Covered and Noncovered Services : Covered Services and Requirements

Concurrent Behavioral Treatment and Behavioral Health Services

ForwardHealth will allow for the concurrent delivery of behavioral treatment services with behavioral health services when both services are identified as medically necessary, per Wis. Admin. Code § DHS 101.03(96m).

ForwardHealth recognizes that coordinated services between behavioral treatment and behavioral health providers may be clinically appropriate.

Covered Central Nervous System Assessments/Tests

Covered central nervous system assessments/tests include the following:

• Psychological testing
• Assessment of aphasia
• Developmental testing, limited and extended
• Neurobehavioral status exams
• Neuropsychological testing

Specific services include assessments and tests with interpretations and reports. BadgerCare Plus and Wisconsin Medicaid cover all of the Central Nervous System Assessments/Tests described in CPT. A list of allowable procedure codes and modifiers is available.

Covered Health and Behavior Assessment and Intervention Services

Health and behavior assessment and intervention services are those offered to members who present with primary physical illnesses, diagnoses, or symptoms and may benefit from assessments and interventions that focus on the biopsychosocial factors related to the member's health status. These services do not represent preventive medicine counseling and risk factor reduction interventions.

BadgerCare Plus and Wisconsin Medicaid cover all of the health and behavior assessment and intervention services described in CPT. A list of allowable procedure codes and modifiers is available.

Covered Outpatient Mental Health Services

Outpatient mental health services include strength-based assessments (including differential diagnostic evaluations), psychotherapy services, mental health clinical consultations, and other psychiatric services in the following settings:

• Home (for members under 21 years of age and the parent[s] of the member)
• Office of a provider
• Hospital
• Nursing home
• School
• Hospital outpatient clinic
• Outpatient clinic

The intensity and modality of treatment should be adjusted to the individual needs of the member. If the nature and severity of the member's disorder requires more intensive treatment than can be safely provided by an outpatient mental health clinic or licensed psychotherapist, a higher LOC should be considered. Examples of circumstances when it may be appropriate to provide outpatient mental health treatment for individuals with higher than typical needs include:

• For a member discharged from an inpatient, residential, or day treatment program in the last 90 days and more frequent treatment is required for stabilization during the member's transition to less restrictive care
• For a member initiating primary treatment in an evidence-based modality that supports a limited period of more frequent intervention
• For a member experiencing a sudden, unexpected increase in symptoms and/or behaviors that can be immediately stabilized with more frequent treatment on an outpatient basis (If more frequent treatment does not reduce the heightened severity of the member's disorder, the member should be referred to a higher LOC.)

Strength-Based Assessments

A strength-based assessment, including a differential diagnostic evaluation, is performed by a Medicaid-enrolled psychotherapy provider. A physician's prescription is not necessary to perform the assessment. Assessing and recovery/treatment planning is an ongoing process in collaboration between the provider and member.

The strength-based assessment must include the following:

• The member's presenting problem
• Diagnosis established from the current DSM including all five axes or, for children up to age 4, the current Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood
• The member's symptoms that support the given diagnosis
• The member's strengths and current and past psychological, social, and physiological data; information related to school or vocational, medical, and cognitive function; past and present trauma; and substance abuse
• The member's unique perspective and own words about how they view their recovery, experience, challenges, strengths, needs, recovery goals, priorities, preferences, values, and lifestyle, areas of functional impairment, and family and community support
• Barriers and strengths to the member's progress and independent functioning
• Necessary consultation to clarify the diagnosis and treatment

Psychotherapy and Treatment/Recovery Planning

Psychotherapy services include strategies to reduce the severity and distress of persistent symptoms, promote personal insight, assist in coping with symptoms, and identify supports that are effective. In addition, services may include individual and family psychoeducation to help the individual and family members develop coping skills for handling problems posed by mental illness in a family member.

The goals of psychotherapy and specific objectives to meet those goals must be documented in the member's treatment/recovery plan that is based on the strength-based assessment. The treatment/recovery plan includes documentation of the signs of improved functioning that will be used to measure progress toward specific objectives at identified intervals as agreed upon by the provider and member. A mental health diagnosis and medications for mental health issues used by the member must be documented in the treatment/recovery plan.

ForwardHealth covers most of the psychiatry services described in CPT.

A list of allowable procedure codes and modifiers for strength-based assessments and psychotherapy and treatment/recovery planning is available.

Mental Health Clinical Consultations

A mental health clinical consultation is a communication from a mental health provider to coordinate services for a BadgerCare Plus or Medicaid beneficiary who is a student under 21 years of age with an established mental health diagnosis or with the parent of the student. The intent of the mental health consultation is to inform individuals working with the member or the parent(s) of the member of the following:

• Member's symptoms
• Strategies for effective engagement, care, and intervention
• Treatment expectations for the member

Per Wis. Stat. § 49.45(29y)(a)2m, a parent is defined as any of the following:

• A parent
• A foster parent
• A guardian
• A relative, other than a parent, who lives with the student

Mental health clinical consultations are reimbursable between an enrolled mental health provider who is currently allowed to render outpatient mental health services and any of the following:

• Educator teams
• Individual educators
• School staff
• Parent(s) of the member

Mental health clinical consultations may be provided via phone or face-to-face interviews. The content and duration of the mental health clinical consultation must be documented. Mental health clinical consultations follow the same documentation requirements as other outpatient mental health services.

Informed Consent

Per Wis. Stat. § 146.81(2), mental health providers are expected to obtain informed consent from the member, the member's parent or legal custodian, or the member's legal representative, as appropriate, before conducting the mental health clinical consultations. Providers should consult with their own legal counsel if they have questions about informed consent requirements.

Definition of Covered Services

Within the provision of mental health and substance abuse services, BadgerCare Plus encourages the concept of recovery for all persons who receive services. This includes consumer involvement in assessment, treatment planning, and outcomes. Also, BadgerCare Plus promotes the use of evidence-based and culturally competent practices.

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.

Expectations and Documentation Requirements for Collaborating Providers

Whether or not PA is required for a service, each provider must separately document their collaboration with the other provider in the member's medical record. The documentation must include services the member is receiving from the other provider and the current schedule of services or the frequency of services from both providers. This will ensure better coordination and continuity of care and will prevent duplication of services.

ForwardHealth requires providers to coordinate with each other at least once every six months, or more often if indicated by the member's condition.

The following shows care collaboration requirements for a collaborating behavioral health provider under two possible scenarios:

• If a behavioral health provider intends to provide a service that requires PA, the behavioral health provider must include the mode and frequency of the coordination between themselves and the collaborating behavioral treatment provider in the PA request and the member's medical record.
• If a behavioral health provider is providing a service that does not require PA, the behavioral health provider must document coordination between themselves and the collaborating behavioral treatment provider in the member's medical record.

Services That Require PA

Collaborating providers must include the following information in their PA request:

• The concurrent services received by the member
• The mode and frequency of the care collaboration between providers (for example, phone calls, meetings, the member's weekly schedule)

Note: ForwardHealth may request additional information, if needed, to establish the medical necessity of the service.

In the event a provider experiences challenges obtaining the required documentation from their collaborating provider, ForwardHealth recommends that the provider submit the PA request, detailing the barriers to obtaining the required documentation. ForwardHealth will consider the current barriers and may allow flexibility to authorize services as appropriate.

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.

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.

Outpatient Mental Health and Outpatient Substance Abuse

The medical necessity must be documented in the member's records and include a current assessment of the member's needs and treatment plan. The assessment and treatment plan must be updated as the needs of the member change. Documentation in progress notes may be used to inform the assessment and treatment planning process but does not replace the requirement for current documentation of a distinct assessment and treatment plan.

If progress toward the measurable goals identified in the treatment plan does not occur, the treatment plan must be amended with modifications to the treatment approach in order to address any barriers to progress, or with more appropriate goals.

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.

Physician Prescription

The following prescription requirements apply to a physician or other health care provider initiating mental health and substance abuse treatment services for a Wisconsin Medicaid and BadgerCare Plus member.

Benefits That Require a Prescription or Order to Initiate Services

Wisconsin Medicaid and BadgerCare Plus require a prescription or order from a physician or other health care provider prior to initiating certain community-based mental health services for a Wisconsin Medicaid and BadgerCare Plus member. Examples of these services include the following:

• Community Support Programs
• Comprehensive Community Services
• HealthCheck "Other Services" Child/Adolescent Day Treatment
• HealthCheck "Other Services" Intensive In-Home Mental Health and Substance Abuse Treatment Services for Children

Benefits That Do Not Require a Prescription to Initiate Services

Wisconsin Medicaid and BadgerCare Plus do not require a prescription from a physician or other health care provider to initiate the following mental health and substance abuse treatment services for a Wisconsin Medicaid and BadgerCare Plus member:

• Outpatient mental health services provided in a Medicaid-enrolled outpatient mental health clinic or in the home for members under 21 years of age
• Outpatient substance abuse treatment provided in a Medicaid-enrolled substance abuse clinic
• Adult mental health day treatment
• Substance abuse day treatment
• Outpatient mental health and substance abuse services in the home or community for adults
• Outpatient mental health and substance abuse services performed in private practice by a Medicaid-enrolled psychiatrist, Ph.D. psychologist, APNP with psychiatric specialty, or a licensed psychotherapist (referred to as licensed mental health professional in Wisconsin law)

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.

Coverage of Outpatient Mental Health Services Concurrent With Other Mental Health or Substance Abuse Services

Policies regarding concurrent coverage of services are as follows:

• Wisconsin Medicaid covers a continuum of non-inpatient hospital substance abuse and mental health services, including day treatment and psychotherapy.
• Wisconsin Medicaid covers outpatient substance abuse services concurrently with outpatient mental health and/or adult mental health day treatment services as long as both services are medically necessary and appropriate.

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 Wisconsin 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.

Coordination With Intensive In-Home Mental Health and Substance Abuse Treatment Services for Children

Members may not concurrently receive mental health services for children provided in the home covered under the outpatient mental health benefit and intensive in-home mental health and substance abuse treatment services for children covered under the HealthCheck "Other Services" benefit. If a member is eligible for both mental health services for children provided in the home covered under the outpatient mental health benefit and intensive in-home mental health and substance abuse treatment services for children covered under the HealthCheck "Other Services" benefit, the provider should determine the most appropriate benefit under which to provide services.

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

Tobacco Cessation Drugs and Services

Under the outpatient mental health benefit, BadgerCare Plus and Wisconsin Medicaid cover medically necessary diagnostic evaluations and psychotherapy related to tobacco cessation provided by psychiatrists, Ph.D. psychologists, and Master's-level therapists.

BadgerCare Plus and Wisconsin Medicaid cover psychotherapy on an individual and group basis.

Tobacco cessation services, as preventive services with an A or B rating from the USPSTF, do not require copayments from any member enrolled in BadgerCare Plus or Medicaid. SeniorCare members are not exempt from copayment for tobacco cessation services.

Drugs for Tobacco Cessation

BadgerCare Plus, Medicaid, and SeniorCare cover legend drugs for tobacco cessation.

BadgerCare Plus and Medicaid also cover OTC nicotine gum, patches, and lozenges.

A written prescription from a prescriber is required for both federal legend and OTC tobacco cessation products. Prescribers are required to indicate the appropriate diagnosis on the prescription. PA is required for uses outside the allowable ICD diagnoses included in the table below.