hospital services handbook for outpatient servicesarchival use only refer to the online handbook for...

ServicesHospital

outpatientservices

outpatientservices

Hospital ServicesHospital Services

ARCHIVAL USE ONLY Refer to the Online Handbook

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IImportant Telephone NumbersWisconsin Medicaid’s Eligibility Verification System (EVS) is available through the following resourcesto verify checkwrite information, claim status, prior authorization status, provider certification, and/orrecipient eligibility.

ServiceInformation

Available Telephone Number Hours

Automated VoiceResponse (AVR)System(Computerized voiceresponse to providerinquiries.)

Checkwrite InformationClaim StatusPrior AuthorizationStatusRecipient Eligibility*

(800) 947-3544(608) 221-4247 (Madison area)

24 hours a day/7 days a week

Personal ComputerSoftwareandMagnetic StripeCard Readers

Recipient Eligibility* Refer to ProviderResources section ofthe All-ProviderHandbook for a list ofcommercial eligibilityverification vendors.

24 hours a day/7 days a week

Provider Services(Correspondentsassist withquestions.)

Checkwrite InformationClaim StatusPrior AuthorizationStatusProvider CertificationRecipient Eligibility*

(800) 947-9627(608) 221-9883

Policy/Billing and Eligibility:8:30 a.m. - 4:30 p.m. (M, W-F)9:30 a.m. - 4:30 p.m. (T)Pharmacy:8:30 a.m. - 6:00 p.m. (M, W-F)9:30 a.m. - 6:00 p.m. (T)

Direct InformationAccess Line withUpdates forProviders(Dial-Up)(Softwarecommunicationspackage andmodem.)

Checkwrite InformationClaim StatusPrior AuthorizationStatusRecipient Eligibility*

Call (608) 221-4746for more information.

7:00 a.m. - 6:00 p.m. (M-F)

Recipient Services(Recipients orpersons calling onbehalf of recipientsonly.)

Recipient EligibilityMedicaid-CertifiedProvidersGeneral MedicaidInformation

(800) 362-3002(608) 221-5720

7:00 a.m. - 9:00 p.m. (M-F)7:30 a.m. - 4:00 p.m. (Sat.)

*Please use the information exactly as it appears on the recipient's identification card or the EVS tocomplete the patient information section on claims and other documentation. Recipient eligibilityinformation available through EVS includes: - Dates of eligibility. - Medicaid managed care program name and telephone number. - Privately purchased managed care or other commercial health insurance coverage. - Medicare coverage. - Lock-In Program status. - Limited benefit information.


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TTable of Contents

Preface ......................................................................................................................... 7

Provider Information ...................................................................................................... 9

Provider Eligibility and Certification ............................................................................ 9Approved Hospital Facility..................................................................................... 9CLIA Certification ................................................................................................. 9

Provider Responsibilities .......................................................................................... 10Verifying Recipient Eligibility ............................................................................... 10

Special Benefit Categories ............................................................................. 10Medicaid Managed Care Coverage .................................................................. 11

Copayments and Billed Amounts ......................................................................... 11Collection of Copayment ................................................................................ 11Recipient Freedom from Liability for Covered Services ..................................... 11

Newborn Reporting ............................................................................................ 11

Covered Services and Related Limitations...................................................................... 13

Outpatient Services Requirements ........................................................................... 13Medically Necessary Care ................................................................................... 13Care Must be Physician or Dentist Directed .......................................................... 13Outpatient Status............................................................................................... 13

Emergency Room Services ............................................................................. 14Inpatient and Outpatient Services for Same Date of Service ............................. 14Admission for Observation Purposes ............................................................... 14Maternity Stays ............................................................................................. 14

Service-Specific Requirements ................................................................................. 14Abortions........................................................................................................... 14

Coverage Policy ............................................................................................ 14Covered Services .......................................................................................... 14Coverage of Mifeprex .................................................................................... 15Physician Counseling Visits Under s. 253.10, Wis. Stats. ................................... 15Services Incidental to a Noncovered Abortion .................................................. 15Services Performed by Providers of a Noncovered Abortion .............................. 16

Dental Services .................................................................................................. 16Diagnostic Testing, Laboratory, and Therapeutic Services ..................................... 16End-Stage Renal Disease Services ....................................................................... 16HealthCheck “Other Services” ............................................................................. 16Outpatient Hospital Therapy Services .................................................................. 16

Substance Abuse and Mental Health Outpatient Clinic Services ........................ 17Outpatient Surgery ............................................................................................. 17Sterilizations ...................................................................................................... 17

Documentation Requirements ........................................................................ 18Sterilization Informed Consent Statement ....................................................... 18

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Related Services That Are Not Hospital Outpatient Services ....................................... 18Hospital-Based Ambulance ................................................................................. 18Services Provided in Unapproved Facilities ........................................................... 18

Substance Abuse and Mental Health Outpatient Clinic Services ........................ 18Substance Abuse Day Treatment and Mental Health Day Treatment ...................... 18

Noncovered Services ............................................................................................... 19Experimental Services ........................................................................................ 19

Prior Authorization ....................................................................................................... 21

Services Requiring Prior Authorization ...................................................................... 21Substance Abuse and Mental Health Outpatient Clinic Services ............................. 21HealthCheck “Other Services” ............................................................................. 21

Procedures for Obtaining Prior Authorization ............................................................. 21Prior Authorization Requests by Fax..................................................................... 22Written Prior Authorization Requests ................................................................... 22

Claims Submission ....................................................................................................... 23

Submitting Claims for Outpatient Services ................................................................ 23Electronic Claims Submission .............................................................................. 23Paper Claims Submission .................................................................................... 23Claims Submission Deadline ............................................................................... 23

Crossover Claims Submission Deadline ........................................................... 23Claim Components ............................................................................................. 24

Revenue Codes ............................................................................................. 24Diagnosis Codes ........................................................................................... 24

Coordination of Benefits .......................................................................................... 24Health Insurance Coverage................................................................................. 24Medicaid Managed Care Coverage ....................................................................... 24Medicare/Medicaid Dual Entitlement ................................................................... 24

Crossover Claims .......................................................................................... 25Spenddown and Medicare Part B Charges ....................................................... 25

Usual and Customary Charges ................................................................................. 25Special Circumstances ............................................................................................. 25

Dilation and Curettage ....................................................................................... 25Inpatient and Outpatient Services for the Same Date of Service ............................ 25Obstetrical and Newborn Stays ........................................................................... 25

Claims for One-Day Mother/Baby Stays .......................................................... 25Claims for Newborns Using Mothers’ Medicaid Identification Numbers ............... 25Establishing Continuous Eligibility of Newborns ............................................... 26

Outpatient Hospital Therapy Services .................................................................. 26Substance Abuse and Mental Health Outpatient Clinic Services ............................. 26

Payment Methods ................................................................................................... 27Wisconsin Medicaid Inpatient and Outpatient State Plans ..................................... 27Medicare Crossover Claims ................................................................................. 27

Follow-Up to Claims Submission ............................................................................... 27


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Appendix ..................................................................................................................... 29

1. Prior Authorization Request Form (PA/RF) Completion Instructions for Outpatient Hospital Services ...................................................................................................... 312. Sample Prior Authorization Request Form (PA/RF) ....................................................... 353. Prior Authorization Alcohol and Other Drug Abuse Attachment (PA/AA) Completion Instructions ............................................................................................................. 374. Sample Prior Authorization Alcohol and Other Drug Abuse Attachment (PA/AA) .......... 395. Prior Authorization Alcohol and Other Drug Abuse Attachment (PA/AA) (for photocopying) ................................................................................................... 436. Prior Authorization Psychotherapy Attachment (PA/PSYA) Completion Instructions ......... 497. Sample Prior Authorization Psychotherapy Attachment (PA/PSYA) ................................. 538. Prior Authorization Psychotherapy Attachment (PA/PSYA) (for photocopying) ................ 559. Prior Authorization by Fax Guidelines ........................................................................ 5910. UB-92 Claim Form Completion Instructions for Outpatient Hospital Services ............... 6111. Sample UB-92 Claim Form — Outpatient Services ..................................................... 6912. Revenue Codes for Hospitals ................................................................................... 71

Glossary of Common Terms .......................................................................................... 73

Index .......................................................................................................................... 77


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Hospital Services Handbook — Outpatient Services Section � September 2003 7

The Wisconsin Medicaid and BadgerCare HospitalServices Handbook is issued to hospital providers whoare Wisconsin Medicaid certified. It containsinformation that applies to fee-for-service Medicaidproviders. The Medicaid information in the handbookapplies to both Medicaid and BadgerCare.

Wisconsin Medicaid and BadgerCare areadministered by the Department of Health and FamilyServices (DHFS). Within the DHFS, the Division ofHealth Care Financing (DHCF) is directly responsiblefor managing Wisconsin Medicaid and BadgerCare.As of January 2003, BadgerCare extends Medicaidcoverage to uninsured children and parents withincomes at or below 185% of the federal poverty leveland who meet other program requirements.BadgerCare recipients receive the same healthbenefits as Wisconsin Medicaid recipients and theirhealth care is administered through the same deliverysystem.

Medicaid and BadgerCare recipients enrolled in state-contracted HMOs are entitled to at least the samebenefits as fee-for-service recipients; however,HMOs may establish their own requirementsregarding prior authorization, billing, etc. If you are anHMO network provider, contact your managed careorganization regarding its requirements. Informationcontained in this and other Medicaid publications isused by the DHCF to resolve disputes regardingcovered benefits that cannot be handled internally byHMOs under managed care arrangements.

Verifying EligibilityWisconsin Medicaid providers should always verify arecipient’s eligibility before providing services, both todetermine eligibility for the current date and todiscover any limitations to the recipient’s coverage.Wisconsin Medicaid’s Eligibility Verification System(EVS) provides eligibility information that providerscan access a number of ways.

Refer to the Important Telephone Numbers page atthe beginning of this section for detailed informationon the methods of verifying eligibility.

Handbook OrganizationThe Hospital Services Handbook consists of thefollowing sections:

• Inpatient Services.• Outpatient Services.

In addition to the Hospital Services Handbook, eachMedicaid-certified provider is issued a copy of the All-Provider Handbook. The All-Provider Handbookincludes the following sections:

• Claims Submission.• Coordination of Benefits.• Covered and Noncovered Services.• Prior Authorization.• Provider Certification.• Provider Resources.• Provider Rights and Responsibilities.• Recipient Rights and Responsibilities.

Legal Framework ofWisconsin Medicaid andBadgerCareThe following laws and regulations provide the legalframework for Wisconsin Medicaid and BadgerCare:

Federal Law and Regulation

• Law: United States Social Security Act; Title XIX(42 US Code ss. 1396 and following) and TitleXXI.

• Regulation: Title 42 CFR Parts 430-498 — PublicHealth.

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8 Wisconsin Medicaid and BadgerCare � September 2003

Wisconsin Law and Regulation

• Law: Wisconsin Statutes: Sections 49.43-49.499and 49.665.

• Regulation: Wisconsin Administrative Code,Chapters HFS 101-108.

Handbooks and Wisconsin Medicaid andBadgerCare Updates further interpret andimplement these laws and regulations.

Handbooks and Updates, maximum allowable feeschedules, helpful telephone numbers and addresses,and much more information about Wisconsin Medicaidand BadgerCare are available at the following Websites:

www.dhfs.state.wi.us/medicaid/www.dhfs.state.wi.us/badgercare/.

Medicaid Fiscal AgentThe DHFS contracts with a fiscal agent, which iscurrently EDS.


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ProviderInform

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PThe Outpatient Services section of the HospitalServices Handbook includes information foroutpatient hospital services providers regardingcovered services, reimbursement methodology,and claims submission information.

Provider Eligibility andCertificationWisconsin Medicaid certifies a hospital aseither an acute care general hospital orinstitution for mental disease (IMD) and basesthe hospital certification on the hospital’seligibility for certification with Medicare or withthe Joint Commission on Accreditation ofHealthcare Organizations.

Wisconsin Medicaid certifies acute caregeneral hospitals and IMDs according to HFS105.07 and 105.21, Wis. Admin. Code,respectively. A facility determined by theWisconsin Department of Health and FamilyServices to be an IMD may not be certified asan acute care general hospital.

Medicare certification does not automaticallycertify a hospital with Wisconsin Medicaid.

The Wisconsin Medicaid hospital certificationpacket contains detailed requirements forcertification. Providers are required to meetthese requirements and report necessarychanges to Wisconsin Medicaid. For moreinformation on becoming certified, or to obtaina certification packet, contact ProviderServices at (800) 947-9627 or (608) 221-9883or visit the Wisconsin Medicaid Web site atwww.dhfs.state.wi.us/medicaid/.

Provider Information

Approved Hospital FacilityOnly covered services provided by an approvedhospital facility are eligible for payment underWisconsin Medicaid’s outpatient hospitalpayment formula. Wisconsin Medicaid defines“hospital facility” as the physical entity,surveyed and approved by the Division ofSupportive Living, Bureau of Quality Assurance(BQA) under ch. 50, Wis. Stats. The BQAfacility approval survey covers the building thatthe hospital identifies as constituting its operation.

This building must meet strict fire and lifesafety codes and administrative and programstandards specifically required by the BQA forhospitals. Wisconsin Medicaid considers theunique costs of hospital functions, includingsafety code compliance in the determination ofhospital outpatient services payment.

CLIA CertificationCongress implemented the Clinical LaboratoryImprovement Act (CLIA) to improve the qualityand safety of laboratory services. CLIAestablishes standards and enforcementprocedures.

CLIA requires all laboratories and providersperforming tests for health assessment or forthe diagnosis, prevention, or treatment ofdisease or health impairment to comply withspecific federal quality standards.

Wisconsin Medicaid complies with thefollowing federal regulations as initiallypublished and subsequently updated:

• Public Health Service CLIA of 1988.• 42 CFR Part 493.

OOnly coveredservices providedby an approvedhospital facilityare eligible forpayment underWisconsinMedicaid’soutpatienthospital paymentformula.


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CLIA governs all laboratory operations,including the following:

• Accreditation.• Certification.• Equipment.• Facility standards.• Fees.• Instrumentation.• Materials.• Patient test management.• Personnel qualifications.• Proficiency testing.• Quality assurance.• Quality control.• Reagents.• Records and information systems.• Sanctions.• Supplies.• Test methods.• Tests performed.

Claims for laboratory tests performed byhospital providers without valid CLIAcertification, including an identification number,are subject to Medicaid denial or recoupment.

To obtain a CLIA certification application, writeto the following address or call:

Bureau of Quality AssuranceDivision of Supportive LivingClinical Laboratory UnitPO Box 2969Madison WI 53701-2969(608) 266-5753

Provider ResponsibilitiesRefer to the All-Provider Handbook for specificresponsibilities as a Medicaid-certified provider.This information includes, but is not limited to,the following:

• Additional state and federal requirements.• Fair treatment of the recipient.• Grounds for provider sanctions.

• Maintenance of records.• Recipient requests for noncovered services.• Services provided to a recipient during

periods of retroactive eligibility.

Verifying Recipient EligibilityWisconsin Medicaid hospital providers shouldalways verify a recipient’s eligibility beforedelivering services, both to determine eligibilityfor the current date and to discover anylimitations to the recipient’s coverage. WisconsinMedicaid’s Eligibility Verification System(EVS) provides eligibility information thatproviders can access a number of ways.

Refer to the Important Telephone Numberspage at the beginning of this section for detailedinformation on how to use the methods ofverifying eligibility. Refer to the RecipientRights and Responsibilities section of the All-Provider Handbook for information about thesemethods of verifying eligibility.

Special Benefit CategoriesSome Medicaid recipients covered under specialbenefits categories have limited coverage.Medical status codes received through the EVSidentify recipients with limited benefits.Providers may refer to the Recipient Rightsand Responsibilities section of the All-ProviderHandbook for more information on thedifferent special benefits categories.

Medicaid Managed Care CoverageThe information in this handbook applies tofee-for-service recipients who receive hospitalservices. Medicaid HMOs may have differentpolicies regarding hospital services. ForMedicaid HMO or managed care policy, contactthe appropriate managed care organization.Wisconsin Medicaid HMOs are required toprovide at least the same benefits as thoseprovided under fee-for-service arrangements.

WWisconsinMedicaid hospitalproviders shouldalways verify arecipient’seligibility beforedeliveringservices, both todetermineeligibility for thecurrent date andto discover anylimitations to therecipient’scoverage.


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Copayments and Billed AmountsExcept for the copayment exemptions noted inthe Recipient Rights and Responsibilities sectionof the All-Provider Handbook, all recipients areresponsible for paying part of the costs involvedin obtaining hospital services. The copaymentfor outpatient hospital services is $3.00 perencounter (per visit).

For more information on copayments andcopayment exemptions, refer to the RecipientRights and Responsibilities section of the All-Provider Handbook.

Collection of CopaymentProviders who perform services that requirerecipient copayment are required to make areasonable attempt to collect that copaymentfrom the recipient. Providers may not waivethe recipient copayment requirement unless theprovider determines that the cost of collectingthe payment, coinsurance, or deductibleexceeds the amount to be collected. Providersmay not deny services to a recipient for failingto make a copayment.

Recipient Freedom from Liability forCovered ServicesProviders may not charge a recipient for coveredservices and items furnished under WisconsinMedicaid except for Wisconsin Medicaidrecipient copayments, if applicable. At the sametime, providers may not deny services torecipients who do not make copayments.

A provider may not charge a recipient forcovered services if the provider fails to:

• Comply with Wisconsin Medicaid policyand is denied Medicaid reimbursement.

• Meet Wisconsin Medicaid programrequirements.

• Seek or obtain necessary priorauthorization to perform the services and isdenied Medicaid reimbursement.

Newborn ReportingWisconsin Medicaid does not reimburse forinfant claims submitted under the mother’sidentification number beyond the first 10 daysof the infant’s life.

Hospitals are required to promptly reportnewborns born to fee-for-service Medicaidrecipients to Wisconsin Medicaid. Establishinga newborn’s Medicaid eligibility results in betterhealth outcomes and fewer delays in providerreimbursement.

Hospitals may report newborns born toMedicaid recipients by submitting a WisconsinMedicaid Newborn Report, or another formdeveloped by the hospitals that contains all thesame information, to Wisconsin Medicaid.Refer to Appendix 11 of the Inpatient Servicessection of this handbook for a sample NewbornReport form.

Hospitals have the option of sending newbornreports in a summary format on a weeklybasis to Wisconsin Medicaid or individualreports for each newborn. However, thesummary report must contain all the informationprovided in the Newborn Report.

If possible, the Newborn Report should besubmitted to Wisconsin Medicaid with thechild’s given name (first and last name), ratherthan “baby boy” or “baby girl” as the firstname. The four-digit year should be includedwhen reporting the child’s date of birth. (Toreport a child’s date of death, the two- or four-digit year format may be used). WisconsinMedicaid still requires hospitals to submit theNewborn Report in instances in which the babyis born alive, but does not survive.

Submit the Newborn Report to WisconsinMedicaid by mail or fax at the followingaddress or fax number:

Wisconsin MedicaidPO Box 6470Madison WI 53716Fax: (608) 224-6318

This information on newborn reporting pertainsto the birth of a newborn to a Medicaidrecipient who is not enrolled in an HMO.

HHospitals mayreport newbornsborn to Medicaidrecipients bysubmitting aWisconsin MedicaidNewborn Report, oranother formdeveloped by thehospitals thatcontains all thesame information,to WisconsinMedicaid.


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Under the Medicaid managed care contract,HMOs are required to report to WisconsinMedicaid the birth of a newborn to a motherenrolled in an HMO. Because of thisrequirement, hospitals and HMOs shouldcoordinate the newborn reporting function toprevent duplicate reporting by the hospital andHMO of the same newborn. Following theseprocedures assures more timely reimbursementfor services provided to infants.

Once the completed Newborn Report issubmitted to Wisconsin Medicaid, the followingprocedures take place:

• A pseudo (temporary) Medicaididentification number is assigned to thenewborn, regardless of whether thenewborn is named (if Medicaid eligibility isnot yet on file).

• A Medicaid Forward card is created forthe child and sent to the mother as soon asthe child’s eligibility is put on file.

• Wisconsin Medicaid sends a letter to themother, notifying her of this eligibility. Theletter also contains a statement that themother is required to sign, stating that thebaby has continued to live with her sincebirth. She must send this statement to hercounty or tribal eligibility worker in theenvelope provided and is required to tellher eligibility worker that she has a newbaby with a temporary Medicaididentification number.

• A copy of this letter is also sent to thecounty economic support agency.

• Once the mother notifies her worker, apermanent Medicaid number is assigned tothe infant.

• The hospital receives a copy of theeligibility notification letter sent to thechild’s mother as confirmation.

Providers with questions regarding newborneligibility may contact Provider Services at(800) 947-9627 or (608) 221-9883.

PProviders withquestionsregarding newborneligibility maycontact ProviderServices at(800) 947-9627 or(608) 221-9883.


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Hospital Services Handbook — Outpatient Services Section � Septmeber 2003 13

Covered Services andRelated Lim

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CCovered Services and RelatedLimitationsOutpatient ServicesRequirementsIn accordance with HFS 107.08(3)(b), Wis.Admin. Code, hospitals providing outpatienthospital services are required to meet the samerequirements that apply to Medicaid-certified,nonhospital providers performing the sameservices. Outpatient services performedoutside the hospital facility are not reimbursedas hospital outpatient services.

Wisconsin Medicaid requires that outpatientservices meet all of the following criteria:

• The care is directed by a physician ordentist.

• The care is medically necessary.• The recipient is not an inpatient.• The service is provided in an approved

hospital facility.

Medically Necessary CareCovered hospital outpatient services are thosemedically necessary preventative, diagnostic,rehabilitative, or palliative items or services.HFS 101.03(96m), Wis. Admin. Code, defines“medically necessary” as a Medicaid-coveredservice that is:

(a) Required to prevent, identify or treat arecipient’s illness, injury or disability; and,

(b) Meets the following standards:1. Is consistent with the recipient’s

symptoms or with prevention, diagnosisor treatment of the recipient’s illness,injury or disability;

2. Is provided consistent with standardsof acceptable quality of care applicableto the type of service, the type ofprovider and the setting in which theservice is provided;

3. Is appropriate with regard to generallyaccepted standards of medical practice;

4. Is not medically contraindicated withregard to the recipient’s diagnoses, therecipient’s symptoms or other

medically necessary services beingprovided to the recipient;

5. Is of proven medical value orusefulness and consistent withs. HFS 107.035, is not experimental innature;

6. Is not duplicative with respect to otherservices being provided to the recipient;

7. Is not solely for the convenience ofthe recipient, the recipient’s family ora provider;

8. With respect to prior authorization of aservice and to other prospectivecoverage determinations made by thedepartment, is cost-effective comparedto an alternative medically necessaryservice which is reasonably accessibleto the recipient; and,

9. Is the most appropriate supply or levelof service that can safely andeffectively be provided to the recipient.

Care Must be Physician or DentistDirectedWisconsin Medicaid requires that coveredhospital outpatient services be performed by, orunder the direction of, a physician or dentist,and be provided in a hospital certified underHFS 105.07 or 105.21, Wis. Admin. Code.

Outpatient StatusOn any given calendar day, a patient in ahospital may be either an inpatient or anoutpatient, but not both. Covered outpatienthospital services are those services providedfor a recipient who is not a hospital inpatient.

A recipient who is admitted as an inpatient andcounted in the midnight census is consideredan inpatient. If a recipient has not been officiallyadmitted to the hospital as an inpatient andcounted in the midnight census, the recipient isconsidered an outpatient.

Wisconsin Medicaid considers all coveredoutpatient services provided during onecalendar day as one outpatient visit.

WWisconsin Medicaidrequires thatcovered hospitaloutpatient servicesbe performed by, orunder the directionof, a physician ordentist, and beprovided in a hospitalcertified under HFS105.07 or 105.21,Wis. Admin. Code.


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Emergency Room ServicesWisconsin Medicaid considers emergencyroom services to be outpatient services unlessthe recipient is admitted to the hospital andcounted in the midnight census.

Inpatient and Outpatient Services forSame Date of ServiceIn accordance with HFS 107.08(4)(a)4, Wis.Admin. Code, if inpatient and outpatientservices are provided for the same recipient,at the same hospital, on the same date ofservice (DOS) as the date of the inpatienthospital admission or discharge, the outpatientservices are not separately reimbursed andmust be included on the inpatient claim. Thisdoes not include reference laboratory services.Include outpatient claims for the hospital onthe same date of admission or date of dischargeon the inpatient claim.

Under HFS 107.08(3)(c)4, Wis. Admin. Code,Wisconsin Medicaid does not reimburseoutpatient claims for services provided to aninpatient in another hospital, except on the dateof admission or the date of discharge. For anyother day during the inpatient stay, the hospitalproviding the outpatient services must arrangepayment with the inpatient hospital.

Admission for Observation PurposesIn some cases, an outpatient recipient may beadmitted for observation for a portion of a day.Because the recipient is not admitted as aninpatient, he or she is not an inpatient.

Maternity StaysWisconsin Medicaid does not have a policy onlength of maternity stays. The length of stay isbased on physician’s judgement of what ismedically necessary. A woman may elect tobe discharged on the same day she delivers. Ahospital stay is considered an inpatient staywhen a recipient is admitted to a hospital anddelivers a baby, even when the mother andbaby are discharged on the date of admission(i.e., they are not included in the midnightcensus). This Medicaid policy applies to thebaby’s stay, as well as the mother’s stay.

Service-SpecificRequirements

Abortions

Coverage PolicyIn accordance with s. 20.927, Wis. Stats.,Wisconsin Medicaid covers abortions when oneof the following situations exists:

1. The abortion is directly and medicallynecessary to save the life of the woman,provided that prior to the abortion thephysician attests, based on his or her bestclinical judgement, that the abortion meetsthis condition by signing a certification.

2. In a case of sexual assault or incest,provided that prior to the abortion thephysician attests to his or her belief thatsexual assault or incest has occurred bysigning a certification, and provided thatthe crime has been reported to the lawenforcement authorities.

3. Due to a medical condition existing prior tothe abortion, the physician determines thatthe abortion is directly and medicallynecessary to prevent grave, long-lastingphysical health damage to the woman,provided that prior to the abortion, thephysician attests, based on his or her bestclinical judgement, that the abortion meetsthis condition by signing a certification.

Covered ServicesWhen an abortion meets the state and federalrequirements for Medicaid payment,Wisconsin Medicaid covers office visits and allother medically necessary related services.Wisconsin Medicaid covers treatment forcomplications arising from an abortion,regardless of whether the abortion itself was acovered service. Because the complicationsrepresent new conditions and thus the servicesare not directly related to the performance ofan abortion.

WWisconsinMedicaidconsidersemergency roomservices to beoutpatientservices unlessthe recipient isadmitted to thehospital andcounted in themidnight census.


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Coverage of MifeprexWisconsin Medicaid reimburses for Mifeprex(known as RU-486 in Europe) under the samecoverage policy that it reimburses other surgicalor medical abortion procedures under s. 20.927,Wis. Stats. Under federal law, only physiciansmay obtain and dispense Mifeprex.

When submitting claims for Mifeprex,providers are required to:

• Use the Healthcare Common ProcedureCoding System (HCPCS) code S0190(Mifepristone, oral, 200 mg), type ofservice (TOS) “1,” for the first dose ofMifeprex, along with the evaluation andmanagement (E&M) code that reflects theservice provided.

• Use the HCPCS code S0191 (Misoprostol,oral, 200 mcg), TOS “1,” for the druggiven during the second visit, along withthe E&M code that reflects the serviceprovided.

• For the third visit, use the E&M code thatreflects the service provided.

• Include the appropriate InternationalClassification of Diseases, NinthRevision, Clinical Modification abortiondiagnosis code with each claimssubmission.

• Attach to each claim a completed abortioncertification statement that includesinformation showing the situation is onewhere Wisconsin Medicaid coversabortion.Note: Wisconsin Medicaid denies claimsfor Mifeprex reimbursement when billedwith a National Drug Code.

Physician Counseling Visits Unders. 253.10, Wis. Stats.Section 253.10, Wis. Stats., provides that awoman’s consent to an abortion is notconsidered informed consent unless at least 24hours prior to an abortion a physician haspersonally provided the woman with certain

information. That information includes, amongother things, all the following:

• Whether the woman is pregnant.• Medical risks associated with the woman’s

pregnancy.• Details of the abortion method that would

be used.• Medical risks associated with the

particular abortion procedure.• “Any other information that a reasonable

patient would consider material andrelevant to a decision of whether or not tocarry a child to birth or to undergo anabortion.”

Wisconsin Medicaid will cover an office visitduring which a physician provides theinformation required under s. 253.10, Wis.Stats., even if the woman decides to undergoan abortion and even if the abortion is notMedicaid covered.

Pursuant to s. 253.10, Wis. Stats., theDepartment of Health and Family Services(DHFS) has issued preprinted materialsummarizing the statutory requirements unders. 253.10, Wis. Stats. Providers may contacttheir local health departments for these materials.

Services Incidental to a NoncoveredAbortionServices incidental to a noncovered abortionare not covered by Wisconsin Medicaid. Suchservices include, but are not limited to, any ofthe following services when directly related tothe performance of a noncovered abortion:

• Laboratory testing and interpretation.• Recovery room services.• Transportation.• Routine follow-up visits.• Ultrasound services.

SSection253.10, Wis.Stats.,provides that awoman’sconsent to anabortion is notconsideredinformedconsent unlessat least 24hours prior toan abortion aphysician haspersonallyprovided thewoman withcertaininformation.


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Services Performed by Providers of aNoncovered AbortionA Medicaid provider performs a noncoveredabortion on a Medicaid recipient. The providerclaims reimbursement for other services thatwere provided to the same recipient betweennine months prior to and six weeks after thenoncovered abortion. Wisconsin Medicaidrequires the provider in this situation to complywith the following requirements:

• All claims must be submitted on paper, notelectronically.

• Each claim must have the following signedwritten statement and information:√ No service billed to Wisconsin

Medicaid on the attached claim formwas directly related to the performanceof a non-Medicaid-covered abortionprocedure. I understand that thisstatement is a representation of amaterial fact made in a claim forpayment under Wisconsin Medicaidwithin the meaning of s. 49.49, Wis.Stats., and HFS 106.06(17), Wis. Admin.Code. Accordingly, if this statement isfalse, I understand that I am subject tocriminal prosecution for Medicaidfraud or termination as a Medicaidprovider, or both.

√ Provider’s name.√ Provider’s Medicaid number.√ Provider’s signature and date.

Dental ServicesOutpatient hospitalization for dental services isallowed on an emergency and nonemergency(elective) basis for some dental services.Hospitalization for the express purpose ofcontrolling apprehension is not a Medicaid-covered service. This policy applies to outpatienthospital and ambulatory surgical centers. Forinformation on criteria for Medicaid-coverednonemergency hospitalization for dental services,refer to the Wisconsin Medicaid DentalHandbook.

Emergency hospitalization, hospital calls, andemergency outpatient dental service (emergencyroom and day surgery) do not require prior

authorization (PA). All elective nonemergencydental procedures require PA if they require PAin other places of service. It is the responsibilityof the dentist, not the hospital, to obtain PA.

Wisconsin Medicaid reimburses hospitalsproviding outpatient dental services by the rate-per-visit payment specific to each hospital.

Diagnostic Testing, Laboratory, andTherapeutic ServicesDiagnostic testing, laboratory, and therapeuticservices are considered outpatient hospitalservices when provided by a hospital certifiedunder s. HFS 105.07 or 105.21, Wis. Admin.Code, and ordered by a physician for a recipientwho is not a hospital inpatient.

End-Stage Renal Disease ServicesWisconsin Medicaid covers dialysis for recipientswith end-stage renal disease (ESRD). Hospitalsare required to assist any patient with ESRD toobtain Medicare eligibility. Refer to the ClaimsSubmission chapter of this section for moreinformation on Medicaid/Medicare dual-entitlees, and refer to the Inpatient Servicessection of this handbook for information onother ESRD services.

HealthCheck “Other Services”Medically necessary services that are nototherwise covered by Wisconsin Medicaidmay be covered if they are provided to arecipient under age 21 as a result of aHealthCheck screening. These are calledHealthCheck “Other Services” and mostrequire PA. Refer to the Prior Authorizationchapter of this section for more PA information.

Outpatient Hospital TherapyServicesOutpatient hospital therapy services (physicaltherapy, occupational therapy, and speech andlanguage pathology services) are required tobe provided within an approved hospital facility.Refer to “Approved Hospital Facility” in theProvider Information chapter of this section formore information on approved hospital facilitycriteria.

DDiagnostic testing,laboratory, andtherapeuticservices areconsideredoutpatient hospitalservices whenprovided by ahospital certifiedunder s. HFS105.07 or 105.21,Wis. Admin. Code,and ordered by aphysician for arecipient who is nota hospital inpatient.


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Wisconsin Medicaid requires therapy servicesprovided outside the approved hospital facilityor in an unapproved portion of a hospitalfacility to obtain separate provider certificationfrom Wisconsin Medicaid and use that providernumber for submitting PA requests and claims.Refer to the Physical Therapy/OccupationalTherapy Handbook and the Speech andLanguage Pathology Handbook for furtherinformation.

Unapproved facility services include servicesprovided at sheltered workshops, nursinghomes, and satellite offices. Refer to theClaims Submission chapter of this section forinformation on submitting claims for therapyservices provided at unapproved facilities.

Substance Abuse and Mental HealthOutpatient Clinic ServicesProviders may submit claims for substanceabuse (alcohol and other drug abuse) and mentalhealth outpatient clinic services on the UB-92claim form only if the services are performedwithin the approved hospital facility. Mentalhealth and substance abuse programs mustobtain certification from the Bureau of QualityAssurance (BQA) before they can be certifiedas Medicaid programs.

Outpatient SurgeryWisconsin Medicaid covers surgical proceduresas an outpatient hospital service when therecipients are not admitted as inpatients andare not counted in the midnight census.

SterilizationsA sterilization is any surgical procedureperformed with the primary purpose ofrendering an individual permanently incapableof reproducing. This does not include proceduresthat, while they may result in sterility, have adifferent purpose such as the surgical removalof a cancerous uterus or cancerous testicles.

Medicaid reimbursement for sterilizations isdependent on providers fulfilling all federal andstate requirements cited below and satisfactorycompletion of an informed consent statement.Federal and state regulations require that theinformed consent statement meet the followingcriteria:

• The recipient is not an institutionalizedindividual.

• The recipient is at least 21 years old on thedate the informed written consent isobtained.

• The recipient gives voluntary informedwritten consent for sterilization.

• The recipient is not a mentally incompetentindividual. Wisconsin Medicaid defines a“mentally incompetent” individual as aperson who is declared mentallyincompetent by a federal, state, or localcourt of competent jurisdiction for anypurposes, unless the individual has beendeclared competent for purposes whichinclude the ability to consent to sterilization.

• At least 30 days, excluding the consentand surgery dates, but not more than 180days, have passed between the date ofwritten consent and the sterilization date,except in the case of premature deliveryor emergency abdominal surgery if:√ In the case of premature delivery, the

sterilization is performed at the timeof premature delivery and writteninformed consent was given at least30 days before the expected date ofdelivery and at least 72 hours beforethe premature delivery. The 30 daysexcludes the consent and surgerydates.

√ The sterilization is performed duringemergency abdominal surgery and atleast 72 hours have passed since therecipient gave written informedconsent for sterilization.

AA sterilization isany surgicalprocedureperformed withthe primarypurpose ofrendering anindividualpermanentlyincapable ofreproducing.


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Documentation RequirementsIf the performing physician has not done so,hospitals are required to attach a copy of thesterilization consent form to the UB-92 claimform for Medicaid payment of sterilizations.Refer to the Claims Submission chapter of thissection for more information on submittingsterilization claims.

Hospitals are encouraged to use the MedicaidInformed Consent Form before all sterilizationsto ensure payment in the event that the patientreceives Medicaid retroactive eligibility. Referto the Wisconsin Medicaid Physician Handbookfor a sample form.

Sterilization Informed Consent StatementThe recipient is required to give voluntarywritten consent on a federally required informedconsent statement. Sterilization coveragerequires accurate and thorough completion of aconsent form. The performing physician isresponsible for obtaining consent. Anycorrections to the statement are required to besigned by the physician and/or recipient, asappropriate. Refer to the Physician Handbookfor more information on informed consentstatements.

Signatures and signature dates of the recipient,physician, and the person obtaining the consentare mandatory. Surgeons’ failure to complywith all the sterilization requirements results indenial of the sterilization claims.

Related Services That AreNot Hospital OutpatientServices

Hospital-Based AmbulanceAll air, water, or land hospital-based ambulanceservices are required to meet the ambulancecertification standards in HFS 105.38, Wis.Admin. Code. Hospitals providing these servicesare required to be individually certified asambulance providers in order to receivereimbursement.

Services Provided in UnapprovedFacilitiesOutpatient rate-per-visit reimbursement is paidonly for services provided in a facility that isapproved by the BQA as a hospital. Claims forservices provided outside a Medicaid-certifiedand BQA-approved hospital must be submittedunder a separate Medicaid provider numberusing the claim form appropriate to the type ofMedicaid service and provider category. Forexample, a freestanding facility that providesservices on the same property as a Medicaid-certified hospital or is affiliated with a Medicaid-certified hospital must submit claims under itsown Medicaid provider number, not under aMedicaid hospital provider number as outpatienthospital services.

Substance Abuse and Mental HealthOutpatient Clinic ServicesIf substance abuse and mental healthoutpatient clinic services are performed in anunapproved portion of a hospital, they are notoutpatient hospital services. If this is the case,the facility must be separately certified byWisconsin Medicaid for Medicaid outpatientpsychotherapy/substance abuse services.Mental health and substance abuse programsmust obtain certification from the BQA beforethey can be certified as Medicaid programs.

Substance Abuse Day Treatmentand Mental Health Day TreatmentSubstance abuse day treatment and mentalhealth day treatment are not consideredoutpatient services; they are consideredseparate Medicaid services. For moreinformation on these services, refer to theSubstance Abuse Day Treatment and MentalHealth Day Treatment Services Handbook.

OOutpatient rate-per-visitreimbursement ispaid only forservices providedin a facility that isapproved by theBQA as a hospital.


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Noncovered ServicesUnder HFS 107.08(4)(a)4 and 6, Wis. Admin.Code, Wisconsin Medicaid does not cover thefollowing:

• Inpatient and outpatient services for thesame recipient, on the same DOS, unlessthe recipient is admitted to a hospital otherthan the facility providing the outpatientcare.

• Hospital laboratory, diagnostic, radiology,and imaging tests not ordered by aphysician, except in emergencies.

Experimental ServicesAs specified in HFS 107.035, Wis. Admin.Code, Wisconsin Medicaid does not coveroutpatient hospital experimental services. TheDHFS considers a service experimental whenthe procedure is not generally recognized bythe professional medical community aseffective or proven for the condition for whichit is being used.

The DHFS may consider a serviceexperimental in one setting or institution, buteffective, proven, and nonexperimental inanother setting, depending on the facility’sexperience and capabilities.

AAs specified inHFS 107.035, Wis.Admin. Code,WisconsinMedicaid does notcover outpatienthospitalexperimentalservices.


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Prior Authorization

PPrior AuthorizationIn accordance with HFS 107.02(3), Wis.Admin. Code, Wisconsin Medicaid requiresprior authorization (PA) for certain services inorder to:

• Prevent unnecessary or inappropriate careand services.

• Safeguard against excess payments.• Assess the quality and timeliness of

services.• Determine if less expensive alternative

care, services, or supplies are usable.• Promote the most effective and

appropriate use of available services andfacilities.

• Curtail misutilization practices of providersand recipients.

Providers are required to obtain PA for certainspecified services before providing the services,unless the service is an emergency. For moreinformation on PA, refer to the All-ProviderHandbook.

Services Requiring PriorAuthorizationCovered hospital services require PA ifprovided out-of-state under nonemergencycircumstance by nonborder status providers.

Substance Abuse and Mental HealthOutpatient Clinic ServicesHospitals certified in providing substance abuse(alcohol and other drug abuse) and mentalhealth outpatient services require PA forservices exceeding $500 of Medicaid-allowedcharges per recipient per calendar year.Hospitals seeking PA for substance abuse andmental health outpatient services provided to

outpatient recipients must indicate on the PriorAuthorization Request Form (PA/RF) theexpected cost, multiply the number ofrequested visits by the Medicaid billed amountof the requested services. Refer to the MentalHealth Provider Handbook for moreinformation.

HealthCheck “Other Services”When requesting PA, providers must indicatethe descriptions of the service and the numberof hours of service requested for HealthCheck“Other Services” on the PA/RF. Leave thesection requesting the procedure code blank; ifa provider is unable to find an appropriate code,Wisconsin Medicaid will assign one. Toexpedite processing of the request, write“HealthCheck Other Services” or “HOS” inred ink at the top of the PA/RF.

Procedures for ObtainingPrior Authorization

Providers may request PA using the PA/RFand other PA forms. Refer to Appendices 1-8of this section for sample PA forms andcompletion instructions.

Providers requesting PA for substance abuseservices are required to include the PriorAuthorization/Alcohol and Other Drug AbuseAttachment (PA/AA) with the PA/RF. Referto Appendices 3-5 of this section for samplePA/AAs and completion instructions.

Providers requesting PA for psychotherapyservices are required to include the PriorAuthorization Psychotherapy Attachment (PA/PSYA) with the PA/RF. Refer to Appendices6-8 of this section for sample PA/PSYAs andcompletion instructions.

HHospitals certifiedin providingsubstance abuse(alcohol andother drugabuse) andmental healthoutpatientservices requirePA for servicesexceeding $500of Medicaid-allowed chargesper recipient percalendar year.


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Prior Authorization Requests by FaxProviders may submit their PA requests toWisconsin Medicaid by fax at (608) 221-8616.To avoid delayed adjudication, do not fax andmail duplicate copies of the same PA/RFs.Refer to Appendix 9 of this handbook forfurther guidelines on submitting PAs by fax.

Written Prior Authorization RequestsSend completed PA forms to:

Wisconsin MedicaidPrior AuthorizationSte 886406 Bridge RdMadison WI 53784-0088

Providers may order PA forms by writing to:

Wisconsin MedicaidClaim Reorder6406 Bridge RdMadison WI 53784-0003

Please specify the type and quantity of formsneeded. Reorder forms are included with eachshipment; do not reorder by telephone.

For more information on PA, including responsesto PA requests, emergency situations, appealprocedures, supporting materials, retroactiveauthorization, and recipient loss of eligibilityduring treatment, refer to the PriorAuthorization section of the All-ProviderHandbook.

TTo avoid delayedadjudication, do notfax and mailduplicate copies ofthe same PA/RFs.


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CClaims Submission

Submitting Claims forOutpatient ServicesProviders have the option of submitting eitherone claim per date of service (DOS) orsubmitting one claim for a series of outpatientservices. Submit all outpatient claims with abill type of “131,” with the exception ofMedicare crossovers where the appropriateMedicare bill type is accepted.

A single outpatient claim must not contain DOSspanning more than one calendar month. Therevenue description and code are required to beon the same line, with the respective individualDOS on subsequent lines.

All claims that providers submit, whether paperor electronic, are subject to the same Medicaidprocessing and legal requirements.

Electronic Claims SubmissionAs an alternative to submission of paperclaims, Wisconsin Medicaid can process claimssubmitted on magnetic tape (tape-to-tape) orthrough telephone transmission via modem.Providers submitting electronically usuallyreduce their claims submission errors.Wisconsin Medicaid provides software forbilling claims electronically. For moreinformation on obtaining electronic billingcapabilities, providers may:

• Refer to the Claims Submission section ofthe All-Provider Handbook.

• Contact the Wisconsin Medicaid ElectronicMedia Claims (EMC) unit at(608) 221-4746 and ask to speak with anEMC coordinator.

Providers who currently use the software andhave technical questions may contactWisconsin Medicaid software customerservice at (800) 822-8050.

Paper Claims SubmissionSubmit claims for hospital services on the UB-92 claim form. Refer to Appendices 10 and 11of this section for a sample UB-92 claim formand completion instructions. Nonhospitalproviders use claim forms appropriate to theirtype of service.

For a complete set of UB-92 claim forminstructions, refer to the UB-92 Billing Manual.To purchase the UB-92 Billing Manual, contactthe Wisconsin Hospital Association at:

Wisconsin Hospital Association5721 Odana RdMadison WI 53719-1289(608) 274-1820 or(800) 362-7121

Wisconsin Medicaid does not provide UB-92claim forms; they cannot be purchased fromthe Wisconsin Hospital Association. UB-92claim forms are available from many suppliers.

Mail completed UB-92 claim forms to:

Wisconsin MedicaidClaims and Adjustments6406 Bridge RdMadison WI 53784-0002

Claims Submission DeadlineWisconsin Medicaid must receive all claims forservices provided to eligible recipients within365 days from the DOS. This policy applies toall initial claims submissions, resubmissions, andadjustment requests.

Refer to the All-Provider Handbook forexceptions to the claims submission deadlineand requirements for submission to Late BillingAppeals.

Crossover Claims Submission DeadlineClaims for services provided to recipientscovered by both Medicare and Medicaid (dualentitlees) are considered crossover claims. For

PProviders havethe option ofsubmitting eitherone claim perdate of service(DOS) orsubmitting oneclaim for a seriesof outpatientservices.


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services provided to dual entitlees, claims forcoinsurance and deductible must be received byWisconsin Medicaid within 365 days of theDOS, or within 90 days of the Explanation ofMedicare Benefits date or the RemittanceAdvice date, whichever is later. This timelineapplies to all initial claims submissions andresubmissions.

Claim Components

Revenue CodesProviders are required to enter revenue codesfor accommodation and ancillary services inItem 42 of the UB-92 claim form. Refer to theUB-92 Billing Manual or Appendix 12 of thishandbook section for a list of allowable revenuecodes.

Outpatient laboratory services identified byrevenue codes 30X, 31X, 923, and 925 alsorequire a Current Procedural Terminologyprocedure code in Item 44 of the UB-92 claimform.

Diagnosis CodesAll diagnoses entered in Item 67 of the UB-92claim form are required to be from theInternational Classification of Diseases,Ninth Revision, Clinical Modification (ICD-9-CM) coding structure.

Providers may order the complete ICD-9-CMcode book by writing to the address indicatedin the Provider Resources section of the All-Provider Handbook.

Coordination of Benefits

Health Insurance CoverageWisconsin Medicaid is generally the payer oflast resort for any Medicaid-covered service.Refer to the Coordination of Benefits sectionof the All-Provider Handbook for moreinformation on programs that pay afterWisconsin Medicaid. If the recipient is coveredunder other health insurance, such as Medicareor commercial health insurance, Wisconsin

Medicaid reimburses that portion of theallowable cost remaining after exhausting allother health insurance sources. Refer to theCoordination of Benefits section of the All-Provider Handbook for more information onservices requiring other health insurance billingand other payers.

Medicaid Managed Care CoverageFor recipients enrolled in a Medicaid managedcare program, the contract between the managedcare program and certified provider establishesall conditions of payment and prior authorization(PA) for hospital services. Wisconsin Medicaiddenies claims for services covered by aMedicaid managed care program.

Medicare/Medicaid Dual EntitlementHospitals are required to send claims forMedicare-covered services provided to dual-entitlees to Medicare before submitting theclaims to Wisconsin Medicaid.

Medicare-allowed claims may be submitted toWisconsin Medicaid for payment of thecoinsurance and deductible. Provider-submitted crossover claims must indicate thenumber of covered days being billed on theclaim in Item 7 of the UB-92 claim form.When providers submit crossover claims toWisconsin Medicaid, they are required tocomplete Item 7 (covered days) on the claimform.

If the service for a dual-entitlee is covered byMedicare, but Medicare denies the claim forany reason besides code “M7,” indicate aMedicare disclaimer code in Item 84 of theUB-92 claim form. Refer to the All-ProviderHandbook for more information about crossoverclaims.

Medicare does not require PA for its coveredservices, but providers are strongly encouragedto obtain Wisconsin Medicaid PA for hospitalservices that require PA before the services areprovided to dual-entitlees. Wisconsin Medicaidrequires a PA number on noncrossoverinstitutional claims submitted for dual-entitlees ifthe services provided require Medicaid PA.

HHospitals arerequired to sendclaims forMedicare-coveredservices providedto dual-entitleesto Medicarebefore submittingthe claims toWisconsinMedicaid.


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Crossover ClaimsPaper claims for certain services to dual-entitlees, such as end-stage renal diseaseservices, automatically crossover to WisconsinMedicaid from Medicare. Claims submitted toMedicare must indicate the following items onthe UB-92 claim form to ensure proper claimsprocessing with Wisconsin Medicaid:

• Indicate covered days in Item 7.• Indicate “T-19” in Item 50.• Indicate the recipient’s Medicaid

identification number in Item 60.

Spenddown and Medicare Part B ChargesIndicate the value code “22” and the actualamount in Item 39, 40, or 41 for recipientspenddown. Refer to the UB-92 BillingManual for more information.

Usual and CustomaryChargesProviders are required to bill their usual andcustomary charge for services provided. Theusual and customary charge is the amount theprovider charges for the same service whenprovided to a private-pay patient.

For providers using a sliding fee scale forspecific services, the usual and customarycharge is the provider’s charge for the servicewhen provided to a non-Medicaid patient.Providers shall not discriminate against aMedicaid recipient by charging a higher fee forthe service than is charged to a private-paypatient.

Special Circumstances

Dilation and CurettageWhen submitting claims for dilation andcurettage surgical procedures, hospitals arerequired to attach a copy of the preoperativehistory and physical exam document and anoperative and pathology report with the UB-92claim form.

Inpatient and Outpatient Services forthe Same Date of ServiceIf inpatient and outpatient services are providedfor the same recipient, at the same hospital, onthe same DOS as the date of the inpatienthospital admission or discharge, the outpatientservices are not separately reimbursed and arerequired to be included on the inpatient claim.This does not include reference laboratoryservices.

Wisconsin Medicaid does not reimburse foroutpatient claims for services provided at onehospital to an inpatient in another hospital,except on the date of admission or the date ofdischarge. For any other day during the inpatientstay, the hospital providing the outpatientservices must arrange payment with theinpatient hospital.

Obstetrical and Newborn Stays

Claims for One-Day Mother/Baby StaysProviders are required to submit a UB-92inpatient claim form for the mother or the babyby following these procedures:

• Indicate bill type “111” for inpatientservices in Item 4.

• Indicate the “From” and “To” dates inItem 6 (they must be the same).

• Indicate the covered days as “1” in Item 7.

The diagnosis codes and procedure codes mustresult in the claim being assigned to one of thediagnosis-related groups (DRGs) in range 601-680 (newborn) or any delivery includingCesarean section transfers. For moreinformation on DRGs, refer to the “ClaimsSubmission” chapter of the Inpatient Servicessection of this handbook.

Claims for Newborns Using Mothers’Medicaid Identification NumbersSubmit a newborn’s claim using the mother’sMedicaid identification number if the baby’soutpatient visit is 10 days or less from thebaby’s date of birth and a Medicaid

WWisconsinMedicaid doesnot reimburse foroutpatient claimsfor servicesprovided at onehospital to aninpatient inanother hospital,except on thedate of admissionor the date ofdischarge.


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identification number has not yet been assignedto the baby. If the baby’s outpatient visit is 11or more days, submit the claim with the baby’sMedicaid identification number when assigned.

Wisconsin Medicaid requires hospitals toindicate the following information whensubmitting a newborn claim:

• The baby’s name in Item 12 of the UB-92claim form (i.e., Smith, Newborn).

• The occurrence code (50 — male, 51—female) in Items 32-35.

• The baby’s date of birth with theoccurrence code.

• The mother’s name and her date of birthin Item 58.

• The mother’s Wisconsin Medicaididentification number in Item 60.

Claims submitted under the baby’s identificationnumber do not need an occurrence code witha date of birth and do not need to indicate themother’s identification number.

Establishing Continuous Eligibility ofNewbornsAccording to federal law, an infant who remainsin his or her mother’s household may continueto receive Wisconsin Medicaid benefits untilthe end of the month in which the child turnsone year old, regardless of changes in familysize or income. Once the infant is one year old,eligibility will be based on family income andsize. The family is responsible for reportingthese changes.

Wisconsin Medicaid applies Medicaid eligibilityfor newborns from the date of birth through themonth in which the child turns one year of age.These policies are for newborns born to motherswho are eligible for Wisconsin Medicaid,including Healthy Start, and whose birth isreported by hospitals.

If a mother was not a Medicaid recipient whenthe baby was born, she can retroactively applyfor Wisconsin Medicaid. If her dates of eligibilityinclude the date of the baby’s birth, her babymay also receive retroactive and continuouseligibility for the first year of his or her life.

Outpatient Hospital Therapy ServicesUse the UB-92 claim form to submit claims foroutpatient hospital therapy services provided atan approved hospital facility. WisconsinMedicaid reimburses these services using theoutpatient hospital rate-per-visit.

Separately certified therapy providers whoprovide services at unapproved locations usethe CMS 1500 claim form when submittingclaims to Wisconsin Medicaid according topolicies and procedures given in the PhysicalTherapy and Occupational Therapy Handbookor the Speech and Language PathologyHandbook.

Substance Abuse and Mental HealthOutpatient Clinic ServicesSubstance abuse (alcohol and other drugabuse) day treatment and mental health daytreatment are not reimbursed as outpatienthospital services. They are considered separateMedicaid services and require separateprovider certification.

If services are performed in an unapprovedportion of a hospital or an off-site location, thefacility is required to be separately certified forMedicaid outpatient psychotherapy/substanceabuse services. The facility is also required toobtain a unique performing provider number.Services performed in an unapproved portionof a hospital are required to be submitted onthe CMS 1500 claim form.

Payment Methods

Wisconsin Medicaid Inpatient andOutpatient State PlansThe Hospital Inpatient and Outpatient StatePlans are Wisconsin Medicaid’s federallyapproved description of methods and standardsfor establishing payment rates to hospitals. TheState Plans include all hospital inpatient andoutpatient rate-setting methodologies. The StatePlans are effective from July 1 to June 30.Each year, Wisconsin Medicaid amends theState Plans. Hospitals are allowed an opportunityto comment on proposed amendments before

IIf a mother was not aMedicaid recipientwhen the baby wasborn, she canretroactively apply forWisconsin Medicaid.


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Wisconsin Medicaid requests approval from thefederal Centers for Medicare and MedicaidServices (CMS) for state plan changes.Providers may obtain copies of the state planon the Wisconsin Medicaid Web site atwww.dhfs.state.wi.us/medicaid/.

Wisconsin Medicaid reimburses outpatienthospital services at a hospital-specific all-inclusive rate-per-visit. Only one rate-per-visitper DOS is reimbursable. Refer to theOutpatient Hospital State Plan for the methodsused in the outpatient rate-per-visit calculation.

Only medically necessary covered servicesprovided within the physical premises of anapproved hospital facility are eligible for theoutpatient hospital payment rate. Medicallynecessary covered services provided in afacility that is not an approved hospital facilityor that is in an unapproved portion of a hospitalfacility are not covered by the Medicaidoutpatient hospital payment.

Medicare Crossover ClaimsWisconsin Medicaid reimburses Medicarecoinsurance on crossover claims for dualentitlees according to s. 49.46, Wis. Stats.Medicare determines a total coinsuranceamount for each claim. Wisconsin Medicaidprorates the total coinsurance across all allowed

claim details or services. Then, for eachallowed claim detail, Wisconsin Medicaid paysthe lesser of the Medicare coinsurance amountallocated to the detail or the Medicaid hospital-specific outpatient rate-per-visit. WisconsinMedicaid pays the Medicare deductible in full.

Follow-Up to ClaimsSubmissionThe provider is responsible for initiating follow-up procedures on claims submitted to WisconsinMedicaid. Processed claims appear on theRemittance and Status Report either as paid,pending, or denied. Wisconsin Medicaid willtake no further action on a denied claim untilthe provider corrects the information andresubmits the claim for processing.

If a claim was paid incorrectly, the provider isresponsible for submitting an AdjustmentRequest Form to Wisconsin Medicaid. Refer tothe Claims Submission section of the All-Provider Handbook for more information on:

• Adjustments to paid claims.• Denied claims.• Duplicate payments.• Good Faith claims filing procedures.• Remittance and Status Reports.• Return of overpayments.

OOnly medicallynecessarycovered servicesprovided withinthe physicalpremises of anapproved hospitalfacility are eligiblefor the outpatienthospital paymentrate.


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Appendix 1Prior Authorization Request Form (PA/RF) Completion Instructions for

Outpatient Hospital Services

Element 1 — Processing TypeEnter the appropriate three-digit processing type from the list below. The “processing type” is a three-digit code used toidentify the category of service being submitted for reimbursement.

127 — Psychotherapy (UB-92 billing providers only)128 — Substance Abuse Services999 — Other (use only if the requested category of services is not listed above)

Element 2 — Recipient’s Medical Assistance ID NumberEnter the recipient’s 10-digit Medicaid identification number. Do not enter any other numbers or letters.

Element 3 — Recipient’s NameEnter the recipient’s last name, first name, and middle initial. Use the Eligibility Verification System (EVS) to obtain thecorrect spelling of the recipient’s name. If the name or spelling of the name on the Medicaid identification card and the EVSdo not match, use the spelling from the EVS.

Element 4 — Recipient AddressEnter the complete address (street, city, state, and ZIP code) of the recipient’s place of residence. If the recipient is aresident of a nursing home or other facility, also include the name of the nursing home or facility.

Element 5 — Date of BirthEnter the recipient’s date of birth in MM/DD/YYYY format (e.g., September 25, 1975, would be 09/25/1975).

Element 6 — SexEnter an “X” to specify the recipient’s gender as male or female.

Element 7 — Billing Provider Name, Address, and ZIP CodeEnter the billing provider’s name and complete address (street, city, state, and ZIP code). No other information should beentered into this element since it also serves as a return mailing label.

Element 8 — Billing Provider Telephone NumberEnter the billing provider’s telephone number, including the area code, of the office, clinic, facility, or place of business.

Element 9 — Billing Provider No.Enter the billing provider’s eight-digit Medicaid provider number.

Element 10 — Dx: PrimaryEnter the appropriate International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM)diagnosis code most relevant to the service/procedure requested for the recipient.

Element 11 — Dx: SecondaryEnter the appropriate ICD-9-CM diagnosis code additionally descriptive of the recipient’s clinical condition.

Element 12 — Start Date of SOI (not required)

Element 13 — First Date Rx (not required)

Element 14 — Procedure CodeEnter the appropriate revenue code, Healthcare Common Procedure Coding System, Current Procedural Terminology code,National Drug Code (NDC), or Wisconsin Medicaid-assigned five-digit procedure code for each service/procedure/itemrequested.


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Appendix 1(Continued)

Element 15 — MODEnter the modifier corresponding to the procedure code (if a modifier is required by Wisconsin Medicaid policy and the codingstructure used) for each service/procedure/item requested.

Element 16 — POSEnter the appropriate Medicaid single-digit place of service code designating where the requested service/procedure/item wouldbe provided/performed/dispensed.

Code Description2 Outpatient Hospital

Element 17 — TOSEnter the appropriate Medicaid single-digit type of service code for each service/procedure/item requested. Numeric Code Description

0 Blood1 Medical (Physician’s Medical Services, Home Health, Independent Nurses, Audiology, Physical

Therapy, Occupational Therapy, Speech and Language Pathology, Personal Care, Mental HealthDay Treatment, and Substance Abuse [alcohol and other drug abuse] Day Treatment)

2 Surgery3 Consultation4 Diagnostic X-Ray — Total Charge5 Diagnostic Lab — Total Charge6 Radiation Therapy — Total Charge7 Anesthesia8 Assistant Surgery9 Other, including:

TransportationFamily Planning ClinicRehabilitation AgencyNurse MidwifeChiropractic

Alpha Code DescriptionC Hospital Outpatient Services, Ancillaries, Mental Health Psychotherapy and Evaluations,

Diagnostic Testing, Substance Abuse Services, and Nursing Home

Element 18 — Description of ServiceEnter a written description corresponding to the appropriate 11-digit NDC, five-digit procedure code, or three-digit revenuecode for each service/procedure/item requested.

Element 19 — QREnter the quantity (e.g., number of services, dollar amount) requested for each service/procedure/item requested.

• Psychotherapy (UB-92 billing providers only) (number of sessions).• Substance Abuse (UB-92 billing providers only) (number of sessions).

Element 20 — ChargesEnter your usual and customary charge for each service/procedure/item requested. If the quantity is greater than “1,”multiply the quantity by the charge for each service/procedure/item requested. Enter that total amount in this element.Note: The charges indicated on the Prior Authorization Request Form (PA/RF) should reflect the provider’s usual and

customary charge for the procedure requested. Providers are reimbursed for authorized services according to theDepartment of Health and Family Service’s Terms of Provider Reimbursement.


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Element 21 — Total ChargeEnter the anticipated total charge for this request.

Element 22 — Billing Claim Payment Clarification StatementAn approved authorization does not guarantee payment. Reimbursement is contingent upon the recipient’s and provider’seligibility at the time the service is provided and the completeness of the claim information. Payment is not made for servicesinitiated prior to approval or after authorization expiration. Reimbursement is in accordance with Wisconsin Medicaidmethodology and policy. If the recipient is enrolled in a managed care program at the time a prior authorized service isprovided, Wisconsin Medicaid reimbursement is only allowed if the service is not covered by the managed care program.

Element 23 — DateEnter the month, day, and year (in MM/DD/YYYY format) the PA/RF was completed and signed.

Element 24 — Requesting Provider SignatureThe signature of the provider requesting/performing/dispensing the service/procedure/item must appear in this element.

DO NOT ENTER ANY INFORMATION BELOW THE SIGNATURE OF THE REQUESTING PROVIDER —THIS SPACE IS USED BY WISCONSIN MEDICAID CONSULTANTS AND ANALYSTS.


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0123456

Appendix 2Sample Prior Authorization Request Form (PA/RF)

1234567890 609 WillowAnytown, WI 55555Recipient, Ima D.

09/25/1975

I.M. Hospital1 W. WilliamsAnytown, WI 55555

555 555-555512345678

$360.00

MM/DD/YYYY

303.92

304.9

945 2 C 3 individual sessions at 60 minutes each 120.00 $360.00

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To avoid delays in prior authorization (PA) request approval, providers should ensure that all clerical information is correctlyentered on the Prior Authorization Request Form (PA/RF) and that all clinical information necessary to document that theservice is medically necessary is included. Carefully complete the Prior Authorization Alcohol and Other Drug AbuseAttachment (PA/AA), attach it to the PA/RF, and submit it to:


Questions regarding the completion of the PA/RF and/or the PA/AA may be directed to Provider Services at(800) 947-9627 or (608) 221-9883.

Recipient Information

Element 1 — Last NameEnter the recipient’s last name. Use the Eligibility Verification System (EVS) to obtain the correct spelling of the recipient’sname. If the name or spelling of the name on the Medicaid identification card and the EVS do not match, use the spellingfrom the EVS.

Element 2 — First NameEnter the recipient’s first name. Use the EVS to obtain the correct spelling of the recipient’s name. If the name or spelling ofthe name on the identification card and the EVS do not match, use the spelling from the EVS.

Element 3 — Middle InitialEnter the recipient’s middle initial from the recipient’s identification card.

Element 4 — Medical Assistance ID NumberEnter the recipient’s 10-digit Medicaid identification number. Do not enter any other numbers or letters.

Element 5 — AgeEnter the age of the recipient in numerical form (e.g., 21, 45, 60)


Element 6 — Performing Provider’s Name and CredentialsEnter the name and credentials of the therapist who will be providing treatment.

Element 7 — Performing Provider’s Medical Assistance Provider Number (not required)

Element 8 — Performing Provider’s Telephone NumberEnter the performing provider’s telephone number, including area code.

Element 9 — Referring/Prescribing Provider’s NameEnter the name of the provider referring/prescribing treatment.

Appendix 3Prior Authorization Alcohol and Other Drug Abuse Attachment (PA/AA)

Completion Instructions


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Element 10 — Referring/Prescribing Provider’s Medical Assistance NumberEnter the referring/prescribing provider’s eight-digit provider number, if available. The remaining portion of this attachment isto be used to document the medical necessity for the service requested.

• Part A — Type of Treatment RequestedDesignate the type of treatment requested (e.g., primary intensive outpatient treatment, aftercare/follow-up service, oraffected family member/codependency treatment). Identify the types of sessions, duration, and schedule. The totalhours must match the quantities indicated on the PA/RF.

If a certified psychotherapist is requesting specific psychotherapy services for the substance abuse (alcohol and other drugabuse)-affected recipient that are not represented by the categories of treatment listed, complete the Prior AuthorizationPsychotherapy Attachment (PA/PSYA).

• Part BProviders may attach copies of assessments, treatment summaries, treatment plans or other documentation in responseto the information requested on the form. Providers are responsible for ensuring that the information attached adequatelyresponds to what is requested.

1. Attach a copy of the signed and dated prescription for substance abuse services (unless the physician is the per-forming provider). The initial prescription must be signed and dated within three months of receipt by Medicaid.Subsequent prescriptions must be dated within twelve months of receipt by Wisconsin Medicaid.

2. Read the ‘Prior Authorization Statement’ before signing and dating the attachment.3. The recipient’s signature is optional.4. The attachment must be signed and dated by the provider requesting/providing the service.

Note: The name and signature of the supervising provider is not required if the performing provider is a physician or psychologist.


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Appendix 4Sample Prior Authorization Alcohol and Other Drug

Abuse Attachment (PA/AA)

x

Recipient Im A 1234567890 29

I.M. Performing, AC XXX XXX - XXXX

I.M. Referring/Prescribing 87654321

X

60 180 60

5X/WK

19 4 Group 3 HR/day, 5 days/WKInd. two one-hour sessions/WKFamily two one-hour sessions/WK

MM/DD/YYYYMM/DD/YYYY

x x

x


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x

MM/DD/YYYY

MM/DD/YYYY — Intake alcoholism checklist and clinical interview

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303.91 alcohol dependence — continuous as manifested by maladaptive patternof use for three years: blackouts, loss of control, legal and family problemsassociated with drinking.

296.2 major depressive disorder

Client has decided to receive treatment and committed himself to abstinence from all mind/mood-altering chemicals. Client has had a patterned use which included drinking four tofive times/week consuming six to 18 beers per drinking bout. Client reports being intoxi-cated at least one time/week. Client began trying to control his drinking about two yearsago after being arrested for drunk driving. Since that time he has received one other DWIconviction. Client reports guilt and shame about his behavior. He reports periods ofviolence while intoxicated which occurred in his family. In addition, client reports apositive genetic history for alcoholism, claiming that his father is alcoholic.

Client lives with his family. His wife reports she has been concerned about his drinking for six yearsand has only recently reported her concern to her spouse. The children in the family consist of a 13-year-old son and a 10-year-old daughter. The son was very quiet during the family assessment anddenied any concern about his dad’s drinking. The daughter was able to express her worry andattempts to discontinue her dad’s drinking. (e.g., hiding his beer). The family agreed to attend oureducational night and also agreed to periodic family sessions. They decided at this time not to beinvolved with more intensive treatment.


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1. Client will learn basic information on alcoholism.2. Client will be able to share his drinking history with group by the second week.3. Client will verbalize and identify self as alcoholic.4. Client will continue abstinence from alcohol.5. Client will develop a self-help program.6. Client will verbalize in his family his own history with alcohol.7. Client will begin to identify and express feelings.8. Client will obtain a sponsor by termination date.

Client will continue to develop and maintain a sober lifestyle. Client will also participate inour 12-week Aftercare program. Client will return to gainful employment.

Alcohol and Drug Counselor

I.M. Authorized 87654321

MM/DD/YYYY


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Appendix 5Prior Authorization Alcohol and Other Drug Abuse Attachment (PA/AA)

(for photocopying)

(A copy of the Prior Authorization Alcohol and Other Drug AbuseAttachment [PA/AA] is located on the following pages.)


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Since having to return a prior authorization (PA) request for corrections or additional information can delay the promptapproval and delivery of services to a recipient, providers should ensure that all clerical information is correctly entered onthe Prior Authorization Request Form (PA/RF) and that all clinical information necessary to document that the service ismedically necessary is included. Carefully complete the Prior Authorization Psychotherapy Attachment (PA/PSYA), attachit to the PA/RF, and submit to:


Questions regarding the completion of the PA/RF and/or the PA/PSYA may be directed to Provider Services at(800) 947-9627 or (608) 221-9883.

General Instructions

The information contained in the PA/PSYA is used to make a decision about the amount and type of psychotherapy that isapproved for Wisconsin Medicaid reimbursement. Thoroughly complete each section and include any material that would behelpful to understand the necessity of the services being requested. Where noted in these instructions, material frompersonal records may be substituted for the information requested on the form.

When submitting the first PA request for a particular individual, please fill out both pages. For continuing PA on the sameindividual, it is not necessary to rewrite the first page, unless new information has caused a change in any of the informationon this page (e.g., a different diagnosis, belief that intellectual functioning is, in fact, significantly below average). When therehas been no change in page one information, please submit a photocopy of page one along with the updated page two.Medical consultants reviewing the PA requests have a file containing the previous requests, but they must base their decisionson the clinical information submitted, so it is important to present all current relevant clinical information. For example, adepressed person may overeat or eat too little, or may sleep a lot or very little; therefore, recording simply that the recipient isdepressed does not present the relevant clinical picture. The documentation should include details on the signs and symptomsthe recipient presents due to the diagnosis.

Prior authorization for psychotherapy is not granted when another provider already has an approved PA for psychotherapyservices for the same recipient. In these cases, Wisconsin Medicaid recommends that the recipient request that previousproviders notify Wisconsin Medicaid that they have discontinued treatment with this recipient. The recipient may also submita signed statement of his or her desire to change providers and include the date of the change. The new provider’s PA maynot overlap with the previous provider’s PA.

Recipient Information

Element 1 — Last NameEnter the recipient’s last name. Use the Eligibility Verification System (EVS) to obtain the correct spelling of the recipient’sname. If the name or spelling of the name on the Medicaid identification card and the EVS do not match, use the spellingfrom the EVS.

Element 2 — First NameEnter the recipient’s first name. Use the EVS to obtain the correct spelling of the recipient’s name. If the name or spelling ofthe name on the Medicaid identification card and the EVS do not match, use the spelling from the EVS.

Element 3 — MIEnter the recipient’s middle initial.

Element 4 — Medical Assistance Identification NumberEnter the recipient’s 10-digit Medicaid identification number. Do not enter any other numbers or letters.

Appendix 6Prior Authorization Psychotherapy Attachment (PA/PSYA) Completion

Instructions


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Element 5 — AgeEnter the age of the recipient in numerical form (e.g., 45, 60, 21).


Element 6 — Performing Provider NameEnter the name of the therapist who will be providing treatment. Circle or enter discipline (credentials) of the therapist who willbe providing treatment at the right of Element 8 (e.g., I.M. Provider, MD., or I.M. Provider Ph.D.).

Element 7 — Performing Provider # (not required)

Element 8 — Performing Provider’s Telephone NumberEnter the telephone number, including area code, of the performing provider.

Element 9 — Supervising Provider’s NameEnter the name of the physician or psychologist who is supervising the treatment if the performing provider is a Master’s-leveltherapist.

Element 10 — Supervising Provider’s Number (not required)

Element 11 — Prescribing Provider’s NameEnter the name of the physician who wrote the prescription for psychotherapy.

Element 12 — Prescribing Provider’s NumberEnter the eight-digit Medicaid provider identification number of the physician who wrote the prescription for psychotherapy.

Documentation

A — DiagnosisEnter the diagnosis codes and descriptions from the most recent version of the Diagnostic and Statistical Manual of MentalDisorders (DSM), using all five axes.

B — Date Treatment Began Date of first treatment by this provider.

C — Diagnosed ByIndicate the procedure(s) used to make the diagnosis.

D — ConsultationIndicate whether there was a consultation done with respect to the recipient’s diagnosis and/or treatment needs. Indicatewhy the consultation was needed.

E — Result(s) of ConsultationSummarize the results of this consultation or attach a copy of the consultant’s report.

F — Presenting SymptomsEnter the presenting symptoms and indicate the degree of severity. This information may be provided as a part of an intakesummary that may be attached to this request form.

G-H — Intellectual FunctioningIndicate whether intellectual functioning is significantly below average (e.g., an I.Q. below 80). If “yes,” indicate the I.Q. orintellectual functioning level.


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I — Historical DataThis information may be submitted in the form of an intake summary, case history, or mental status exam as long as allinformation relevant to the request for treatment authorization is included.

J — Present GAF (DSM)Enter the global assessment of functioning scale score from the most recent version of the DSM. For continuing PA requests,indicate whether the recipient is progressing in treatment, using measurable indicators when appropriate.

K — Present Mental Status/SymptomatologyIndicate the recipient’s current mental status and symptoms. For continuing authorization requests, indicate the progress thathas been made since the beginning of treatment or since the previous authorization. This information may be supplied in theform of an intake summary or a treatment summary as long as the summary presents a crystallization of the progress todate. It is not acceptable to send progress notes which do not summarize the progress to date.

L — Updated/Historical DataFor continuing requests, indicate any new information about the recipient’s history which may be relevant to determine theneed for continued treatment.

M — Treatment ModalitiesIndicate the treatment modalities to be used.

N — Number of Minutes Per SessionIndicate the length of session for each modality.

O-P — Frequency of Requested Sessions and Total Number of Sessions RequestedIf requesting sessions at a higher frequency, please indicate why they are needed. If a series of treatments that are notregular is anticipated (e.g., frequent sessions for a few weeks, with treatment tapering off thereafter), indicate the totalnumber of hours of treatment requested, the time period over which the treatment is requested, and the expected pattern oftreatment. The total hours must match the quantity(ies) indicated on the PA/RF.

Example: A provider requests 15 hours of treatment over a 12-week period. The recipient attends a one and one-half hour group every other week (six groups for a total of nine hours). There are one-hour weekly individual sessions for four weeks and every other week for the following four weeks (six individual sessions for a total of six hours).

Q — Psychoactive MedicationIndicate all the medications the recipient is taking which may affect the recipient’s symptoms that are being treated. Indicatewhether a medication review has been done in the past three months.

R — Rationale for Further TreatmentIndicate the symptoms or problems in functioning that require further treatment. If recipient has not progressed in treatmentthus far, indicate reasons for believing that continued treatment is helping.

S — Goals/Objectives of TreatmentSummarize current goals/objectives of treatment. A treatment plan may be attached in response to this item.

T — Steps to TerminationIndicate how you are preparing the recipient for termination. When available, indicate a planned date of termination.

U — Family MembersAdequate justification is required if an individual provider provides services to more than one family member in individualpsychotherapy.


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Signature of Performing ProviderWisconsin Medicaid requires the performing provider’s signature to process the PA request. Read the Prior AuthorizationStatement before dating and signing the attachment.

Recipient SignatureSignature indicates the signer has read the form. Signature is optional.

Signature of Supervising ProviderSignature required only if the performing provider is not a physician or psychologist.

Other Required Information

In addition to the above information, Wisconsin Medicaid requires the following to process the PA request:• Attach a copy of the signed and dated prescription for psychotherapy*. The initial prescription must be dated within

three months of receipt by Wisconsin Medicaid. Subsequent prescriptions must be dated within 12 months of receipt byWisconsin Medicaid.

* If the performing provider is a physician, a prescription need not be attached.


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Appendix 7Sample Prior Authorization Psychotherapy Attachment (PA/PSYA)

X X MAST Hookings Symptom

Medication & assessed for ability to progress in psychotherapy which was seen as positive.

Insomnia, anergy: suicidal ideation, history of 1 attempt 2 years ago, much guilt and self reproach.

RECIPIENT IMA D 1234567891 26

I.M. PERFORMING (555) 555-5555

I.M. SUPERVISING I.M. PRESCRIBING 01234567

major depression, recurrent,in partial 296.35 remission

Adjustment disorder withdepressed mood. 309.00

Rule out Histrionic

X X

x x

N/A

DSM-IV

MM/DD/YYYY with this provider.

Ima is from a step-family home with the stepfather being “alcoholic.” She was 14 years old when her stepbrother committedsuicide. Reported history of physical & sexual abuse in family of origin. Long history of depressed mood. Diagnosed as havingmajor depression 1 year ago when hospitalized at Anytown Hospital in Anytown, WI (MM/DD/YY-MM/DD/YY). No furthertreatment history. Seeking out help at this time due to husband being accused of abusing her 3 children. At time of hospitalization,reported being very suicidal & having some auditory hallucinations. Denies substance abuse usage. Currently well-groomed,pleasant, no signs of psychomotor retardation. Thought and speech intact. Very tearful. Admits suicidal thoughts; no plans.Oriented in all spheres.

26

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50 X

Since treatment started 4 weeks ago, recipient is able to sleep most of the night. Continues to betearful & hurt about abuse situation. Having more energy to care for self. Some lack of appetitecontinues. Periods of anxiety are often noted.

Client is considering divorce. Still separated at this time. Client’s 3 children live with her and this hasincreased stress. We will begin to see her with children on an as-needed basis.

X

60

X X(as needed)

X

13 Individual 6 Family

xDesipramine 150 mg h.s. and 200 mg Dilantin for seizure disorder (total daily dose).

1. Continues to have many life stressors (i.e., separation, child abuse).2. Ongoing mild suicidal risk.3. Beginning to explore own decisions around divorce with these stressors.4. Therapy is essential to prevent rehospitalization.

1. Continue to support & monitor mood; promote a positive self-image.2. Continue to help in dealing with stress through teaching cognitive and relaxation techniques for stress

management.3. Increase self-awareness of own past abuse and its relationship to current reality.

Have referred recipient to ongoing self-help group to deal with past issues around family alcoholism. Itis too early to start termination process at this time; however, we have discussed the time-limitednature of the psychotherapy and have set a goal of terminating in 6 months.

No, not at this time. A family session for diagnostic purposes is planned in the near future.

MM/DD/YYYY


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Appendix 8Prior Authorization Psychotherapy Attachment (PA/PSYA)

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(A copy of the Prior Authorization Psychotherapy Attachment [PA/PSYA] is located onthe following pages.)


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Providers may fax prior authorization (PA) requests to Wisconsin Medicaid at (608) 221-8616. Prior authorization requestssent to any Wisconsin Medicaid fax number other than (608) 221-8616 may result in processing delays.

When faxing PA requests to Wisconsin Medicaid, providers should be aware of the following:• Faxing a PA request eliminates one to three days of mail time. However, the adjudication time of the PA request has

not changed. All actions regarding PA requests are made within the time frames outlined in the Prior Authorizationsection of the All-Provider Handbook.

• Faxed PA requests must be received by 1:00 p.m., otherwise, they will be considered as received the following businessday. Faxed PA requests received on Saturday, Sunday, or a holiday will be processed on the next business day.

• After faxing a PA request, providers should not send the original paperwork, such as the carbon Prior AuthorizationRequest Form (PA/RF), by mail. Mailing the original paperwork after faxing the PA request will create duplicate PArequests in the system and may result in a delay of several days to process the faxed PA request.

• Providers should not photocopy and reuse the same PA/RF for other requests. When submitting a new request for PA,it must be submitted on a new PA/RF so that the request is processed under a new PA number. This requirementapplies whether the PA request is submitted by fax or by mail.

• When resubmitting a faxed PA request, providers are required to resubmit the faxed copy of the PA request, includingattachments, which includes Wisconsin Medicaid’s 15-digit internal control number located on the top half of the PA/RF.This will allow the provider to obtain the earliest possible grant date for the PA request (apart from backdating forretroactive eligibility). If any attachments or additional information that was requested is received without the rest ofthe PA request, the information will be returned to the provider.

• When faxing information to Wisconsin Medicaid, providers should not reduce the size of the PA/RF to fit on thebottom half of the cover page. This makes the PA request difficult to read and leaves no space for consultants to write aresponse if needed or to sign the request.

• If a photocopy of the original PA request and attachments is faxed, the provider should make sure these copies are clearand legible. If the information is not clear, it will be returned to the provider.

• Refaxing a PA request before the previous PA request has been returned will create duplicate PA requests and mayresult in delays.

• If the provider does not indicate his or her fax number, Wisconsin Medicaid will mail the decision back to the provider.

• Wisconsin Medicaid will attempt to fax a PA request response to a provider three times. If unsuccessful, the PA requestwill be mailed to the provider.

Appendix 9Prior Authorization by Fax Guidelines


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Use these billing instructions to avoid denied claims or inaccurate claim payment. Enter all required data on the UB-92 claimform in the appropriate data item. Do not include attachments. UB-92 items are required unless “optional” or “not required”is specified.

These instructions are for the completion of the UB-92 claim for Wisconsin Medicaid. For complete billing instructions, refer tothe National UB-92 Uniform Billing Manual prepared by the National Unified Billing Committee (NUBC). The National UB-92Uniform Billing Manual contains important coding information not available in these instructions. Providers may purchase theNational UB-92 Uniform Billing Manual by writing or calling:

American Hospital AssociationNational Uniform Billing Committee29th Fl1 N FranklinChicago IL 60606(312) 422-3390

For more information, go to the NUBC web site at www.nubc.org/.

Wisconsin Medicaid recipients receive a Medicaid identification card upon being determined eligible for WisconsinMedicaid. Always verify a recipient’s eligibility before providing nonemergency services by using the Eligibility Verifica-tion System (EVS) to determine if there are any limitations on covered services and to obtain the correct spelling of therecipient’s name. Refer to the Provider Resources section of the All-Provider Handbook or the Medicaid Web site atwww.dhfs.state.wi.us/medicaid/ for more information about the EVS.

Item 1* — Provider Name, Address, and Telephone NumberEnter the name of the hospital submitting the claim and the complete mailing address to which the hospital wishes paymentsent. Include the hospital’s city, state, and ZIP code.

Item 2 — ERO Assigned Number (not required)

Item 3 — Patient Control No. (not required)

Item 4 — Type of BillEnter the three-digit type of bill number. The bill number for outpatient hospital claims is:

131 = Hospital, Outpatient, Admit through Discharge Claim

Item 5 — Fed. Tax No. (not required)

Item 6 — Statement Covers Period (From - Through)Enter both dates in MMDDYY format (e.g., May 9, 2003, would be 050903).

Item 7 — COV D.Covered days must represent the actual number of visits (days of service) in the “from - through” period.

Item 8 — N-C D. (not required)

Item 9 — C-I D. (not required)

Item 10— L-R D. (not required)

Item 11 — Unlabeled Field (reserved for state use)

Appendix 10UB-92 Claim Form Completion Instructions for Outpatient Hospital

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Item 12 — Patient NameEnter the recipient’s last name, first name, and middle initial. Use the Eligibility Verification System (EVS) to obtain the correctspelling of the recipient’s name. If the name or spelling of the name on the Medicaid identification card and the EVS do notmatch, use the spelling from the EVS.

*Items are also referred to as “Form Locators” in the UB-92 Billing Manual.

Item 13 — Patient Address (not required)

Item 14 — Birthdate (not required)

Item 15 — Sex (not required)

Item 16 — MS (not required)

Item 17 — Admission Date (not required)

Item 18 — Admission HR (not required)

Item 19 — Admission Type (not required)

Item 20 — Admission SRC (required for bill types 11X, 13X, and 21X)Enter the code indicating the source of this admission. Refer to the UB-92 Billing Manual for more information on this item.

Item 21 — D HR (not required)

Item 22 — STAT (not required)

Item 23 — Medical Record No. (not required)

Items 24-30 — Condition Codes (required, if applicable)


Items 32-35 a-b — Occurrence (Codes and Dates) (required, if applicable)

Item 36 — Occurrence Span (Code/From - Through) (required, if applicable)



Items 39-41 a-d — Value Codes (Codes and Amounts) (required, if applicable)Refer to the UB-92 Manual for more information.

Item 42 — REV. CD.Enter the revenue code which identifies a specific outpatient service. Refer to the UB-92 Billing Manual for a list of revenuecodes and their descriptions.

Item 43 — Description (not required)

Item 44 — HCPCS/Rates (required, if applicable)Enter the procedure code applicable to outpatient laboratory services identified by revenue codes 30X, 31X, 923, and 925.


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Item 45 — Serv. Date (required, if applicable)Enter the date the service was provided in the format of MMDDYY.

Item 46 — Serv. UnitsEnter the total number of covered accommodation days, ancillary units of service, or visits, where appropriate.

Item 47 — Total Charges (by revenue code category)Enter the total charges pertaining to the related revenue code for the current billing period as entered in Item 6.

Item 48 — Non-covered Charges (not required)


Item 50 A-C — PayerIdentify all third-party payers (including Medicare and commercial health insurance). Enter “T19” for Wisconsin Medicaidand “MED” for Medicare. For a list of identifiers for commercial health insurance, refer to the UB-92 Billing Manual.

Item 51 A-C — Provider No.Enter the number assigned to the provider by the payer indicated in Item 50 A, B, and C.

Item 52 A-C — Rel Info (not required)

Item 53 A-C — Asg Ben (not required)

Item 54 A-C — Prior Payments (required, if applicable)There must be a dollar amount or $0.00 reported here for the third-party payer identified in Item 50. Do not include anyMedicare payments.

Item 55 A-C — Est Amount Due (not required)



Item 58 A-C — Insured’s NameIf submitting a claim for a newborn and using the mother’s Medicaid identification number, both the mother’s name and birthdate should be indicated here.

Item 59 A-C — P. Rel (not required)

Item 60 A-C — Cert. — SSN — HIC. — ID No.Enter the recipient’s 10-digit Medicaid identification number as it appears on his/her identification card.Note: The hospital may submit a claim for the baby during the baby’s first ten days of life using the mother’s Medicaid

identification number, identifying the baby’s sex with occurrence code “50” or “51” and indicating the occurrence(birth) date. Otherwise, the claim should be submitted using the baby’s Medicaid identification number, once assigned.

Item 61 A-C — Group Name (not required)

Item 62 A-C — Insurance Group No. (not required)

Item 63 A-C — Treatment Authorization Codes (required, if applicable)Indicate the approved seven-digit Medicaid prior authorization number.


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Item 64 A-C — Esc (not required)

Item 65 A-C — Employer Name (not required)

Item 66 A-C — Employer Location (not required)

Item 67 — Prin. Diag. CD.The principal diagnosis code identifies the condition chiefly responsible for the patient’s visit or treatment. Enter the fullInternational Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code (up to five digits)describing the principal diagnosis (e.g., the condition established after study to be chiefly responsible for causing the admissionor other health care episode). Any condition which is not manifested upon admission or that develops subsequently should notbe selected as the principal diagnosis.

Manifestation codes are not to be recorded as the principal diagnosis; code the underlying disease first. The principaldiagnosis code may not include “E” codes. “V” codes may be used as the principal diagnosis, unless restricted by thepayer.

Items 68-75 — Other Diag. Codes (required, if applicable)Enter the ICD-9-CM diagnosis codes corresponding to additional conditions that coexist at the time of admission, or developsubsequently, and which have an effect on the treatment received or the length of stay. Diagnoses which relate to an earlierepisode and which have no bearing on this episode are to be excluded.

Item 76 — Adm. Diag. CD. (not required)

Item 77 — E-Code (not required)


Item 79 — P.C. (not required)

Item 80 — Principal Procedure Code and Date (not required)

Item 81 — Other Procedure Codes and Dates (not required)

Item 82 a-b — Attending Phys. IDEnter the Unique Physician Identification Number (UPIN) or license number and name.

Item 83 a-b — Other Phys. IDEnter the UPIN or license number and name.

Item 84 a-d — Remarks (enter information when applicable)Enter third-party insurance (commercial insurance coverage) unless the service does not require third-party billing. Third-partyinsurance must be billed before billing Wisconsin Medicaid.

Other Insured’s NameProviders must bill commercial health insurance before billing Wisconsin Medicaid unless the service does not require healthinsurance billing according to the Coordination of Benefits section of the All-Provider Handbook. Leave this item blank whenthe following applies:

• The provider has not billed the commercial health insurance because eligibility verification did not indicate other coverage.• The service does not require commercial health insurance billing according to the Coordination of Benefits section of the

All-Provider Handbook.• Eligibility verification indicates “DEN” only.• When eligibility verification indicates “HPP,” “BLU,” “WPS,” “CHA,” or “OTH,” and the service requires


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commercial health insurance billing according to the Coordination of Benefits section of the All-Provider Handbook,indicate one of the following codes:

Code DescriptionOI-P Use the OI-P disclaimer code when the recipient’s health insurance pays any portion. The claim indicates

the amount paid by the health insurance company to the provider or the insured.OI-D Use the OI-D disclaimer code only when these three criteria are met:

√ Eligibility verification indicates “HPP,” “BLU,” “WPS,” “CHA,” “DEN,” or “OTH.”√ The service requires billing health insurance before Wisconsin Medicaid.√ The charges have been billed to the health insurance company and the insurance company has denied

them.OI-Y Use the OI-Y disclaimer code when the insurance card indicates other coverage but the insurance company

was not billed for reasons including:√ The provider knows the service in question is not covered by the insurer (i.e., has a previous denial).√ Insurance failed to respond to a follow-up claim.

When eligibility verification indicates “HMO” or “HMP,” one of the following disclaimer codes must be indicated, if applicable:

Code DescriptionOI-P Use the OI-P disclaimer code when the health insurance pays any portion. The amount paid is indicated on

the claim.OI-H Use the OI-H disclaimer code only when these two criteria are met:

√ Eligibility verification indicates “HMO” or “HMP.”√ The HMO or HMP does not cover the service or the billed amount does not exceed the coinsurance or

deductible amount.

Note: Providers may not use OI-H if the HMO or HMP denied payment because an otherwise covered servicewasnot provided by a designated provider. Wisconsin Medicaid does not reimburse services covered by anHMO or HMP except for the copayment and deductible amounts. Providers who receive a capitationpayment from the HMO may not bill Wisconsin Medicaid for services which are included in the capitationpayment.

Medicare must be billed before Wisconsin Medicaid. Indicate a Medicare disclaimer code if all the following statementsare true:

• Medicare covers the procedure at least sometimes.• The recipient’s Wisconsin Medicaid eligibility verification shows he or she has Medicare coverage for the service

performed. For example, the service is covered by Medicare Part A and the recipient has Medicare Part A.• The nonphysician provider’s Wisconsin Medicaid file shows he or she is Medicare certified. (If necessary,

Medicare will retroactively certify physicians for the date and the service provided if they held a valid license whenthe service was performed.

Code DescriptionM-1 Medicare benefits exhausted. Use this code when Medicare has denied the claim because the recipient’s lifetime

benefit, spell of illness, or yearly allotment of available benefits is exhausted.Use M-1 in these two instances only:For Medicare Part A (all three criteria must be met):• The provider is identified in Wisconsin Medicaid files as certified for Medicare Part A.• The recipient is eligible for Medicare Part A.• The service performed is covered by Medicare Part A but is not payable due to benefits being exhausted.


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For Medicare Part B (all three criteria must be met):• The provider is identified in Wisconsin Medicaid files as certified for Medicare Part B.• The recipient is eligible for Medicare Part B.• The procedure provided is covered by Medicare Part B but is not payable due to benefits being exhausted.

M-5 Provider is not Medicare-certified. Use this code when the provider is identified in Wisconsin Medicaid filesas being Medicare certified but the provider is billing for dates of service before or after his or her Medicarecertification effective dates.Use M-5 in these two instances only:For Medicare Part A (all three criteria must be met):• The provider is not certified for Medicare Part A.• The recipient is eligible for Medicare Part A.• The procedure provided is covered by Medicare Part A.For Medicare Part B (all three criteria must be met):• The provider is not certified for Medicare Part B.• The recipient is eligible for Medicare Part B.• The procedure provided is covered by Medicare Part B.

M-6 Recipient not Medicare-eligible. Use this code when Medicare denies payment for services related to chronicrenal failure because the recipient is not eligible for Medicare. Bill Medicare first even when the recipient isidentified in Wisconsin Medicaid files as not eligible for Medicare.Use M-6 in these two instances only:For Medicare Part A (all three criteria must be met):• The provider is identified in Wisconsin Medicaid files as certified for Medicare Part A.• Medicare denies the recipient eligibility.• The service is related to chronic renal failure.For Medicare Part B (all three criteria must be met):• The provider is identified in Wisconsin Medicaid files as certified for Medicare Part B.• Medicare denies the recipient eligibility.• The service is related to chronic renal failure.

M-7 Medicare disallowed or denied payment. Use this code when Medicare denies the claim for reasons relatedto policy, not billing errors. Use M-7 in these two instances only:For Medicare Part A (all three criteria must be met):• The provider is identified in Wisconsin Medicaid files as certified for Medicare Part A.• The recipient is eligible for Medicare Part A.• The service is covered by Medicare Part A, but is denied by Medicare Part A.For Medicare Part B (all three criteria must be met):• The provider is identified in Wisconsin Medicaid files as certified for Medicare Part B.• The recipient is eligible for Medicare Part B.• The service is covered by Medicare Part B, but is denied by Medicare Part B.

M-8 Noncovered Medicare service. Use this code when Medicare was not billed because the service, undercertain circumstances (for example, diagnosis), is not covered.For Medicare Part A (all three criteria must be met):• The provider is identified in Wisconsin Medicaid files as certified for Medicare Part A.• The recipient is eligible for Medicare Part A.• The service is usually covered by Medicare Part A, but not under certain circumstances (for example,

diagnosis).


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For Medicare Part B (all three criteria must be met):• The provider is identified in Wisconsin Medicaid files as certified for Medicare Part B.• The recipient is eligible for Medicare Part B.• The service is usually covered by Medicare Part B, but not under certain circumstances (for example,

diagnosis).

Leave the element blank if Medicare is not billed because eligibility verification indicated no Medicare coverage.If Medicare allows an amount on the recipient’s claim, attach the Explanation of Medicare Benefit to the claim and leavethis element blank. Do not enter Medicare paid amounts on the claim form. Refer to the Claims Submission section ofthe All-Provider Handbook for more information about submitting claims for dual-entitlees.

Item 85 — Provider RepresentativeEnter an authorized signature indicating that the information entered on the face of this claim is in conformance with thecertification on the back of this claim. A facsimile signature is acceptable.

Item 86 — DateEnter the date on which the claim is submitted to the payer.


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Appendix 11Sample UB-92 Claim Form — Outpatient Services

RECIPIENT IMA D.

IM BILLING HOSPITAL327 HOSPITAL RDANYTOWN WI 55555(555) 327-5555 032101 032101 1

55555ABCD 131

032762 3 1 11-598-99RZ

300 LABORATORY 81000 1 23 00306 LAB/BACT-MICRO 89050 1 46 00450 EMERG ROOM 1 39 00

001 TOTAL 108 00

45009 — Blue Cross BC111 25 00T19 — WI Medicaid 88008800 83 00

1234567890

V288

OI-PIma Provider 060301

A12345 I.M. Referring, M.D.


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Appendix 12Revenue Codes for Hospitals

Policy Specific Revenue Codes

Revenue codes that require a service-specific third digit from the UB-92Billing Manual

11X, 12X, 13X, 15X, 16X, 17X, 20X, 21X, 25X, 36X, 51X,71X, 90X, 91X, 92X, 94X, 96X

Revenue codes that require a CurrentProcedural Terminology laboratoryprocedure code for outpatient services

30X, 31X, 923, 925

Revenue codes for dental services 512 (Use when providing dental services as part of anoutpatient visit.)

Revenue codes for vision care services 519 (Use when providing vision care services as part of anoutpatient visit.)

Outpatient observation room 719 (Use when recipient is under observation afterrecovering from ambulatory surgery.)

Revenue codes exempt from recipientcopayment

820-859, 901, 918

Note: Revenue code 253 is exempt from recipientcopayment on crossover claims.

Revenue code 450 is exempt from copayment foroutpatient services.

Noncovered revenue codes 140-149, 180-189, 220-221, 229, 294, 374, 547-548, 550,609, 624, 637, 660-669, 670-679, 780-789, 880, 990-999

Noncovered revenue codes forpsychiatric hospitals 520, 529, 940, 949

Noncovered revenue codes for generalhospitals billing psychiatric orsubstance abuse services

520, 529, 940, 949

Nonbillable revenue codes Nonbillable for bill type 11X:

100-101, 115, 135, 155, 240, 249, 253, 259, 279, 291-293,299, 479, 530-531, 539, 540-546, 549, 551-552, 559, 570-572, 579, 580-582, 589, 590, 599, 600-604, 650-657, 659,912-913, 960-964, 969, 971-979, 981-989

Nonbillable for bill type 13X:

180-239, 240, 249, 259, 279, 299, 540-546, 549, 550-552,559, 570-572, 579, 580-582, 589, 590, 599, 600-604, 650-657, 659, 912-913, 990-999

Billable, noncovered revenue code 180

Restricted revenue codes 110-114, 116-117, 119

Revenue code for medication checks 510

The following is a complete list of Medicaid-allowable revenue codes for inpatient and outpatient hospital claims.


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Glossary

GAdjustmentA modified or changed claim that was originallyallowed, at least in part, by Wisconsin Medicaid.

Allowed statusA Medicaid or Medicare claim that has at least oneservice that is reimbursable.

BadgerCareBadgerCare extends Medicaid coverage through aMedicaid expansion under Titles XIX and XXI touninsured children and parents with incomes at orbelow 185% of the federal poverty level and who meetother program requirements. The goal of BadgerCareis to fill the gap between Medicaid and privateinsurance without supplanting or “crowding out” privateinsurance.

BadgerCare benefits are identical to the benefits andservices covered by Wisconsin Medicaid andrecipients’ health care is administered through the samedelivery system.

BQABureau of Quality Assurance. The BQA surveyshospital facilities to ensure they meet strict fire and lifesafety codes, and administrative and program standardsspecifically required by the Department of Health andFamily Services (DHFS) for hospitals.

CLIAClinical Laboratory Improvement Act. Congressimplemented CLIA to improve the quality and safety oflaboratory services. CLIA establishes standards andenforcement procedures.

CMSCenters for Medicare and Medicaid Services. An agencyhoused within the U.S. Department of Health andHuman Services (DHHS), CMS administers Medicare,Medicaid, related quality assurance programs, and otherprograms. Formerly known as the Health Care FinancingAdministration (HCFA).

CPTCurrent Procedural Terminology. A listing of descriptiveterms and codes for reporting medical, surgical,therapeutic, and diagnostic procedures. These codes aredeveloped, updated, and published annually by theAmerican Medical Association and adopted for billingpurposes by the Centers for Medicare and MedicaidServices (CMS), formerly HCFA, and WisconsinMedicaid.

Crossover claimA Medicare-allowed claim for a dual entitlee sent toWisconsin Medicaid for possible additional payment ofthe Medicare coinsurance and deductible.

DHCFDivision of Health Care Financing. The DHCFadministers Wisconsin Medicaid for the Department ofHealth and Family Services (DHFS) under statutoryprovisions, administrative rules, and the state’sMedicaid plan. The state’s Medicaid plan is acomprehensive description of the state’s Medicaidprogram that provides the Centers for Medicare andMedicaid Services (CMS), formerly HCFA, and theU.S. Department of Health and Human Services(DHHS), assurances that the program is administeredin conformity with federal law and CMS policy.

DHFSWisconsin Department of Health and Family Services.The DHFS administers the Wisconsin Medicaidprogram. Its primary mission is to foster healthy, self-reliant individuals and families by promotingindependence and community responsibility;strengthening families; encouraging healthy behaviors;protecting vulnerable children, adults, and families;preventing individual and social problems; and providingservices of value to taxpayers.

DHHSDepartment of Health and Human Services. The UnitedStates government’s principal agency for protecting thehealth of all Americans and providing essential humanservices, especially for those who are least able to helpthemselves. The DHHS includes more than 300programs, covering a wide spectrum of activities,including overseeing Medicare and Medicaid; medical

Glossary of Common Terms


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and social science research; preventing outbreak ofinfectious disease; assuring food and drug safety; andproviding financial assistance for low-income families.

DOSDate of service. The calendar date on which a specificmedical service is performed.

Dual entitleeA recipient who is eligible for both Medicaid andMedicare, either Medicare Part A, Part B, or both.

ECSElectronic Claims Submission. Claims transmitted via thetelephone line and fed directly into Wisconsin Medicaid’sclaims processing subsystem.

Emergency servicesThose services which are necessary to prevent death orserious impairment of the health of the individual. (For theMedicaid managed care definition of emergency, refer tothe Managed Care Guide or the Medicaid managed carecontract.)

EOBExplanation of Benefits. Appears on providers’Remittance and Status (R/S) Reports and informsMedicaid providers of the status of or action taken on theirclaims.

EVSEligibility Verification System. The EVS allows providersto verify recipient eligibility prior to providing services.Providers may access recipient eligibility informationthrough the following methods:• Commercial magnetic stripe card readers.• Commercial personal computer software and Internet

access.• Wisconsin Medicaid’s Automated Voice Response

(AVR) system.• Wisconsin Medicaid’s Direct Information Access Line

with Updates for Providers (Dial-Up).• Wisconsin Medicaid’s Provider Services (telephone

correspondents).

Fee-for-serviceThe traditional health care payment system under whichphysicians and other providers receive a payment for eachunit of service provided rather than a capitation paymentfor each recipient.

Fiscal agentThe Department of Health and Family Services (DHFS)contracts with Electronic Data Systems (EDS) to providehealth claims processing services for Wisconsin Medicaid,including provider certification, claims payment, providerservices, and recipient services. The fiscal agent alsoissues identification cards to recipients, publishesinformation for providers and recipients, and maintains theWisconsin Medicaid Web site.

HCFAHealth Care Financing Administration. Please refer todefinition under CMS.

HCPCSHealthcare Common Procedure Coding System. A listing ofservices, procedures, and supplies offered by physiciansand other providers. HCPCS includes Current ProceduralTerminology (CPT) codes, national alphanumeric codes,and local alphanumeric codes. The national codes aredeveloped by the Centers for Medicare and MedicaidServices (CMS), formerly HCFA, to supplement CPTcodes. Formerly known as HCFA Common ProcedureCoding System.

HealthCheckA program which provides Medicaid-eligible childrenunder age 21 with regular health screenings.

ICD-9-CMInternational Classification of Diseases, NinthRevision, Clinical Modification. Nomenclature formedical diagnoses required for billing. Available throughthe American Hospital Association.

IMDInstitution for Mental Disease. Wisconsin Medicaidcertifies hospitals as IMDs in accordance with HFS105.21, Wis. Admin. Code, and based on the hospital’seligibility for certification with Medicare or the JointCommission on Accreditation of Healthcare Organizations(JCAHO).

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InpatientA recipient who is admitted to the hospital as an inpatientand is counted in the midnight census.

Maximum allowable fee scheduleA listing of all procedure codes allowed by WisconsinMedicaid for a provider type and Wisconsin Medicaid’smaximum allowable fee for each procedure code.

MedicaidMedicaid is a joint federal/state program established in1965 under Title XIX of the Social Security Act to pay formedical services for people with disabilities, people 65years and older, children and their caretakers, andpregnant women who meet the program’s financialrequirements.

The purpose of Medicaid is to provide reimbursement forand assure the availability of appropriate medical care topersons who meet the criteria for Medicaid. Medicaid isalso known as the Medical Assistance Program, Title XIX,or T19.

Medically necessaryAccording to HFS 101.03(96m), Wis. Admin. Code, aMedicaid service that is:a) Required to prevent, identify or treat a recipient’s

illness, injury or disability; andb) Meets the following standards:

1. Is consistent with the recipient’s symptoms orwith prevention, diagnosis or treatment of therecipient’s illness, injury or disability;

2. Is provided consistent with standards ofacceptable quality of care applicable to type ofservice, the type of provider and the setting inwhich the service is provided;

3. Is appropriate with regard to generallyaccepted standards of medical practice;

4. Is not medically contraindicated with regard tothe recipient’s diagnoses, the recipient’ssymptoms or other medically necessaryservices being provided to the recipient;

5. Is of proven medical value or usefulness and,consistent with s. HFS 107.035, is notexperimental in nature;

6. Is not duplicative with respect to other servicesbeing provided to the recipient;

7. Is not solely for the convenience of therecipient, the recipient’s family or a provider;

8. With respect to prior authorization of a serviceand to other prospective coveragedeterminations made by the department, iscost-effective compared to an alternativemedically necessary service which isreasonably accessible to the recipient; and

9. Is the most appropriate supply or level ofservice that can safely and effectively beprovided to the recipient.

OutpatientA recipient who has not been officially admitted to thehospital as an inpatient and has not been counted in themidnight census.

PAPrior authorization. The written authorization issued by theDepartment of Health and Family Services (DHFS) to aprovider prior to the provision of a service.

POSPlace of service. A single-digit code which identifies theplace where the service was performed.

R/S ReportRemittance and Status Report. A statement generated bythe Medicaid fiscal agent to inform providers regarding theprocessing of their claims.

State PlanWisconsin Medicaid’s federally approved description ofmethods and standards for establishing payment rates tohospitals.

TOSType of service. A single-digit code which identifies thegeneral category of a procedure code.

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Index

IIndexClaims submission, 23

Deadline, 23Electronic, 23Follow-up, 27Paper, 23

Continuous eligibility of newborns, 26

Copayments, 11

Dental services, 16

Diagnosis codes, 24

Eligibility,Provider, 9Recipient, 10

End-stage renal disease services, 16

HealthCheck “Other Services, 16, 21

MedicaidManaged care, 24

Medicare/Medicaid dual entitlement, 24

Newborn reporting, 11

Prior authorization, 21Services requiring, 21Procedures for obtaining, 21

Provider eligibility and certification, 9

State plans, 26

Sterilizations, 17

Surgery, 17

Therapy services, 16

UB-92 claim form, 23Completion instructions, 61Sample form, 69

UB-92 Billing Manual, 23How to purchase, 23

Usual and customary charges, 25

hospital services handbook for outpatient servicesarchival use only refer to the online handbook for...

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