Prior Authorization : General Information

An Overview

The PA review process includes both a clerical review and a clinical review. The PA request will have one of the statuses detailed in the following table.

Approval Criteria

Comprehensive information about the member helps to establish the functional potential of the member and forms the basis for determining whether the member will benefit from the requested services. No single factor, such as diagnosis or age of the member, will result in automatic approval or denial of a PA request for extension of therapy services, maintenance therapy services, or services that always require PA.

It is essential that documentation is complete, accurate, and specific to the member's current condition and needs. Providers are required to submit the following when submitting the PA/TA:

• A written report of the member's evaluation.
• An individualized POC if not documented on the PA/TA.
• A copy of the IEP if the member is a school-aged member (ages 3 up to 21).^*
• A copy of the IPP if the member is in a residential or day facility for the developmentally disabled. The IPP must document coordination and integration of the active treatment and medical care plan of the member.

^* ForwardHealth does not require submitted documentation of coordination of care or the IEP for the initial PA of an episode of therapy services. Elements 16 and 17 of the PA/TA do not need to be completed when requesting these services. An episode of therapy services lasts until the member is discharged from the current plan of care.

Also, per Wis. Admin. Code § DHS 90.07(3)(b), when submitting non-Birth to 3 PA requests for therapeutic services for children ages 0–3 years (that is, outpatient treatment PA requests for therapeutic services), providers must confirm that the child has been referred to the Birth to 3 Program. Confirmation of referral can be completed by, but is not limited to, caregiver discussion regarding the availability of the Birth to 3 Program, review of member medical records with confirmed referral in the record, or direct referral by the therapy provider to the Birth to 3 Program.

Providers may provide the IFSP or Child Enrollment Status Regarding Birth to 3 Program form as a method of confirmation that the child has been referred to the Birth to 3 Program, but the IFSP and Child Enrollment Status Regarding Birth to 3 Program form are not required to be submitted for children ages 0–3 years.

Providers should ensure that the method of confirmation of the referral is maintained in the member's medical records and is readily available upon audit requests.

Only one team member needs to submit the IEP or IPP with a PA request. The team should discuss who will submit the IEP or IPP. The other providers should reference the PA request that was submitted with the IEP or IPP by indicating the PA number and the date the PA was submitted. The team member designated to submit the IEP or IPP should receive an additional copy from the coordinator. If the member does not have an IEP or IPP, the provider is required to indicate the reason these documents do not exist.

Communication With Members

ForwardHealth recommends that providers inform members that PA is required for certain specified services before delivery of the services. Providers should also explain that, if required to obtain PA, they will be submitting member records and information to ForwardHealth on the member's behalf. Providers are required to keep members informed of the PA request status throughout the entire PA process.

Member Questions

A member may call Member Services to find out whether or not a PA request has been submitted and, if so, when it was received by ForwardHealth. The member will be advised to contact the provider if more information is needed about the status of an individual PA request.

Coordination of Care

For the initial PA of an episode of care, providers are not required to submit documentation of coordination of care with SBS or community-based service providers for members under 21.

Providers are required to submit written attestation of coordination with SBS on subsequent PA requests when a member is receiving both community-based services and SBS in the same treatment discipline (for example, outpatient speech therapy and speech therapy in the school). This attestation must be documented on Element 16 of the PA/TA, on the POC, or on another document. Providers are required to maintain documentation of coordination of care in the member's medical record.

Providers are required to submit documentation of coordination of care with other community-based service providers on subsequent PA requests.

Failure to coordinate care or to maintain documentation of coordination of care leading to duplicate services may result in denial of claims or recovery of funds.

Using PA Collaboratives to Coordinate Care

PA collaboratives can link two or more PA requests for the same member together so providers can easily see and maintain them. Providers can indicate that their PA request is part of a collaborative when they submit their PA request through the ForwardHealth Portal.

After successfully submitting a PA request to a PA collaborative, providers can view all PA requests within it. Through the PA Collaboration panel on the Portal, providers have the option to attest that the PA should remain in the collaborative or they may choose to opt out of the collaborative.

Definition

PA is the electronic or written authorization issued by ForwardHealth to a provider prior to the provision of a service. In most cases, providers are required to obtain PA before providing services that require PA. When granted, a PA request is approved for a specific period of time and specifies the type and quantity of service allowed.

Designating an Address for Prior Authorization Correspondence

Correspondence related to PA will be sent to the practice location address on file with ForwardHealth unless the provider designates a separate address for receipt of PA correspondence. This policy applies to all PA correspondence, including decision notice letters, returned provider review letters, returned amendment provider letters, and returned supplemental documentation such as X-rays and dental models.

Photographs submitted to ForwardHealth as additional supporting clinical documentation for PA requests will not be returned to providers and will be disposed of securely.

Providers may designate a separate address for PA correspondence using the demographic maintenance tool.

Examples of Standards of Medical Necessity as Evaluated on Prior Authorization Requests

The following information and case examples are offered to illustrate how the standards of medical necessity, as defined in Wis. Admin. Code § DHS 101.03(96m), are applied when PT, OT, or SLP services are reviewed by ForwardHealth.

Example 1: Many members having the same diagnosis may have certain characteristics in common; however, the physical expression and functional severity of their conditions can vary greatly. As a result, documentation in the PA request must include a medical diagnosis as well as a problem statement (treatment diagnosis) related to the medical diagnosis that identifies the specific treatment needs of the individual.

For example, physical therapy is requested for a four-year-old child with spastic diplegic cerebral palsy and a gross motor age equivalency of 44-48 months. A POC to address "continued development of age-appropriate mobility skills" would not meet the ForwardHealth application of this standard because no impairments, functional limitations, or disabilities have been identified. The reviewer would question how the requested service treats an illness, injury, or disability. If the therapist identified tight hamstrings but provided no evidence that hamstring contractures were causing any functional problems, the same questions remain.

If instead, the physical therapist's evaluation identified functional limitations including problems with climbing, frequent falls when walking from the bus to home, or other restrictions in outdoor mobility due to tight hamstrings, it may be appropriate to authorize a limited course of PT. In this case, PT may be necessary to improve dynamic range of motion and lower extremity strength, to facilitate functional skill acquisition, and to educate the member/caregivers on a home program including recommendations about when to seek medical attention for developing problems, such as worsening contractures.

Example 2: A nine-year-old is an independent household ambulator and presents with hypotonic trunk muscles. They have been receiving OT for the past six months. The new PA request includes continued treatment strategies of trunk elongation and rib cage mobilization with ongoing goals of preparing for strengthening/stability exercises and preventing frequent respiratory infections. No documentation of trunk range of motion, upper body strength testing, or frequency of respiratory infection is provided.

Measurable goals reflect treatment that is expected to reduce identified impairments and produce sustained changes in function and are necessary to describe how treatment will affect injury, illness, or disability. The medical necessity of the POC would be questioned because no deficits are reported, and no evidence is provided to support that soft tissue mobilization has resulted or would likely result in any sustainable change in the member's trunk control or any improvement in functional performance over time. The PA documentation does not support that a correlation exists between improving rib cage mobility and decreasing the member's susceptibility to respiratory infections. The PA request would be returned requesting this additional information.

Example 3: A PA is submitted for SLP services for a four-year-old child. The child only speaks at home and was referred by the family doctor for an SLP assessment. The standardized/non-standardized tests performed by the SLP provider indicate that the child's receptive and expressive language skills are age appropriate. The PA requests SLP services twice per week to improve the child's social language skills. In this situation, the ForwardHealth consultant may question if the services of an SLP provider are required, since the standardized tests indicate the child's language skills are age appropriate and do not identify an injury, illness, or disability potentially remediable by an SLP provider.

Example 1: The client is a 35-year-old with cerebral palsy who is seven weeks post ankle fusion. Prior to surgery, they had been able to ambulate with a walker in their home. The PA request includes a PT POC to assess and/or teach transfer skills and evaluate orthotics and equipment needs. This POC reflects a situation where episodic therapy is warranted to maximize functional capacity following an orthopedic intervention. This PA request would be approved because it is consistent with treatment of the client's recent change in medical condition.

Example 2: A 16-year-old with a remote history of anoxic brain injury is dependent for all activities of daily living. An OT PA request is submitted to increase head control at midline from the member's current level of 3-5 seconds to 5-10 seconds. No progress has been documented in this area following extensive intervention to improve head control. When functional limitations persist for long periods and have not been remediable, compensatory strategies may be more appropriate. The PA request would be returned for additional information to support the benefit of continued direct treatment for improving head control as an effective or functional intervention.

Example 3: A PA is submitted for SLP services for a 45-year-old member diagnosed with intellectual disability, emotional disturbance, and seizure disorder. Their sheltered workshop supervisor referred the client for an SLP evaluation because over the past two months, both workshop staff and home caregivers have had difficulties understanding them due to decreased speaking rate and slurred speech. Upon assessment, the member's regression appears to coincide with the start of a new medication.

Without additional information, the ForwardHealth consultant would return the PA request questioning whether the member's decreased intelligibility may be related to the medication. Documentation of sufficient clinical information may then result in approval of SLP services for a brief episode of care to improve intelligibility.

Example: A PA request for sensory integration therapy is submitted for a nine-year-old with pervasive developmental disorder. Goals include decreased behavioral outbursts in natural environments like a noisy gym or shopping mall, improved sleeping patterns, and better ability to "self-regulate." The PA would be returned asking the provider to explain how skills learned in therapy would be generalized from the controlled environment of the clinic setting to the child's natural environment(s) of home or community. The ForwardHealth consultant may further question whether these issues would be more appropriately addressed by a behavioral therapist or through a consistent behavioral management home program.

Example 1: A PA is submitted with the therapist reporting that a member is "not testable" or with the majority of the therapy evaluation obtained from unstructured observation or from other sources. If the treating therapist is unable to establish a member's baseline functional skills and limitations, it will be impossible to later evaluate and document any changes that may result from therapeutic intervention. Initiating treatment without performing a comprehensive assessment that includes baseline measurements of the member's abilities and physical impairments is not appropriate with regard to generally accepted standards of practice. If a problem area is not or cannot be tested during the initial evaluation, it should be explained why data could not be obtained and that subsequent PAs will contain baseline data for reported problem areas as well as interval progress. This PA would be returned asking for additional information.

Example 2: An occupational therapist working with a child with a history of dysphagia submits a PA request with a goal for the child to tolerate a wider variety of foods. No clinical assessment of the child's oral motor/swallowing skills or results from a radiological swallow study have been documented to indicate that the proposed oral intake is safe. The PA request would be returned requesting this additional clinical information to assure that the treatment goals are appropriate.

Example: An 85-year-old is eight weeks post hip fracture with subsequent open reduction and internal fixation. The POC submitted with the PA includes goals of transferring with assistive device, achieving independence on stairs, and increasing unilateral weight bearing for improved balance, strength, and endurance while walking. No weight bearing restrictions or hip precautions are included in the information submitted. In the absence of this standard medical information, the reviewer may question whether the goals are appropriate (or possibly contraindicated) depending on the recommended postoperative hip precautions. Also, the requested frequency or intensity of therapy may be inappropriate depending on the member's weight bearing status.

Example 2: For a member with the recent onset of dysphagia and a swallow study that indicates aspiration, an oral motor evaluation and initial course of treatment is medically necessary to see if swallowing abilities can be improved. If a subsequent request is submitted that indicates the member has been unable to maintain their weight with oral feedings or if clinical signs of aspiration such as cough or respiratory infection persist, then continued SLP services to address improving oral feeding skills without assessing the need for further dietary modifications (change in liquid/solid consistency) may be medically contraindicated. This PA would be returned for additional clinical information to support the safety of the requested therapy.

In assessing whether a service is experimental in nature, the Wisconsin DHS shall consider whether the service is a proven effective treatment for the condition for which it is intended or used, as evidenced by:

• The current and historical judgment of the medical community (as reflected by medical research, studies, or publications in peer-reviewed journals).
• The extent to which other health insurers provide coverage for the service.
• The current judgment of experts or specialists in the medical area for which the service is to be used.
• The judgment of the Wisconsin Medicaid Medical Audit Committee of the Wisconsin Medical Society or of any other committee that may be under contract to DHS as identified in Wisconsin Administrative Code.

The following interventions have been determined to be experimental: Facilitated Communication and Auditory Integration Therapy. The Wisconsin Medical Society has also determined that electrical stimulation for the treatment of open wounds can only be applied to Stage III or IV decubiti. Prior authorization for continued treatment is considered only if granulation tissue has formed or a 25 percent reduction in the affected area has occurred within 45 days of initiating electrical stimulation. Any PA request for electrical stimulation that falls outside these parameters is considered unproven and would be denied.

Example 1: A 78-year-old with a diagnosis of Alzheimer's disease resides in a nursing home that specializes in the care of Alzheimer patients. The client transfers with moderate assistance and receives PT two times per week for gait training and to improve transfer skills. The member's transfer and ambulation skills have not progressed over the past month and the nursing staff has been instructed in safe transfer and ambulation techniques. The PT POC recommends continued PT services designed to maintain the member's abilities, stating that the member requires the skills of a therapist because they have Alzheimer's. Caregivers who have been properly instructed by a physical therapist regarding the member's unique set of problems should be skilled in working with this patient. Therefore, this PA request would be denied because it is duplicative to the member's maintenance care program.

Example 2: A child with autism is receiving intensive behavioral services with treatment goals of improved peer play, turn taking, sharing, and concentrating on conversation. The OT PA request includes goals for the child to participate in a group game following rules with proper sequencing and attention to task. The clinical intent of both services appears to be directed toward achieving the same outcome. Therefore, the PA request would be returned for clarification.

Example 1: A child with a history of traumatic brain injury receives PT services at school during the academic year. The IEP does not include recommendations for Extended School Year PT over the summer months. Physical therapy services are being requested at a community-based clinic during the summer because, without therapy, the member's day lacks structured activities. Unless the services being requested require the professional skills of a therapist, the request may be viewed as an alternative to recreational or other community-based activities and appears to be submitted solely for convenience.

Example 2: An OT PA request is submitted to provide range of motion and strengthening. The member has skills that are sufficient to perform the program at home with supervision or in a community or recreational setting. In this case, the PA would be returned for additional information to explain why the skills of a therapist are required.

Example 3: A PA request is submitted for SLP services for a 38-year-old diagnosed with developmental delays. The member lives in a group home and communicates with an augmentative communication device. Previous therapy and product manuals have been provided for the member and caregivers to program and use the device. The PA requests SLP services for the purpose of creating a new communication page for the device. In this case, the Medicaid consultant would question if the service being requested is solely for convenience and if the member's caregiver or family member familiar with the device could create a new page.

Example 1: A physical therapist has requested therapy services three times per week to work on a POC that is focused on repetition of skills to build endurance. A PA request for PT services at this frequency would be modified or denied. It would be more cost-effective for the client to work on building endurance through a home exercise program. Modification would allow the therapist to monitor the member's progress and to revise the home program as needed, instead of providing direct therapy to work on repetition of an already achieved skill. Programs that involve ongoing muscle strengthening and fitness often involve instructing the client to carry out activities independent of assistance or stressing recreational activities that encourage mobility and reinforce functional movement.

Example 2: An OT PA request is received to provide range of motion for a member who resides in a nursing home. A restorative nursing plan is in place and meets the functional needs of this individual. The therapy POC being requested does not include more advanced functional outcomes requiring the skills of a therapist. Occupational therapy services, in addition to restorative nursing, are not cost-effective and the PA request would be denied.

Example: A 10-year-old child with cerebral palsy has received many years of OT. Their current level of functional upper extremity dressing skills includes the ability to push their arm through their sleeve only when the shirt is held over their head and the sleeve is held in place for them. No volitional grasp or release is demonstrated. The OT POC is submitted for ongoing direct treatment to improve independent living skills. For this member, it appears that they reached a plateau, that no functional gains in upper extremity dressing skills can reasonably be anticipated, and that compensatory strategies and equipment are the most appropriate level of service that can be effectively provided. The direct skills of an occupational therapist may no longer be necessary at this time to maximize their functional performance. A more appropriate level of service may be provided by an occupational therapist on a consultative basis to monitor compensatory strategies and equipment and to evaluate further direct OT needs.

Example 2: A PA is submitted for SLP services to improve intelligibility in a 9-year-old child with a diagnosis of dyskinetic cerebral palsy. A review of the child's extensive therapy history indicates that there has been little functional improvement in the child's intelligibility. Standardized tests and subjective reporting also indicate that the child's intelligibility has not changed appreciably in three years despite receiving both school and community-based SLP services. The child has acquired an augmentative communication device to supplement their speech. In this situation, the Medicaid consultant would question if community-based SLP services focused on improving intelligibility remains the most appropriate level of service that can be effectively provided to this member.

Flexibility of Approved Services

ForwardHealth allows flexible use of approved, medically necessary PT, OT, and SLP sessions so a provider may meet a member's needs.

ForwardHealth may approve a specific number of PT, OT, and SLP sessions that can be used flexibly. For example, rather than being restricted to providing PT, OT, and SLP services once a week for 10 weeks as approved on a PA request, a provider and member may change the frequency of the sessions over the 10-week period. Therefore, PT, OT, and SLP services could be provided once a week for the first four weeks and twice a week every other week for the next six weeks.

The number of PT, OT, and SLP sessions used may not exceed the approved quantity and must be used between the PA grant and expiration dates.

Plan of Care Must Reflect Flexibility of Approved Services

ForwardHealth requires that the frequency and duration of PT, OT, and SLP services be written in the member's POC under Wis. Admin. Code §§ DHS 107.16, 107.17, and 107.18. To use the sessions flexibly, PT, OT, and SLP providers are required to have a physician's prescription that allows PT, OT, and SLP services to be used flexibly.

Note: Flexibility applies to all sessions approved on PAs including extension of therapy, maintenance therapy and SOI.

Duration of Approved Services

Prior authorization requests for PT, OT, and SLP services must meet the criteria of medically necessary under Wis. Admin. Code § DHS 101.03(96m).

In addition, the duration and frequency on a PA request should accurately reflect the POC.

If the PA request meets the criteria of medically necessary and the duration and frequency accurately reflect the POC, ForwardHealth should allow the following duration and number of sessions for PT, OT, and SLP services provided to individuals with ongoing treatment needs:

• Up to three sessions per week, for a duration of up to 26 weeks (maximum of 78 sessions)
• One or less than one therapy session per week, for a duration of up to 52 weeks (maximum of 52 sessions)

Duration applies for extension of therapy and maintenance therapy PAs but not SOI.

Coordinating Multiple PA Requests

ForwardHealth allows providers to request coordination of grant and expiration dates for the same member for multiple therapy disciplines. The intent of this provision is to increase coordinated planning by PT, OT, and SLP providers and enable members and their families to benefit from a coordinated service delivery plan. Providers can facilitate this process by consulting with other PT, OT, and SLP providers. ForwardHealth will respond to coordination requests when possible. Providers should request the same grant and expiration dates on each PA request and note that it is for coordination of care purposes.

When initiating PA coordination, providers may need to request shorter duration periods to synchronize the PA requests.

Using PA Collaboratives to Coordinate Multiple PA Requests

To facilitate coordination of care, providers can use PA collaboratives to link two or more PA requests for the same member together so providers can easily see and maintain them. Providers can indicate that their PA request is part of a collaborative when they submit their PA request through the ForwardHealth Portal.

After successfully submitting a PA request to a PA collaborative, providers can view all PA requests within it. Through the PA Collaboration panel on the Portal, providers have the option to attest that the PA should remain in the collaborative or they may choose to opt out of the collaborative.

General Principles for Prior Authorization Requests

A PA request for extension of therapy services, maintenance therapy services, or services that always require PA may be approved if the documentation provided establishes the following:

• Services are reasonably expected to be effective in achieving predictable and functional results for the member.
• Services are coordinated with the goals and activities of all other medical, educational, and vocational disciplines involved with the member.
• Services are cost-effective when compared with other available services that meet the member's treatment needs.
• Professional skills of a PT, OT, or SLP provider are required to meet the member's functional needs and therapy treatment needs.
• Treatment goals are reasonable given the member's current age and health status.
• Pertinent medical and social history is provided in sufficient detail to support that attainment of treatment goals would result in measurable and sustained benefit to the member.
• Frequency and duration of the requested services are based on the estimated length of time required for the member to realistically achieve the treatment goals.
• Medical diagnosis and problem statement (treatment diagnosis) identify the specific treatment needs of the member.
• Progress statements are objective, measurable, and demonstrate the desired outcome from the PT, OT, or SLP services in terms of functional improvements that can be generalized to settings outside the immediate treatment environment.
• Short-term objectives are realistic and attainable by the end of the requested PA.
• Long-term objectives describe the predicted functional changes expected by the end of the episode of care (not necessarily at the end of the requested PA).
• A plan to educate the member or caregiver and transition responsibility of the PT, OT, or SLP program is created, including an HEP.

Medical Necessity

ForwardHealth relies on its definition of medically necessary, as stated in Wis. Admin. Code § DHS 101.03(96m), to determine whether a particular service may be reimbursed by Wisconsin Medicaid. Medical necessity for PT, OT, and SLP services is focused on intervention activities that are designed to produce specific outcomes.

ForwardHealth uses the PA process to determine whether the standards of medical necessity are met and to assure that appropriate PT, OT, and SLP services are provided to members. ForwardHealth consultants evaluate PA requests for PT, OT, and SLP services on a case-specific basis. A PA request may be approved only if the documentation submitted in the PA request establishes that the standards of medical necessity, in addition to all other program requirements, are met.

Common reasons for finding a "lack of medical necessity" include the following:

• Baseline performance is not documented in terms of the member's current functional abilities and limitations.
• Clinical information is not provided in sufficient detail to suggest that both of the following are true:
• Treatment goals are reasonable given the current age and health status of the member.
• Attainment of treatment goals would result in predictable functional improvement to the member.
• Documentation fails to support that the professional skills of a PT, OT, or SLP provider are required to meet the member's functional needs and therapy treatment needs.
• The member has failed to make progress toward the targeted goals and objectives in a reasonable time period, and the PT, OT, or SLP provider has not modified the treatment plan or objectives in spite of the anticipated outcomes not being achieved.

Relationship of Medical Necessity to Clinical Practice Principles

PT, OT, or SLP services reimbursed by Wisconsin Medicaid reflect the following principles of clinical practice:

• An intervention plan should not be based solely on the presence of a medical diagnosis.
• Frequency or duration of treatment is determined by rate of change as a result of therapy, rather than level of severity.¹
• Decisions about direct service intervention are contingent on timely monitoring of patient or client response and progress made toward achieving the anticipated goals and expected outcomes.²
• The need for the service has been determined in collaboration with the primary caregivers and others working together on behalf of the individual.
• Families or caregivers affect the priorities for intervention through their direct and proactive participation in the therapeutic process and should be encouraged to participate in all treatment decisions.
• Intervention is unlikely to promote lasting functional improvements if the only opportunity to develop new skills occurs during sessions with the therapist.
• Therapeutic intervention strategies include an educational focus and home program that enables the family or caregiver and eventually the individual to facilitate and reinforce long-term gains.

¹ American Occupational Therapy Association.

² Guide to Physical Therapist Practice, 2001 American Physical Therapy Association, p. 38 and 46.

Prior Authorization Numbers

Upon receipt of the PA/RF, ForwardHealth will assign a PA number to each PA request.

The PA number consists of 10 digits, containing valuable information about the PA (for example, the date the PA request was received by ForwardHealth, the medium used to submit the PA request).

Each PA request is assigned a unique PA number. This number identifies valuable information about the PA. The following table provides detailed information about interpreting the PA number.

Reasons for Prior Authorization

Only about 4 percent of all services covered by Wisconsin Medicaid require PA. PA requirements vary for different types of services. Refer to ForwardHealth publications and Wis. Admin. Code ch. DHS 107 for information regarding services that require PA. According to Wis. Admin. Code § DHS 107.02(3)(b), PA is designed to do the following:

• Safeguard against unnecessary or inappropriate care and services
• Safeguard against excess payments
• Assess the quality and timeliness of services
• Promote the most effective and appropriate use of available services and facilities
• Determine if less expensive alternative care, services, or supplies are permissible
• Curtail misutilization practices of providers and members

PA requests are processed based on criteria established by the Wisconsin DHS.

Providers should not request PA for services that do not require PA simply to determine coverage or establish a reimbursement rate for a manually priced procedure code. Also, new technologies or procedures do not necessarily require PA. PA requests for services that do not require PA are typically returned to the provider. Providers having difficulties determining whether or not a service requires PA may call Provider Services.

Referrals to Out-of-State Providers

PA may be granted to out-of-state providers when nonemergency services are necessary to help a member attain or regain their health and ability to function independently. The PA request may be approved only when the services are not reasonably accessible to the member in Wisconsin.

Out-of-state providers are required to meet ForwardHealth's guidelines for PA approval. This includes sending PA requests, required attachments, and supporting documentation to ForwardHealth before the services are provided.

Note: Emergency services provided out-of-state do not require PA; however, claims for such services must include appropriate documentation (e.g., anesthesia report, medical record) to be considered for reimbursement. Providers are required to submit claims with supporting documentation on paper.

When a Wisconsin Medicaid provider refers a member to an out-of-state provider, the referring provider should instruct the out-of-state provider to go to the Provider Enrollment Information home page on the ForwardHealth Portal to complete a Medicaid Out-of-State Provider Enrollment Application.

All out-of-state nursing homes, regardless of location, are required to obtain PA for all services. All other out-of-state nonborder-status providers are required to obtain PA for all nonemergency services except for home dialysis supplies and equipment.

Reimbursement Not Guaranteed

Wisconsin Medicaid may decline to reimburse a provider for a service that has been prior authorized if one or more of the following program requirements is not met:

• The service authorized on the approved PA request is the service provided.
• The service is provided within the grant and expiration dates on the approved PA request.
• The member is eligible for the service on the date the service is provided.
• The provider is enrolled in Wisconsin Medicaid on the date the service is provided.
• The service is billed according to service-specific claim instructions.
• The provider meets other program requirements.

Providers may not collect payment from a member for a service requiring PA under any of the following circumstances:

• The provider failed to seek PA before the service was provided.
• The service was provided before the PA grant date or after the PA expiration date.
• The provider obtained PA but failed to meet other program requirements.
• The service was provided before a decision was made, the member did not accept responsibility for the payment of the service before the service was provided, and the PA was denied.

There are certain situations when a provider may collect payment for services in which PA was denied.

Other Health Insurance Sources

Providers are encouraged, but not required, to request PA from ForwardHealth for covered services that require PA when members have other health insurance coverage. This is to allow payment by Wisconsin Medicaid for the services provided in the event that the other health insurance source denies or recoups payment for the service. If a service is provided before PA is obtained, ForwardHealth will not consider backdating a PA request solely to enable the provider to be reimbursed.

Sources of Information

Providers should verify that they have the most current sources of information regarding PA. It is critical that providers and staff have access to these documents:

• Wisconsin Administrative Code: Chapters DHS 101 through DHS 109 are the rules regarding Medicaid administration.
• Wisconsin Statutes: Sections 49.43 through 49.99 provide the legal framework for Wisconsin Medicaid.
• ForwardHealth Portal: The Portal gives the latest policy information for all providers, including information about Medicaid managed care enrollees.

Status Inquiries

Providers may inquire about the status of a PA request through one of the following methods:

• Accessing WiCall, ForwardHealth's AVR system
• Calling Provider Services

Providers should have the 10-digit PA number available when making inquiries.