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HealthCheck Information for Providers

HealthCheck is the Wisconsin Medicaid term for the federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. It provides preventative services for ForwardHealth members under age 21. The goal of HealthCheck is to provide comprehensive health care services that are covered under the federal Medicaid program and are medically necessary to treat, correct, or reduce a member’s illnesses and conditions.

The HealthCheck benefit covers most services and items for people under 21 who have Medicaid coverage. If they have a ForwardHealth ID card, they have Wisconsin Medicaid.

Use this webpage to understand more about HealthCheck and HealthCheck Other Services and learn about specific details to help you in your role as a provider.

Understanding HealthCheck

HealthCheck covers preventative services, also known as well-child checks. Well-child checks follow guidelines from the American Academy of Pediatrics’ Periodicity Schedule. These periodic and follow-up comprehensive health screens include:

  • Dental checks
  • Growth and development checks
  • Head-to-toe physical exams
  • Health information
  • Hearing and vision checks
  • Immunizations
  • Lab tests
  • Nutrition checks

HealthCheck also covers any follow-up visits and special appointments scheduled after well-child checks discover concerns that should be looked at further.

Understanding HealthCheck Other Services

HealthCheck Other Services allows members under 21 to get services or items ForwardHealth typically doesn’t cover or that exceeds quantities ForwardHealth typically allows. Federal EPSDT laws require this coverage. Members can get HealthCheck Other Services if the service is:

  • Able to be covered according to federal Medicaid law.
  • Determined medically necessary by ForwardHealth.

HealthCheck Other Services covers some common services or items such as:

  • Behavioral and mental health treatment
  • Durable medical equipment (DME)
  • Disposable medical supplies (DMS)
  • Dental care (including orthodontia)
  • Over-the-counter (OTC) medications
  • Personal care services

Prior Authorization and HealthCheck Other Services

Because HealthCheck Other Services can cover services and items not typically covered by ForwardHealth, almost all services or items requested under the HealthCheck Other Services benefit require prior authorization (PA). The PA process allows ForwardHealth to determine the medical necessity of the requested service or item.

The PA request process for HealthCheck Other Services is the same as the usual PA process for many services and items. However, PA requests for HealthCheck Other Services also must include documentation from the provider that:

  • Details why the services or items typically covered by ForwardHealth do not meet the member’s needs.
  • Identifies why the member needs the requested service or item and how it supports or sustains the member’s highest level of function, prevents a condition from worsening, or makes a condition more tolerable.

Different ForwardHealth benefits, such as pharmacy services, could require additional forms and/or supporting documentation. Find more information about pharmacy and OTC drugs from the ForwardHealth Online Handbook HealthCheck Other Services Over-the-Counter Drug Information topic #23377. The Online Handbook also provides more details about other benefit areas.

HealthCheck Resources

Provider Resources

  • HealthCheck Other Services OTC Drug Information topic #23377
  • Forms needed to submit a PA for OTC drugs not routinely covered by ForwardHealth:
    • Prior Authorization Request Form (PA/RF), F-11018
    • Prior Authorization/Drug Attachment (PA/DGA), F-11049
  • HealthCheck Other Services OTC Drug Coverage Provider Flyer, P-03630A

Resources to Share with Members and Families

To request printed copies, complete a Forms/Publication Order form, F-80025A, and email it as an attachment to dhsfmorder@dhs.wisconsin.gov.

HealthCheck and HealthCheck Other Services FAQs

Are specific forms or prior authorization (PA) needed to access HealthCheck services?

HealthCheck well-child checks and associated immunizations and recommended screens are available without PA. No special forms are required.

HealthCheck outreach and case management services are also available without PA. ForwardHealth-enrolled outreach and case management agencies, or the member’s managed care organization (MCO), may initiate outreach to the member. The member can also contact these agencies for information and assistance in obtaining HealthCheck screens or services.

Services that result from a HealthCheck referral, such as follow-up visits or special appointments, usually require PA and are subject to all applicable PA requirements.

What is a HealthCheck well-child check?

HealthCheck well-child checks are age-appropriate medical wellness check-ups that occur on a regular basis and include these components:

  • A comprehensive health and developmental history including:
    • A health history
    • A nutritional assessment
    • A developmental-behavioral assessment
    • Health education and guidance for the member and caregiver
  • A comprehensive, unclothed physical exam
  • A hearing screen
  • A vision screen
  • An oral assessment, plus referral to a dentist beginning when the first tooth erupts or by age 1
  • Age-appropriate immunizations according to age and health history, per the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices guidelines
  • Appropriate laboratory tests (including blood lead level testing when appropriate for age)

Conditions identified during a well-child check may be referred for additional evaluation. These follow-up visits or special appointments are also covered by ForwardHealth.

What is a HealthCheck follow-up visit or special appointment?

Follow-up visits or special appointments are visits with qualified providers that occur outside the American Academy of Pediatrics Periodicity Schedule. They may be recommended by any professional who comes into contact with the child such as physicians, dentists, health officials, or educators. Follow-up visits or special appointments can be problem-focused or may include any or all components of the comprehensive screen. These visits may be required to diagnose a new illness or condition or to determine whether a previously diagnosed illness or condition requires additional services.

Who can be a HealthCheck screener?

Wis. Admin. Code § DHS 105.37(1)(a) defines the types of providers and agencies that may qualify for HealthCheck screener enrollment

What are HealthCheck outreach and case management services?

Wisconsin Medicaid-enrolled HealthCheck outreach and case management agencies and MCOs provide outreach and basic case management services to inform members about and help them obtain HealthCheck services. These agencies may identify when a member has missed a well-child check according to the periodicity schedule or may identify health needs through other public health programs such as blood lead screening or nutrition programs. To make a referral for case management services, the provider can contact the county human service agency of the member’s residence. The provider can also contact the specific program that will support the member.

Case management services are specifically related to helping the member obtain HealthCheck services such as assisting with scheduling, arranging transportation to a HealthCheck visit, or ensuring that appropriate referrals and follow-ups occur after a HealthCheck visit.

Do MCOs follow fee-for-service requirements for HealthCheck services, as well as HealthCheck Other Services?

All HealthCheck requirements must be adhered to for members who receive services under managed care arrangements. ForwardHealth is responsible for medically necessary services not included in the managed care contract. It is the MCO’s responsibility to ensure members are aware of HealthCheck and to assist members with accessing benefits and services.

How do members access HealthCheck Other Services?

HealthCheck Other Services usually require PA, since ForwardHealth determines coverage on a case-by-case basis, depending on the needs of the member.

ForwardHealth and HealthCheck cover most diagnostic and intervention services a member may need. However, when a well-child check, follow-up visit, or special appointment identify a member’s need for items not typically covered or that exceed quantities typically allowed, the provider should submit a PA for consideration under HealthCheck Other Services.

What types of providers are allowed to submit PA requests for HealthCheck Other Services?

Any Medicaid-enrolled provider can submit a PA request for HealthCheck Other Services. ForwardHealth providers include doctors, nurse practitioners, dentists, physical therapists, occupational therapists, speech therapists, psychologists, psychiatrists, and other health care professionals enrolled through ForwardHealth.

What are examples of services covered under HealthCheck Other Services?

Members under age 21 can use HealthCheck Other Services to get services or items ForwardHealth typically does not cover or that exceed quantities typically allowed.

For example:

  • A service ForwardHealth typically does not cover:
    • ForwardHealth covers most routine dental services for members under 21 without PA, but orthodontic services are not typically covered. If a dentist determines that orthodontic services are medically necessary for a member under 21, a PA should be submitted to request the approval of orthodontic services under HealthCheck Other Services.
  • A service that exceeds typical quantities allowed by ForwardHealth:
    • ForwardHealth typically covers one mobility base every five years for a member. If a member under 21 has a primary mobility base that limits access to their community and/or participation in age-appropriate activities, a secondary mobility base could be considered under HealthCheck Other Services.
    • ForwardHealth covers one ankle foot orthosis per year without PA. If a physician determines that an additional orthosis is medically necessary for a member under 21, a PA should be submitted to request approval of the additional one under HealthCheck Other Services.

How will I know if a service is federally allowable?

Federally allowable ForwardHealth services are listed in Social Security Act § 1905(a). These services may be defined or otherwise clarified in other sections of the Act.

Based on federal law, ForwardHealth cannot reimburse for these services and items:

  • Structural or home modifications (such as ramps, stair lifts, fences, permanent fixtures for ceiling lifts)
  • Vehicles and vehicle modifications (such as vehicle lifts or carriers)
  • Items already purchased by the family or another funding source (ForwardHealth does not reimburse.)
  • Experimental services and items

Providers can also refer to ForwardHealth’s definition of noncovered services

What does medical necessity under HealthCheck Other Services mean?

For a service or item to be considered medically necessary under HealthCheck Other Services, the service must support or sustain the member’s highest level of function, prevent a condition from worsening, or make a condition more tolerable. Providers must ensure that documentation submitted with the PA request clearly outlines why the requested service is medically necessary.

The determination of whether a service is medically necessary is made on a case-by-case basis, considering the individual needs of the member.

If a PA request for a member under 21 does not meet the medical necessity standards outlined in Wis. Admin. Code § DHS 101.03(96m), the PA request will automatically be reviewed under HealthCheck Other Services. The provider will not need to submit a second PA.

I am submitting a PA request for HealthCheck Other Services on behalf of my patient. What PA request form should I use?

Most service areas, including pharmacy OTC drugs, will require a completed Prior Authorization Request Form (PA/RF), F-11018. However, other service areas have their own request forms. These include:

  • Dental: Prior Authorization Dental Request Form (PA/DRF), F-11035
  • Hearing Instruments: Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1), F-11020

Prior Authorization for HealthCheck Other Services topic #1 outlines PA forms and documentation in more detail.

PA submission requirements for OTC drugs requested under the HealthCheck Other Services benefit are found in the HealthCheck Other Services Over-the-Counter Drug Information topic #23377.

Do I need a PA attachment form with the PA/RF, PA/DRF, or PA/HIAS1 when submitting a PA request under HealthCheck Other Services?

Yes. A service-specific PA attachment is required. If a provider is unclear which PA attachment form to use, they can submit the rationale and clinical documentation (for example, test results or clinical notes) in its place. For submissions through the ForwardHealth Portal, the provider must respond Yes to the question, “Does this fall under HealthCheck ‘Other Services’?” so clinical documentation can be submitted without a PA attachment form. PA submission requirements for OTC drugs requested under the HealthCheck Other Services benefit are found in the HealthCheck Other Services Over-the-Counter Drug Information topic #23377.

The Prior Authorization for HealthCheck Other Services topic #1 outlines PA forms and documentation in more detail.

Do I need to check the HealthCheck Other Services box on the PA/RF?

It is helpful but not essential to check the HealthCheck Other Services box on the form.

If a PA request for a member under 21 does not meet the medical necessity standards outlined in Wis. Admin. Code § DHS 101.03(96m), the PA request will automatically be reviewed under HealthCheck Other Services.

However, if you are entering a PA request on the secure Provider area of the Portal and you do not know which attachment form to use, you must select Yes for HealthCheck Other Services on the first screen of the Portal PA request. Checking Yes will allow you to submit the PA without an attachment form. While you might not need to complete an attachment form, you still need to upload clinical documentation that supports your request.

Do I need to have a PA request denied before submitting a PA request for HealthCheck Other Services?

No. If a PA request for a member under 21 does not meet the medical necessity standards outlined in Wis. Admin. Code § DHS 101.03(96m), the PA request will automatically be reviewed under HealthCheck Other Services. Providers do not need to submit an additional PA request for the request to be considered under HealthCheck Other Services.

Does the parent, guardian, or caregiver of the member need to provide any paperwork to ForwardHealth for requested HealthCheck Other Services?

No. The health care provider is responsible for submitting any required forms and/or clinical documentation for requesting HealthCheck Other Services. Providers may ask parents, guardians, or caregivers for related documentation that may not be available in the provider’s records such as a member’s Individualized Education Plan or clinical documentation from other providers.

Is there a specific HealthCheck Other Services procedure code?

No. When submitting a PA request for HealthCheck Other Services, providers should enter the procedure code that most accurately describes the service, even if the code is not ordinarily covered by ForwardHealth. Unlisted procedure codes can be requested if the service is not accurately described by established procedure codes.

For proper claims processing, when services are approved through HealthCheck Other Services, providers are required to submit claims with the procedure codes and modifiers, or National Drug Codes as indicated on the PA response. More information about how to submit a HealthCheck Other ServicesPA request for a service not routinely covered by ForwardHealth is available in the Online Handbook.

My PA request was approved with modifications. What does that mean?

Approved with modifications indicates that ForwardHealth approved the PA request but changed or modified something from the provider’s original request. ForwardHealth makes modifications in alignment with Wis. Admin. Code § DHS 107.02(3)(b). Common modifications include changes in the frequency or intensity of the service requested or changes in the duration of the treatment period.

When ForwardHealth modifies a PA request, they notify both the provider and the member. The provider will receive a more detailed explanation for the modification. The member and/or caregiver may need provider assistance to understand why the request was modified. The member has the right to appeal the decision.

My PA request was returned. What does that mean?

A return is not a denial. A PA request will be returned if it is incomplete or additional information is needed to substantiate medical necessity under ForwardHealth or HealthCheck Other Services. When ForwardHealth returns a PA, the return message details what the providers need to do. Providers should read the message and submit the appropriate materials to support the request.

Providers have 30 days to resubmit the PA with the additional forms or information requested in the return message. A PA will become inactive after 30 days. If this occurs, a new PA will need to be submitted.

 
 
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