Prior Authorization : Personal Care Screening Tool

Services Incidental to Activities of Daily Living and Medically Oriented Tasks

When the screener indicates on the PCST that the member needs services incidental to ADL and that the PCW will provide those services, the PCST automatically calculates the maximum amount of time to allocate for services incidental to the ADL and MOTs.

BadgerCare Plus covers the following services that are incidental to ADL and MOTs:

• Changing the member's bed and laundering the member's bed linens and personal clothing
• Light cleaning in essential areas of the home used during personal care activities
• Care of eyeglasses and hearing aids
• Meal preparation, food purchasing, and meal service

The weekly amount of personal care time prior authorized for the member combines the amount of time prior authorized for ADL, MOTs, and for services incidental to the ADL and MOTs. Neither travel time nor PRN time qualifies to have time added for services incidental to ADL and MOTs.

Calculating Time for Prior Authorization of Services to the Member Living Alone

For the member living "alone," as indicated in PCST Element 8, the time for services incidental to ADL and MOTs is calculated in an amount equal to one-third of the time allocated for the ADL and MOT services. For example, if the PCST allocates 900 weekly minutes for ADL and MOTs, it adds 300 minutes to bring the weekly allocation to a total of 1200 minutes. In allocating units, the PCST divides the total weekly minutes by 15 minutes and rounds up. In this example, the PCST allocated 80 units per week because the PCST calculated the weekly number of minutes to be between 1,186 and 1,200 minutes.

Billing for Services Provided to the Member Living Alone

BadgerCare Plus requires that the weekly amount of time billed for ADL and/or MOTs represents at least 75 percent of the weekly amount of time billed for PCW services. In order to bill for services incidental to ADL and MOTs on the DOS, the provider is required to bill at least one ADL and/or MOT service.

For example, if the weekly amount billed for ADL and/or MOTs adds up to 900 minutes, then the weekly amount of time billed for services incidental to ADL and MOTs may be equal to or less than 300 minutes. The provider may bill up to 1,200 minutes weekly of PCW services for ADL, MOTs, and services incidental to ADL and MOT activities combined as long as the number of minutes billed for services incidental to ADL is equal to or less than 25 percent of the amount of time billed.

The provider is to bill for each DOS and only for the actual time used to provide prior authorized services. Refer to the chart below for rounding guidelines when converting minutes of service provided into billing units.

Time units are calculated based on rounding accumulated minutes of service for each day. The following chart illustrates the rules of rounding and gives the appropriate billing unit.

Calculating Time for Prior Authorization of Services to the Member Not Living Alone

When a living arrangement other than "alone" is checked in PCST Element 8, then the time for services incidental to ADL and MOTs is calculated in an amount equal to one-fourth of the time allocated for the ADL and MOT services. For example, if the PCST allocates 1,120 weekly minutes weekly for ADL and MOTs, it adds 280 minutes to bring the weekly allocation to a total of 1,400 minutes. In allocating units, the PCST divides the total weekly minutes by 15 minutes and rounds up. In this example, the PCST allocated 94 units per week because the PCST calculated the total weekly number of minutes to be between 1,396 and 1,410 minutes.

Billing for Services Provided to the Member Not Living Alone

BadgerCare Plus requires that the weekly amount of time billed for ADL and/or MOTs represents at least 80 percent of the weekly amount of time billed for PCW services. In order to bill for services incidental to ADL and MOTs on the DOS, the provider is required to bill at least one ADL and/or MOT service.

For example, if the weekly amount billed for ADL and/or MOTs adds up to 1,120 minutes, then the weekly amount of time billed for services incidental to ADL and MOTs may be equal to or less than 280 minutes. The provider may bill up to 1,400 minutes of PCW services weekly for ADL, MOTs, and services incidental to ADL and MOT activities combined as long as the number of minutes billed for services incidental to ADL MOTs is equal to or less than 20 percent of the amount of time billed.

The provider is to bill for each DOS and only for the actual time used to provide prior authorized services. Refer to the above chart for rounding guidelines when converting minutes of service provided into billing units.

Determining Allocations for Amounts Authorized During Manual Review

When BadgerCare Plus authorizes services requiring nurse consultant review of the PCST, the nurse consultant manually calculates the additional time for services incidental to those services. Nurse consultants calculate the time using the previously described methods for determining the amounts allocated for the member that is living alone or is in a living situation other than alone.