the total charges on the claim. The name of the laboratory does not need to be indicated on the claim; however, this information must be documented in the provider's records.
• The DOS must be the date the specimen is obtained from the member.

Medical Necessity

Wisconsin Medicaid reimburses only for services that are medically necessary as defined under Wis. Admin. Code § DHS 101.03(96m). Wisconsin Medicaid may deny or recoup payment if a service fails to meet Medicaid medical necessity requirements.

Member Payment for Covered Services

Under state and federal laws, a Medicaid-enrolled provider may not collect payment from a member, or authorized person acting on behalf of the member, for covered services even if the services are covered but do not meet program requirements. Denial of a claim by ForwardHealth does not necessarily render a member liable. However, a covered service for which PA was denied is treated as a noncovered service. (If a member chooses to receive an originally requested service instead of the service approved on a modified PA request, it is also treated as a noncovered service.) If a member requests a covered service for which PA was denied (or modified), the provider may collect payment from the member if certain conditions are met.

If a provider collects payment from a member, or an authorized person acting on behalf of the member, for a covered service, the provider may be subject to program sanctions including termination of Medicaid enrollment.

On-Site Blood Lead Testing

Providers who currently hold a CLIA certificate of waiver or higher complexity CLIA certification level may be reimbursed for on-site blood lead testing using LeadCare II or similar CLIA-waived instruments if the following guidelines are met:

• Providers are successfully participating in a proficiency testing program as administered by the WSLH or another CMS-approved proficiency testing program.
• Providers are reporting all blood lead test results, regardless of the lead level, to the WCLPPP as required.

To be reimbursed for the on-site blood lead test, providers should indicate on the claim procedure code 83655 (Lead). Procedure code 99000 (Handling and/or conveyance of specimen for transfer from the office to a laboratory) is not separately reimbursable when procedure code 83655 is billed. Providers are eligible to be reimbursed for an appropriate office visit.

On-site blood lead testing is covered under these guidelines for Medicaid and BadgerCare Plus. There is no copayment for on-site blood lead testing in either plan.

Proficiency Testing

Reimbursement for on-site blood lead testing of Medicaid and BadgerCare Plus members is conditional on successful participation in a proficiency testing program. Programs are available through the WSLH and other proficiency testing providers, e.g., the CAP.

The WSLH has more than one proficiency testing option available. Testing sites using instruments viewed as using moderate or high complexity test methods must participate in a program meeting a specific CLIA configuration of three 5 sample events per year. Sites employing instruments viewed as waived technology under CLIA, e.g. LeadCare II, have the option of enrolling in a less expensive program that is more limited in scope, with two 3 sample events per year. For additional information about proficiency testing, and what option is best for your instrumentation, you can contact WSLH at 800-462-5261.

Reporting of Results

Providers are required to report all on-site blood lead test results to the WCLPPP, regardless of the lead level. For reporting requirements, refer to Wis. Admin. Code § DHS 181. Providers may use the Blood Lead Lab Reporting form. To establish a mechanism for reporting results, providers may call the WCLPPP at 608-266-5817 and ask for the data manager.

Online Resources for Information on the Treatment and Prevention of Lead Poisoning

Lead-Safe Wisconsin includes information on the prevention and treatment of childhood lead poisoning, including blood lead testing guidelines, medical management, public health interventions, surveillance data, and educational materials and resources for families.

Providers may also contact the WCLPPP.

Periodicity Schedule

As required by 42 C.F.R. § 441.58, Wisconsin Medicaid follows the AAP's periodicity schedule for screening services.

HealthCheck provides access to comprehensive medical, vision, hearing, and dental screens according to the periodicity schedule recommended by the AAP.

This schedule specifies the time period when services appropriate at each stage of the member's life should be done, beginning with a neonatal examination at birth up to the member's 21st birthday.

Claims submitted for comprehensive screening packages performed more frequently than allowed under the periodicity schedule are not reimbursable. A comprehensive screening may only be billed if all age-specific components of a screen are assessed and documented.

Program Requirements

For a covered service to meet program requirements, the service must be provided by a qualified Medicaid-enrolled provider to an enrolled member. In addition, the service must meet all applicable program requirements, including—but not limited to—medical necessity, PA, claims submission, prescription, and documentation requirements.

Referrals

The member must be referred for any needed follow-up care that cannot be provided at the time of the HealthCheck screen, including mandatory referral for an annual dental examination beginning when the first tooth erupts or by age 1 if the member is not regularly receiving dental care.

Referral Requirements

Following a HealthCheck screen, the case management provider is responsible for ensuring that all necessary referral appointments are kept. A critical responsibility of the case manager is the removal of all barriers a member may encounter for accessing various services on referral. Prompt scheduling of all appointments and referrals will enable the case manager to complete timely member follow-up.

Types of Referrals

Treatment Referral

Treatment referrals result from a HealthCheck interperiodic or comprehensive screen, when findings indicate the need for further evaluation, diagnosis, or treatment.

Mandatory Dental Referral

Beginning when the first tooth erupts or by age 1, all children must be referred to a dentist for an oral assessment.

Self-Referral

Self-referrals may occur when the member expresses a particular need to the case manager (e.g., day care, Head Start) or chooses to receive services from a provider other than the screening provider or the screener's referral. Case managers are required to be sensitive to these requests and assist the member with identification of other sources of treatment and services.

Referral From Another Provider

Referrals from other providers may result from a previous screening referral or the referral provider may make additional referrals for member care. Case managers are required to be prepared to assist and follow-up these referrals.

Support Referral

Support referrals (for non-Medicaid-reimbursable services) may include other maternal and child health services in the community, employment development programs, food assistance, WIC, nutrition counseling, food stamps, special educational services, housing, and other needs. Case managers must develop a thorough knowledge of local community resources and the member's needs to facilitate these referrals.

Discussion and Resolution of Potential Barriers

The referral process must also include a discussion and resolution of potential barriers to member follow through, such as the following:

• Transportation difficulties
• Cost concerns
• Lack of knowledge of providers
• Language and cultural barriers
• Failure to understand the need for care
• Confidentiality concerns (adolescents)

The member should also know the periodicity schedule and date of the next periodic exam. It is recommended that case managers send a reminder notice one week prior to the next periodic screening date.

Services That Do Not Meet Program Requirements

As stated in Wis. Admin. Code § DHS 107.02(2), BadgerCare Plus and Wisconsin Medicaid may deny or recoup payment for covered services that fail to meet program requirements.

Examples of covered services that do not meet program requirements include the following:

• Services for which records or other documentation were not prepared or maintained
• Services for which the provider fails to meet any or all of the requirements of Wis. Admin. Code § DHS 106.03, including, but not limited to, the requirements regarding timely submission of claims
• Services that fail to comply with requirements or state and federal statutes, rules, and regulations
• Services that the Wisconsin DHS, the PRO review process, or BadgerCare Plus determines to be inappropriate, in excess of accepted standards of reasonableness or less costly alternative services, or of excessive frequency or duration
• Services provided by a provider who fails or refuses to meet and maintain any of the enrollment requirements under Wis. Admin. Code ch. DHS 105
• Services provided by a provider who fails or refuses to provide access to records
• Services provided inconsistent with an intermediate sanction or sanctions imposed by DHS

Silver Diamine Fluoride

ForwardHealth covers silver diamine fluoride services for children and adults without PA. Silver diamine fluoride is a conservative treatment of an active, non-symptomatic carious lesion by topical application of a caries-arresting or inhibiting medicament without mechanical removal of sound tooth structure.

Clinical Criteria

The following are clinical criteria for coverage of silver diamine fluoride services:

• Treat and/or stabilize asymptomatic teeth with active carious lesion
• Treat difficult dental carious lesions such as exposed roots and root furcation
• Treat members with extreme caries risk (Xerostomia or Severe Early Childhood Caries)
• Treat carious lesions for members challenged by behavioral or medical management
• Treat carious lesions that may not all be treated in one visit
• Treat members who have limited and/or no access to restorative dental care

Providers are encouraged to review American Academy of Pediatric Dentistry policy guidelines and chairside guide regarding appropriate use of silver diamine fluoride.

Allowable Procedure Code

ForwardHealth covers the application of silver diamine fluoride identified by CDT procedure code D1354 (Interim caries arresting medicament application- per tooth) without PA.

Limitations and Requirements

The following limitations and requirements apply to coverage of silver diamine fluoride services:

• Allowed for treatment of asymptomatic and active dental caries only
• Allowed once per tooth, per six-month period
• Allowed for all ages
• Not allowed on the same DOS as the restoration of that tooth
• Reimbursable when rendered by dentists, dental hygienists, and HealthCheck providers only

Note: Frequency limitation may be exceeded for up to four times per tooth per 12-month period for members with high caries risk. Providers are required to retain documentation demonstrating medical necessity.

Claim Submission

When submitting claims for silver diamine fluoride services, providers are required to include the tooth number(s) or
letter(s).

Reimbursement

Reimbursement for procedure code D1354 is allowed once per day, per member, per tooth. For reimbursement amounts, refer to the maximum allowable fee schedule.

Additional Provider Responsibilities

Providers are required to disseminate the risks and benefits of silver diamine fluoride use and to discuss treatment alternatives as applicable. Providers are required to obtain written consent from the member or parent/legal guardian, particularly highlighting expected staining to treated lesion, potential staining of skin and clothes, and the need for reapplication for disease control, prior to providing the service. To ensure compliance with program requirements, the written consent document should be retained with the member's dental record and be available upon request.

Vaccines for Children Program

The federal VFC Program was created to provide vaccines to eligible children through enrolled public and private providers. The VFC Program is part of a national approach to improving immunization services and levels.

Any child 18 years of age or younger who meets at least one of the following criteria is eligible for the VFC Program:

• Eligible for BadgerCare Plus or Medicaid.
• American Indian or Alaska Native, as defined by the Indian Health Care Improvement Act.
• Uninsured.
• Underinsured. (These children have health insurance but the benefit plan does not cover immunizations. Children in this category may only receive immunizations from a FQHC or an RHC; they cannot receive immunizations from a private health care provider using a VFC-supplied vaccine.)

When a vaccine becomes available through the VFC Program, the VFC Program notifies providers with clinical information about new vaccines, including the date they may begin ordering the vaccine. On the first of the month following that date, ForwardHealth will begin reimbursing only the administration fee for that vaccine.

Benefits of the Vaccines for Children Program

The VFC Program provides the following benefits:

• Vaccines are provided at no charge to public and private providers to immunize all eligible children.
• Eliminates or reduces vaccine costs as a barrier to the vaccination of eligible children.
• Vaccines recommended by the ACIP are automatically covered after approval by the CDC.

Reimbursement for Vaccines Provided to Children

If a vaccine is available through the VFC Program, providers are required to use vaccines from the VFC supply for members 18 years of age or younger. ForwardHealth reimburses only the administration fee for vaccines supplied by the VFC Program.

For vaccines that are not supplied by the VFC Program, providers may use a vaccine from a private stock. In these cases, ForwardHealth reimburses for the vaccine and the administration fee.

Beyfortus (nirsevimab), a monoclonal antibody, is used for the prevention of lower respiratory tract disease caused by RSV in infants or children. Although not a vaccine, the CDC's ACIP voted to include Beyfortus in the VFC Program. Providers are required to obtain Beyfortus for children from the VFC supply. ForwardHealth only reimburses an administration code for Beyfortus supplied through the VFC Program.