covered and noncovered services - wisconsin · all-provider handbook — covered and noncovered...

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CContacting Wisconsin Medicaid

Web Site dhfs.wisconsin.gov/

The Web site contains information for providers and recipients about the following:

Available 24 hours a day, seven days a week

• Program requirements. • Publications. • Forms.

• Maximum allowable fee schedules. • Professional relations representatives. • Certification packets.

Automated Voice Response System (800) 947-3544 (608) 221-4247

The Automated Voice Response system provides computerized voice responses about the following:

Available 24 hours a day, seven days a week

• Recipient eligibility. • Prior authorization (PA) status.

• Claim status. • Checkwrite information.

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

Correspondents assist providers with questions about the following: • Clarification of program

requirements. • Recipient eligibility.

• Resolving claim denials. • Provider certification.

Available: 8:30 a.m. - 4:30 p.m. (M, W-F) 9:30 a.m. - 4:30 p.m. (T)

Available for pharmacy services: 8:30 a.m. - 6:00 p.m. (M, W-F) 9:30 a.m. - 6:00 p.m. (T)

Division of Health Care Financing Electronic Data Interchange Helpdesk

(608) 221-9036 e-mail: [email protected]

Correspondents assist providers with technical questions about the following: Available 8:30 a.m. - 4:30 p.m. (M-F) • Electronic transactions. • Companion documents.

• Provider Electronic Solutions software.

Web Prior Authorization Technical Helpdesk (608) 221-9730

Correspondents assist providers with Web PA-related technical questions about the following:

Available 8:30 a.m. - 4:30 p.m. (M-F)

• User registration. • Passwords.

• Submission process.

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

Correspondents assist recipients, or persons calling on behalf of recipients, with questions about the following:

Available 7:30 a.m. - 5:00 p.m. (M-F)

• Recipient eligibility. • General Medicaid information.

• Finding Medicaid-certified providers. • Resolving recipient concerns.


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HHandbook OrganizationThe following tables show the organization of this All-Provider Handbook and list some of the topics included ineach section. It is essential that providers refer to service-specific publications for information about service-specificprogram requirements.

Certification and Ongoing Responsibilities Claims Information

• Certification and recertification. • Change of address or status. • Documentation requirements. • Noncertified providers. • Ongoing responsibilities. • Provider rights. • Provider sanctions. • Recipient discrimination prohibited. • Release of billing information.

• Follow-up procedures. • Good Faith claims. • Preparing and submitting claims. • Reimbursement information. • Remittance information. • Submission deadline. • Timely filing appeals requests.

Coordination of Benefits Covered and Noncovered Services

• Commercial health insurance. • Crossover claims. • Medicare. • Other Coverage Discrepancy Report, HCF 1159. • Primary and secondary payers. • Provider-based billing.

• Collecting payment from recipients. • Covered services. • Emergency services. • HealthCheck “Other Services.” • Medical necessity. • Noncovered services.

Informational Resources Managed Care

• Electronic transactions. • Eligibility Verification System. • Maximum allowable fee schedules. • Forms. • Medicaid Web site. • Professional relations representatives. • Provider Services. • Publications.

• Covered and noncovered HMO and SSI MCO services. • Enrollee HMO and SSI MCO eligibility. • Enrollment process. • Extraordinary claims. • HMO and SSI MCO claims submission. • Network and non-network provider information. • Provider appeals.

Prior Authorization Recipient Eligibility

• Amending prior authorization (PA) requests. • Appealing PA decisions. • Grant and expiration dates. • Prior authorization for emergency services. • Recipient loss of eligibility during treatment. • Renewal requests. • Review process. • Submitting PA requests.

• Copayment requirements. • Eligibility categories. • Eligibility responsibilities. • Eligibility verification. • Identification cards. • Limited benefit categories. • Misuse and abuse of benefits. • Retroactive eligibility.


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PHC 1300-C

Table of Contents

Preface ........................................................................................................................................ 3

Covered Services .......................................................................................................................... 5

Definition ................................................................................................................................. 5Program Requirements ....................................................................................................... 5

Medical Necessity ......................................................................................................... 5Prior Authorization ......................................................................................................... 5Services That Do Not Meet Program Requirements ........................................................ 6

Emergency Services ................................................................................................................ 6Services Not Separately Reimbursable....................................................................................... 6Recipient Payment for Covered Services ................................................................................... 7

Noncovered Services..................................................................................................................... 9

Definition ................................................................................................................................. 9Recipient Payment for Noncovered Services .............................................................................. 9

Missed Appointments ......................................................................................................... 9Avoiding Missed Appointments ....................................................................................... 9

Translation Services ............................................................................................................ 9

Collecting Payment from Recipients .............................................................................................. 11

Conditions That Must Be Met ................................................................................................. 11

HealthCheck “Other Services” ...................................................................................................... 13

Prior Authorization .................................................................................................................. 14

Appendix .................................................................................................................................... 15

1. Services Not Covered by Wisconsin Medicaid ........................................................................... 17

Index ......................................................................................................................................... 19


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All-Provider Handbook — Covered and Noncovered Services November 2005 3

PPrefaceThis All-Provider Handbook is issued to all Medicaid-certified providers. The information in this handbookapplies to Medicaid and BadgerCare.

Medicaid is a joint federal and state program establishedin 1965 under Title XIX of the federal Social SecurityAct. Wisconsin Medicaid is also known as the MedicalAssistance Program, WMAP, MA, Title XIX, and T19.

BadgerCare extends Medicaid coverage through aMedicaid expansion under Titles XIX and XXI. The goalof BadgerCare is to fill the gap between Medicaid andprivate insurance without supplanting or crowding outprivate insurance. BadgerCare recipients receive thesame benefits as Medicaid recipients, and their healthcare is administered through the same delivery system.

Wisconsin Medicaid and BadgerCare are administeredby the Department of Health and Family Services(DHFS). Within the DHFS, the Division of Health CareFinancing is directly responsible for managing WisconsinMedicaid and BadgerCare.

Unless otherwise specified, all information contained inthis and other Medicaid publications pertains to servicesprovided to recipients who receive care on a fee-for-service basis. Refer to the Managed Care section of thishandbook for information about state-contractedmanaged care organizations.

Wisconsin Medicaid andBadgerCare Web SitesPublications (including provider handbooks andWisconsin Medicaid and BadgerCare Updates),maximum allowable fee schedules, telephone numbers,addresses, and more information are available on thefollowing Web sites:

• dhfs.wisconsin.gov/medicaid/.• dhfs.wisconsin.gov/badgercare/.

PublicationsMedicaid publications apply to both Wisconsin Medicaidand BadgerCare. Publications interpret and implementthe laws and regulations that provide the framework forWisconsin Medicaid and BadgerCare. Medicaidpublications provide necessary information aboutprogram requirements.

Legal FrameworkThe 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 andfollowing) and Title XXI.

✓ Regulation — Title 42 CFR Parts 430-498 andParts 1000-1008 (Public Health).

• Wisconsin Law and Regulation:✓ Law — Wisconsin Statutes: 49.43-49.499 and

49.665.✓ Regulation — Wisconsin Administrative Code,

Chapters HFS 101-109.

Laws and regulations may be amended or added at anytime. Program requirements may not be construed tosupersede the provisions of these laws and regulations.


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4 Wisconsin Medicaid and BadgerCare dhfs.wisconsin.gov/medicaid/ November 2005


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Covered Services


CCovered ServicesThis chapter contains general informationabout services covered by WisconsinMedicaid. The information in this chapter is notall-inclusive. Providers should refer to HFS101.03(35) and 107, Wis. Admin. Code, and toservice-specific publications for moreinformation about Medicaid-covered services.

DefinitionA covered service is a service, item, or supplyfor which Medicaid reimbursement is availablewhen all program requirements are met.

Program RequirementsFor a covered service to meet programrequirements, the service must be provided bya qualified Medicaid-certified provider to aneligible recipient. In addition, the service mustmeet all applicable program requirements,including, but not limited to, medical necessity,prior authorization (PA), claims submission,prescription, and documentation requirements.Refer to the other sections of this handbookand to service-specific publications for moreinformation about program requirements.

Medical NecessityWisconsin Medicaid reimburses only forservices that are medically necessary asdefined under HFS 101.03(96m), Wis. Admin.Code. Wisconsin Medicaid may deny orrecoup payment if a service fails to meetMedicaid medical necessity requirements.

Services defined as “medically necessary”meet the following:

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,diagnosis, or treatment of therecipient’s illness, injury, or disability;

2. Is provided consistent with standardsof acceptable quality of careapplicable to the type of service, thetype of provider, and the setting inwhich the service is provided;

3. Is appropriate with regard to generallyaccepted standards of medicalpractice;

4. Is not medically contraindicated withregard to the recipient’s diagnoses, therecipient’s symptoms, or othermedically necessary services beingprovided to the recipient;

5. Is of proven medical value orusefulness and, consistent with s. HFS107.035, Wis. Admin. Code, is notexperimental in nature;

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

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

8. With respect to PA of a service and toother prospective coveragedeterminations made by theDepartment of Health and FamilyServices (DHFS), is cost-effectivecompared to an alternative medicallynecessary service that is reasonablyaccessible to the recipient; and

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

Prior AuthorizationAbout 4 percent of Medicaid services requirePA. In most cases, providers are required toobtain PA for those services before providingthem.

Services that require PA are identified in HFS107, Wis. Admin. Code, and in service-specificpublications. Refer to the Prior Authorizationsection of this handbook and to service-specific

AA covered serviceis a service, item,or supply forwhich Medicaidreimbursement isavailable when allprogramrequirements aremet.


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publications for more information about PArequirements.

Services That Do Not Meet ProgramRequirementsAs stated in HFS 107.02(2), Wis. Admin.Code, Wisconsin Medicaid may deny orrecoup payment for covered services that failto meet program requirements.

Examples of covered services that do not meetprogram requirements include the following:

• Services for which records or otherdocumentation were not prepared ormaintained.

• Services for which the provider fails tomeet any or all of the requirements ofHFS 106.03, Wis. Admin. Code, including,but not limited to, the requirementsregarding timely submission of claims.

• Services that fail to comply with Medicaidrequirements or state and federal statutes,rules, and regulations.

• Services that the DHFS, the Peer ReviewOrganization review process, or WisconsinMedicaid determines to be inappropriate,in excess of accepted standards ofreasonableness or less costly alternativeservices, or of excessive frequency orduration.

• Services provided by a provider who failsor refuses to meet and maintain any of thecertification requirements under HFS 105,Wis. Admin. Code.

• Services provided by a provider who failsor refuses to provide access to records.

• Services provided inconsistent with anintermediate sanction or sanctions imposedby the DHFS.

Emergency ServicesIn emergency situations, Wisconsin Medicaidmodifies certain program requirements andreimbursement procedures. Emergencyservices are defined in HFS 101.03(52), Wis.Admin. Code, as “those services which arenecessary to prevent the death or seriousimpairment of the health of the individual.”

Wisconsin Medicaid does not reimburse foremergency services unless they are Medicaid-covered services.

Additional definitions and procedures foremergencies exist in other situations, such asdental and mental health. Refer to service-specific publications for more informationabout program requirements for emergencyservices.

Program requirements and reimbursementprocedures may be modified in the followingways:

• Prior authorization or other programrequirements may be waived inemergency situations. Refer to the PriorAuthorization section of this handbook andto service-specific publications for moreinformation.

• Noncertified providers may be reimbursedfor emergency services. Refer to theCertification and Ongoing Responsibilitiessection of this handbook for moreinformation.

• Non-U.S. citizens may be eligible forMedicaid-covered services in emergencysituations. Refer to the Recipient Eligibilitysection of this handbook for moreinformation.

Services Not SeparatelyReimbursableIf reimbursement for a service is included inthe reimbursement for the primary procedureor service, it is not separately reimbursable.For example, routine venipuncture is notseparately reimbursable but is included in thereimbursement for the laboratory procedure orthe laboratory test preparation and handlingfee. Also, durable medical equipment (DME)delivery charges are included in thereimbursement for DME items.

AAs stated in HFS107.02(2), Wis.Admin. Code,WisconsinMedicaid maydeny or recouppayment forcovered servicesthat fail to meetprogramrequirements.


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Covered Services


Recipient Payment forCovered ServicesUnder state and federal laws, a Medicaid-certified provider may not collect paymentfrom a recipient, or authorized person acting onbehalf of the recipient, for Medicaid-coveredservices even if the services are covered butdo not meet program requirements. Denial of aclaim by Wisconsin Medicaid does notnecessarily render a Medicaid recipient liable.However, a covered service for which PA wasdenied is treated as a noncovered service. (If arecipient chooses to receive an originallyrequested service instead of the serviceapproved on a modified PA request, it is alsotreated as a noncovered service.) If a recipient

requests a covered service for which PA wasdenied (or modified), the provider may collectpayment from the recipient if certain conditionsare met. Refer to the Collecting Payment fromRecipients chapter of this section for moreinformation.

If a provider collects payment from a recipient,or authorized person acting on behalf of therecipient, for a Medicaid-covered service, theprovider may be subject to program sanctionsincluding termination of Medicaid certification.Providers should refer to the Certification andOngoing Responsibilities section of thishandbook for more information about providersanctions.

UUnder state andfederal laws, aMedicaid-certifiedprovider may notcollect payment froma recipient, orauthorized personacting on behalf ofthe recipient, forMedicaid-coveredservices even if theservices are coveredbut do not meetprogramrequirements.


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Noncovered Services


NNoncovered ServicesThis chapter contains general informationabout services not covered by WisconsinMedicaid. The information in this chapter is notall-inclusive. Providers should refer to chs.HFS 101.03(103) and 107, Wis. Admin. Code,and to service-specific publications for moreinformation. In addition, providers should referto Appendix 1 of this section for a general listof noncovered services as it appears in HFS107.03, Wis. Admin. Code.

DefinitionA noncovered service is a service, item, orsupply for which Medicaid reimbursement isnot available.

Recipient Payment forNoncovered ServicesA provider may collect payment from arecipient for noncovered services if certainconditions are met. Refer to the CollectingPayment from Recipients chapter of thissection for more information.

Providers may not collect payment from arecipient, or authorized person acting on behalfof the recipient, for certain noncoveredservices or activities provided in connectionwith covered services, including the following:

• Charges for missed appointments.• Charges for telephone calls.• Charges for time involved in completing

necessary forms, claims, or reports.• Translation services.

Missed AppointmentsThe federal Centers for Medicare andMedicaid Services does not allow stateMedicaid programs to permit providers tocollect payment from a recipient, or authorizedperson acting on behalf of the recipient, for amissed appointment.

Avoiding Missed AppointmentsWisconsin Medicaid offers the followingsuggestions to help avoid missed appointments:

• Remind recipients of upcomingappointments (by telephone or postcard)prior to scheduled appointments.

• Encourage the recipient to call his or hercounty/tribal social or human servicesagency if transportation is needed.

• If the appointment is made through theHealthCheck screening or targeted casemanagement programs, encourage thestaff from those programs to ensure thatthe scheduled appointments are kept.

Translation ServicesTranslation services are considered part of theprovider’s overhead cost and are notseparately reimbursable by WisconsinMedicaid. Providers may not collect paymentfrom a recipient, or authorized person acting onbehalf of the recipient, for translation services.

Providers should contact the AffirmativeAction and Civil Rights Compliance Officerat (608) 266-9372 for information aboutwhen translation services are required byfederal law. Providers may also write to:

AA/CRC Office1 W Wilson St Rm 561PO Box 7850Madison WI 53707-7850

AA noncoveredservice is aservice, item, orsupply for whichMedicaidreimbursement isnot available.


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Collecting Payment

from Recipients

CCollecting Payment from RecipientsMedicaid providers may not collect paymentfrom a recipient, or authorized person acting onbehalf of the recipient, except for the following:

• Required recipient copayments for certainservices. (Refer to the Recipient Eligibilitysection of this handbook for moreinformation.)

• Commercial insurance payments made tothe recipient. (Refer to the Coordination ofBenefits section of this handbook for moreinformation.)

• Spenddown. (Refer to the RecipientEligibility section of this handbook for moreinformation.)

• Charges for a private room in a nursinghome or hospital. (Refer to service-specific publications for more information.)

• Noncovered services if certain conditionsare met.

• Covered services for which priorauthorization (PA) was denied (or anoriginally requested service for which aPA request was modified) if certainconditions are met. These services aretreated by Wisconsin Medicaid asnoncovered services.

• Services provided to a recipient in a limitedbenefit category when the services are notcovered under the limited benefit and ifcertain conditions are met.

If a provider inappropriately collects paymentfrom a recipient, or authorized person acting onbehalf of the recipient, that provider may besubject to program sanctions includingtermination of Medicaid certification. Refer to

the Certification and Ongoing Responsibilitiessection of this handbook for more informationabout provider sanctions.

Conditions That Must BeMetA recipient may request a noncovered service,a covered service for which PA was denied(or modified), or a service that is not coveredunder the recipient’s limited benefit category.The charge for the service may be collectedfrom the recipient if the following conditionsare met prior to the delivery of that service:

• The recipient accepts responsibility forpayment.

• The provider and recipient make paymentarrangements for the service.

Providers are strongly encouraged to obtain awritten statement in advance documenting thatthe recipient has accepted responsibility for thepayment of the service.

Furthermore, the service must be separate ordistinct from a related, covered service. Forexample, a vision provider may provide arecipient with eyeglasses covered byWisconsin Medicaid but then, upon therecipient’s request, provide and charge therecipient for anti-glare coating, which is anoncovered service. Charging the recipient ispermissible in this situation because the anti-glare coating is a separate service and can beadded to the lenses at a later time.

PProviders arestronglyencouraged toobtain a writtenstatement inadvancedocumenting thatthe recipient hasacceptedresponsibility forthe payment of theservice.


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HealthCheck “O

therServices”

HHealthCheck “Other Services”HealthCheck is Wisconsin Medicaid’s federallymandated program known nationally as Earlyand Periodic Screening, Diagnosis, andTreatment (EPSDT). HealthCheck servicesconsist of a comprehensive health screening ofMedicaid recipients under 21 years of age. Onoccasion, a HealthCheck screening mayidentify the need for health care services thatare not otherwise covered by WisconsinMedicaid or that exceed Medicaid limitations.These services are called HealthCheck “OtherServices.” Federal law requires that theseservices be reimbursed by Wisconsin Medicaidthrough HealthCheck “Other Services” if theyare medically necessary and prior authorized.The purpose of HealthCheck “Other Services”is to assure that medically necessary medicalservices are available to recipients under 21years of age.

For a service to be reimbursed throughHealthCheck “Other Services,” the followingrequirements must be met:

• The condition being treated is identified ina HealthCheck screening that occurredwithin 365 days of the prior authorization(PA) request for the service.

• The service is provided to a recipient whois under 21 years of age.

• The service may be covered under federalMedicaid law.

• The service is medically necessary andreasonable.

• The service is prior authorized byWisconsin Medicaid before it is provided.

• Services currently covered by WisconsinMedicaid are not considered acceptable totreat the identified condition.

Wisconsin Medicaid has the authority to do allof the following:

• Review the medical necessity of allrequests.

• Establish criteria for the provision of suchservices.

• Determine the amount, duration, and scopeof services as long as limitations arereasonable and maintain the preventiveintent of the HealthCheck program.

Prior AuthorizationTo receive PA for HealthCheck “OtherServices,” providers are required to submit thefollowing:

• A completed Prior Authorization RequestForm (PA/RF), HCF 11018 (or PriorAuthorization Dental Request Form[PA/DRF], HCF 11035, or PriorAuthorization Request for HearingInstrument Audiological Services[PA/HIAS1], HCF 11020).✓ The provider should write

“HealthCheck Other Services” in redink at the top of the form.

✓ The provider may omit the procedurecode if he or she is uncertain what itis. The Medicaid consultant will assignone for approved services.

• The appropriate service-specific PAattachment.

• Verification that a comprehensiveHealthCheck screening has been providedwithin 365 days prior to WisconsinMedicaid’s receipt of the PA request. Thedate and provider of the screening must beindicated.

• Necessary supporting documentation.

Call Provider Services at (800) 947-9627 or(608) 221-9883 for more information aboutHealthCheck “Other Services” and todetermine the appropriate PA attachment.

OOn occasion, aHealthCheckscreening mayidentify the needfor health careservices that arenot otherwisecovered byWisconsinMedicaid or thatexceed Medicaidlimitations.


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Appendix


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Appendix


Appendix 1

Services Not Covered by Wisconsin Medicaid

The following specific services are not covered by Wisconsin Medicaid. This list is not all-inclusive. Refer to service-specificpublications for more information about noncovered services.

HFS 107.03 “Services not covered”HFS 107.03, Wis. Admin. Code, defines “services not covered” under Wisconsin Medicaid to include the following:

(1) Charges for telephone calls;(2) Charges for missed appointments;(3) Sales tax on items for resale;(4) Services provided by a particular provider that are considered experimental in nature;(5) Procedures considered by the department to be obsolete, inaccurate, unreliable, ineffectual, unnecessary, imprudent

or superfluous;(6) Personal comfort items, such as radios, television sets and telephones, which do not contribute meaningfully to the

treatment of an illness;(7) Alcoholic beverages, even if prescribed for remedial or therapeutic reasons;(8) Autopsies;(9) Any service requiring prior authorization for which prior authorization is denied, or for which prior authorization was

not obtained prior to the provision of the service except in emergency circumstances;(10) Services subject to review and approval pursuant to s. 150.21, Stats., but which have not yet received approval;(11) Psychiatric examinations and evaluations ordered by a court following a person’s conviction of a crime, pursuant to

s. 972.15, Stats.;(12) Consultations between or among providers, except as specified in s. HFS 107.06(4)(e);(13) Medical services for adult inmates of the correctional institutions listed in s. 302.01, Stats.;(14) Medical services for a child placed in a detention facility;(15) Expenditures for any service to an individual who is an inmate of a public institution or for any service to a person

21 to 64 years of age who is a resident of an institution for mental disease (IMD), unless the person is 21 years ofage, was a resident of the IMD immediately prior to turning 21 and has been continuously a resident since then,except that expenditures for a service to an individual on convalescent leave from an IMD may be reimbursed byMA.

(16) Services provided to recipients when outside the United States, except Canada or Mexico;(17) Separate charges for the time involved in completing necessary forms, claims or reports;(18) Services provided by a hospital or professional services provided to a hospital inpatient are not covered services

unless billed separately as hospital services under s. HFS 107.08 or 107.13(1) or as professional services under theappropriate provider type. No recipient may be billed for these services as noncovered;

(19) Services, drugs and items that are provided for the purpose of enhancing the prospects of fertility in males orfemales, including but not limited to the following:(a) Artificial insemination, including but not limited to intra-cervical and intra-uterine insemination;(b) Infertility counseling;(c) Infertility testing, including but not limited to tubal patency, semen analysis or sperm evaluation;(d) Reversal of female sterilization, including but not limited to tubouterine implantation, tubotubal anastomoses

or fimbrioplasty;(e) Fertility-enhancing drugs used for the treatment of infertility;(f) Reversal of vasectomies;(g) Office visits, consultations and other encounters to enhance the prospects of fertility; and(h) Other fertility-enhancing services and items;


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(20) Surrogate parenting and related services, including but not limited to artificial insemination and subsequent obstetricalcare;

(21) Ear lobe repair;(22) Tattoo removal;(23) Drugs, including hormone therapy, associated with transsexual surgery or medically unnecessary alteration of sexual

anatomy or characteristics;(24) Transsexual surgery;(25) Impotence devices and services, including but not limited to penile prostheses and external devices and to insertion

surgery and other related services; and(26) Testicular prosthesis.


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Index

IIndexCollecting Payment from Recipients, 11

Covered Services

definition, 5services not separately reimbursable, 6

Emergency Services, 6

HealthCheck “Other Services,” 13

Medical Necessity, 5

Noncovered Services

definition, 9general list, 17collecting payment from recipients for, 9, 11

Program Requirements

general information, 5services that do not meet program requirements, 6

Services for Which Prior Authorization Is Denied, 7, 11


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covered and noncovered services - wisconsin · all-provider handbook — covered and noncovered...

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