| Program Name: | BadgerCare Plus and Medicaid | Handbook Area: | Outpatient Mental Health | | 12/09/2025 | Prior Authorization : Services Requiring Prior AuthorizationTopic #6119 Central Nervous System Assessments and Tests
PA is not required for central nervous system assessments and tests. Central nervous system testing may be part of the mental health evaluation, but it does not require PA and must be billed under the appropriate codes. Topic #6120 Health and Behavior Assessments and Interventions
Up to eight units per DOS of any combination of health and behavior assessment and intervention services may be coverable.
Psychiatrists and APNPs with a psychiatric specialty providing health and behavior assessment and intervention services should refer to the Physician service area for information related to E&M and preventive medicine services.
Providers may not report health and behavior assessment and intervention services in conjunction with psychiatric diagnostic procedures or psychotherapy on the same date. Topic #6118 Outpatient Mental Health Services
Differential Diagnostic Evaluation
PA requirements are as follows:
- Adult mental health day treatment (procedure code H2012 with modifiers HE [mental health program] and U6 [functional assessment])
- Substance abuse day treatment (procedure code H2012 with modifiers HF [substance abuse program] and U6 [assessment])
- Additional assessment hours beyond the eight hours every rolling 12 months requires PA. Providers may request additional assessment hours beyond the PA limit by submitting the PA/EA along with the PA/RF.
Topic #3755 Services Requiring Prior Authorization
The majority of mental health and substance abuse services do not require PA. Some higher intensity mental health and substance abuse services require PA before they are provided.
Wisconsin Medicaid does not reimburse providers for services provided either before the grant date or after the expiration date indicated on the approved PA/RF. If the provider delivers a service either before the grant date or after the expiration date of an approved PA or provides a service that requires PA without obtaining PA, the provider is responsible for the cost of the service. In these situations, providers may not collect payment from the member.
PA does not guarantee payment. To receive Medicaid reimbursement, provider enrollment and member eligibility on the DOS, as well as other Medicaid requirements, must be met.
The following table lists mental health and substance abuse services that require PA and, for those services requiring PA, maximum grant period allowed for PA, required PA forms, and maximum backdating allowed when specifically requested.
| Service |
Prior Authorization Required? |
When Is Prior Authorization Required? |
Maximum Prior Authorization Grant Period* |
Required Prior Authorization Forms |
Backdating |
| Adult Mental Health Day Treatment Services |
PA is required for all day treatment services for
members while they are inpatient hospital patients and for all day
treatment services while the members are concurrently receiving
outpatient psychotherapy, OT services, and/or substance
abuse services of any kind. |
PA required after 90 hours per calendar year except for
the two situations in the preceding column. PA is required
before the first hour for these two situations. |
6 months |
PA/RF
PA/AMHDTA |
Up to 10 business days prior to the first date of receipt at ForwardHealth (initial request only) |
| Case Management for Mental Health/Substance Abuse Services** |
No |
N/A |
N/A |
N/A |
N/A |
| Central Nervous System Assessments/Tests |
No |
N/A |
N/A |
N/A |
N/A |
| Child/Adolescent Day Treatment Services (HealthCheck "Other Services") |
Yes |
Immediately |
3 months |
PA/RF
PA/CADTA |
Up to 10 business days prior to the first date of receipt at ForwardHealth (initial request only) |
| Clozapine Management Services |
No |
N/A |
N/A |
N/A |
N/A |
| Community Recovery Services** |
No |
N/A |
N/A |
N/A |
N/A |
| Community Support Program Services** |
No |
N/A |
N/A |
N/A |
N/A |
| Comprehensive Community Services** |
No |
N/A |
N/A |
N/A |
N/A |
| Crisis Intervention Services** |
No |
N/A |
N/A |
N/A |
N/A |
| Health and Behavior Assessments |
No |
N/A |
N/A |
N/A |
N/A |
| Health and Behavior Interventions |
No |
N/A |
N/A |
N/A |
N/A |
| In-Home Mental Health/Substance Abuse Treatment Services for Children (HealthCheck
"Other Services") |
Yes |
Immediately |
3 months |
PA/RF
PA/ITA |
Up to 10 business days prior to the first date of receipt at ForwardHealth (initial request only) |
| Narcotic Treatment Services |
No |
N/A |
N/A |
N/A |
N/A |
| Outpatient Mental Health Services (Evaluation, Psychotherapy) |
No |
N/A |
N/A |
N/A |
N/A |
| Outpatient Mental Health and/or Substance Abuse Services in the Home or
Community for Adults** |
No |
N/A |
N/A |
N/A |
N/A |
| Outpatient Substance Abuse Services |
No |
N/A |
N/A |
N/A |
N/A |
| Substance Abuse Day Treatment Services*** |
Yes |
Immediately |
6 weeks |
PA/RF
PA/SADTA |
Up to five business days prior to the first date of receipt at ForwardHealth (initial request only) |
| * |
These grant periods are listed in the PA guidelines. |
| ** |
These services are billable only by income maintenance or tribal agencies. Providers are required to have a contractual arrangement with their income maintenance or tribal agency. Authorizations must be obtained from the income maintenance or tribal agency. |
| *** |
PA is not required for the substance abuse assessment, the limit for which is three hours per member, per provider in a calendar year. PA is required before providing any substance abuse day treatment services to a member following the assessment. |
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