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Program Name: BadgerCare Plus and Medicaid Handbook Area: HealthCheck (EPSDT)

Covered and Noncovered Services : HealthCheck "Other Services"

Topic #1

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:

  • A current, valid order or prescription for the service being requested:
    • Prescriptions are valid for 12 or fewer months from the date of the signature (depending on the service area).
    • Updated prescriptions may be required more frequently for some benefits.
  • A completed PA/RF, for most service areas, including the following:
    • For Element 1, check the HealthCheck "Other Services" box.
    • For Element 19, enter the procedure code that most accurately describes the service, even if the code is not ordinarily covered by Wisconsin Medicaid. Unlisted procedure codes can be requested if the service is not accurately described by existing procedure codes.
    • For Element 20, enter informational procedure code modifier EP (Service provided as part of Medicaid early periodic screening diagnosis and treatment [EPSDT] program) to indicate that the service is requested as a HealthCheck "Other Services" benefit.
    • For Element 22, include the description of the service.
  • A completed PA/DRF, or PA/HIAS1 when the PA/RF is not applicable
  • A PA attachment form(s) for the related service area, if known, or clinical documentation substantiating the medical necessity of the requested procedure code and:
    • The rationale detailing why services typically covered by Wisconsin Medicaid are not considered acceptable to address the identified condition or why services were discontinued.
    • The rationale detailing why the requested service is needed to correct or ameliorate the member's condition.

    Note: Providers may call Provider Services to determine the appropriate PA attachment.

  • Evidence the requested service is clinically effective and not harmful (If the requested service is new to Wisconsin Medicaid, additional documentation regarding current research and/or safety of the intervention may be submitted.)
  • The MSRP for requested equipment or supplies
  • The 11-digit NDC for any dispensed OTC drugs on pharmacy PA requests

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.

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