|Program Name: ||BadgerCare Plus and Medicaid ||Handbook Area: ||HealthCheck (EPSDT) |
Covered and Noncovered Services : HealthCheck "Other Services"
Prior Authorization for HealthCheck "Other Services"
Providers submitting PA requests for HealthCheck "Other Services" should review the two types of PA requests. The following types of PA requests have their own submission requirements:
- Requests for exceptions to coverage limitations
- Requests for federally allowable Medicaid services not routinely covered by Wisconsin Medicaid
PA Submission Requirements for Exceptions to Coverage Limitations
HealthCheck "Other Services" may additionally cover established Medicaid health care services that are limited in coverage for members under 21 years of age.
If a PA request is submitted requesting additional coverage for a benefit where there is established policy, the request is automatically processed under the HealthCheck "Other Services" benefit to evaluate whether the requested service is likely to correct or ameliorate the member's condition, including maintaining current status or preventing regression.
Examples of coverage limitations include service amounts that are prohibited by policy, or the requested service is not expected to result in a favorable improvement in the member's condition or diagnosis.
Every PA request for a member under age 21 is first processed according to standard Medicaid guidelines and then reviewed under HealthCheck "Other Services" guidelines. For these reasons, providers do not need to take additional action to identify the PA request as a HealthCheck "Other Services" request.
If an established benefit will be requested at a level that exceeds Wisconsin Medicaid coverage limits, in addition to the required PA documentation detailed in the appropriate service area of the Online Handbook, the request should provide:
- The rationale detailing why standard coverage is not considered acceptable to address the identified condition.
- The rationale detailing why the requested service is needed to correct or ameliorate the member's condition.
PA Submission Requirements for Services Not Routinely Covered by Wisconsin Medicaid
HealthCheck "Other Services" allows coverage of health care services that are not routinely covered by Wisconsin Medicaid, but are federally allowable and medically necessary to maintain, improve, or correct the member's physical and mental health, per § 1905(a) of the Social Security Act. These HealthCheck "Other Services" require PA since the determination of medical necessity is made on a case-by-case basis depending on the needs of the member.
If a PA request is submitted requesting coverage for a service that does not have established policy and is not an exception to coverage limitations, the provider is required to identify the PA as a HealthCheck "Other Services" request by checking the HealthCheck "Other Services" box and submit the following information:
Providers may call Provider Services for more information about HealthCheck "Other Services."
If the PA request is incomplete or additional information is needed to substantiate the necessity of the requested service, the PA request will be returned to the provider. A return for more information is not a denial.