| Program Name: | BadgerCare Plus and Medicaid | Handbook Area: | Outpatient Mental Health | | 05/18/2024 | Provider Enrollment and Ongoing Responsibilities : Provider EnrollmentTopic #3745 Agency Requirements
Prior to obtaining Wisconsin Medicaid enrollment, mental health and substance abuse providers are required to be certified by the Wisconsin DHS,
DQA. Income maintenance or tribal agencies that request billing-only status do not need to be certified by the DQA.
The following enrollment requirements for outpatient mental health services include tables for Central Nervous System Assessments/Tests and Health and Behavior Assessment/Intervention. These additional services are included because mental health and substance abuse service providers sometimes provide these services to members.
Outpatient Mental Health Services (Evaluation, Psychotherapy)
| Type of Agency: Agency Providing the Service |
| Function of the Provider's NPI: Outpatient mental health billing/rendering NPI |
| Certification Requirements
|
| DQA |
Wisconsin Medicaid Enrollment |
Section of Enrollment Application to Be Completed* |
Income Maintenance or Tribal Agency Required? |
Additional Requirements |
| The agency is required to obtain a Wisconsin 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). |
The agency is required to do the following:
- Have a DQA certificate on file.
- Complete and submit a Mental Health/Substance Abuse Agency Enrollment Application. A Medicaid-enrolled rendering provider is required to perform the service.
|
Mental Health Outpatient Services |
No |
No |
| Type of Agency: Agency Providing the Service |
| Function of the Provider's NPI: Hospitals will receive one of the following: outpatient mental health clinic billing/rendering NPI or outpatient hospital number.
|
| Certification Requirements |
| DQA |
Wisconsin Medicaid Enrollment |
Section of Enrollment Application to Be Completed* |
Income Maintenance or Tribal Agency Required? |
Additional Requirements |
| The agency is required to obtain a Wisconsin 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). |
Hospitals are required to complete one of the following:
- The
Hospital Enrollment Packet if billing as an outpatient hospital (using revenue codes on the UB-04 Claim Form). Outpatient hospitals utilizing Master's-level therapists are required to be certified as a 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. Wisconsin Medicaid defines "hospital facility" as the physical entity surveyed and approved
by the Division of Supportive Living, DQA, under Wis. Stats.
ch. 50.
- The Mental Health/Substance Abuse Agency Enrollment Application if billing as a certified outpatient mental health clinic (using procedure codes on the 1500 Health Insurance Claim Form).
|
Complete the Hospital Enrollment Application, not a section of the Mental Health/Substance Abuse Agency Enrollment Application. |
No |
No |
| Type of Agency: Agency Only Allowed to Bill for the Service |
| Function of the Provider's NPI: Outpatient mental health clinic billing/rendering NPI |
| Certification Requirements |
| DQA |
Wisconsin Medicaid Enrollment |
Section of Enrollment Application to Be Completed* |
Income Maintenance or Tribal Agency Required? |
Additional Requirements |
| Not required |
The agency is required to complete and submit a Mental Health/Substance Abuse Agency Enrollment Application to be a billing-only provider for outpatient mental health services. A Medicaid-enrolled rendering provider is required to perform the service. |
Mental Health Outpatient Services |
Yes |
No |
Central Nervous System Assessments/Tests
| Type of Agency: Agency Providing the Service |
| Function of the Provider's NPI: Outpatient mental health clinic billing/rendering NPI |
| Certification Requirements |
| DQA |
Wisconsin Medicaid Enrollment |
Section of Enrollment Application to Be Completed* |
Income Maintenance or Tribal Agency Required? |
Additional Requirements |
| The agency is required to obtain a Wisconsin 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). |
The agency is required to do the following:
|
Mental Health Outpatient Services |
No |
No |
| Type of Agency: Agency Only Allowed to Bill for the Service |
| Function of the Provider's
NPI: Outpatient mental health clinic billing NPI |
| Certification Requirements |
| DQA |
Wisconsin Medicaid Enrollment |
Section of Enrollment Application to Be Completed* |
Income Maintenance or Tribal Agency Required? |
Additional Requirements |
| Not required |
The agency is required to complete and submit a Mental Health/Substance Abuse Agency Enrollment Application to be a billing-only provider for an outpatient mental health clinic. A Medicaid-enrolled rendering provider is required to perform the service
(psychiatrist or psychologist). |
Mental Health Outpatient Services |
Yes |
No |
Health and Behavior Assessment/Intervention
| Type of Agency: Agency Providing the Service |
| Function of the Provider's NPI: Outpatient mental health facility billing/rendering NPI |
| Certification Requirements |
| DQA |
Wisconsin Medicaid Enrollment |
Section of Enrollment Application to Be Completed* |
Income Maintenance or Tribal Agency Required? |
Additional Requirements |
| The agency is required to obtain a Wisconsin 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). |
The agency is required to do the following:
- Have a DQA certificate on file.
- Complete and submit a Mental Health/Substance Abuse Agency Enrollment Application. A Medicaid-enrolled rendering provider is required to perform the service (certified psychotherapist, licensed psychotherapist, QTT, psychologist, or psychiatrist).
|
Mental Health Outpatient Services |
No |
No |
| Type of Agency: Agency Only Allowed to Bill for the Service |
| Function of the Provider's NPI: Outpatient mental health facility billing NPI |
| Certification Requirements |
| DQA |
Wisconsin Medicaid Enrollment |
Section of Enrollment Application to Be Completed* |
Income Maintenance or Tribal Agency Required? |
Additional Requirements |
| Not required |
The agency is required to complete and submit a Mental Health/Substance Abuse Agency Enrollment Application to be a billing-only provider for an outpatient mental health clinic. A Medicaid-enrolled rendering provider is required to perform the service. |
Mental Health Outpatient Services |
Yes |
No |
* These are sections of the Medicaid Mental Health/Substance Abuse Agency Enrollment Application.
Outpatient Mental Health Services for Children When Provided in the Home
Allowable provider types for outpatient mental health services for children provided in the home are the same as the allowable provider types for outpatient mental health services provided in a clinic setting. Outpatient mental health services for children provided in the home must be provided by a Medicaid-enrolled mental health provider working through a DHS 35-certified outpatient mental health clinic. Providers not working through a DHS 35-certified clinic may not receive reimbursement for outpatient mental health services provided in the home. Since a provider must be working through a DHS 35-certified outpatient mental health clinic, all the requirements indicated in Wis. Admin. Code ch. DHS 35, apply, including the requirement that a clinic providing services to persons 13 years of age and younger must have qualified staff with appropriate training and experience available to work with children and adolescents.
When submitting a claim for outpatient mental health services for children provided in the home, providers should list the NPI of the DHS 35-certified outpatient mental health clinic as the biller. If the rendering provider's NPI is different from the billing provider's NPI, providers should also list the NPI of the rendering provider on the claim. |