• Covered Services
  • Introduction
  • Definition
    • Introduction
    • Program Requirements
  • Emergency Services
  • Services Not Separately Reimbursable
  • Recipient Payment for Covered Services
• Noncovered Services
  • Introduction
  • Definition
  • Recipient Payment for Noncovered Services
    • Introduction
    • Missed Appointments
    • Translation Services
• Collecting Payment from Recipients
  • Introduction
  • Conditions That Must Be Met
• HealthCheck "Other Services"
  • Introduction
  • Prior Authorization
• Appendix
  • Appendix 1 — Services Not Covered by Wisconsin Medicaid
• PDF

Covered and Noncovered Services

HealthCheck "Other Services"

HealthCheck is Wisconsin Medicaid’s federally mandated program known nationally as Early and Periodic Screening, Diagnosis, and Treatment (EPSDT). HealthCheck services consist of a comprehensive health screening of Medicaid recipients under 21 years of age. On occasion, a HealthCheck screening may identify the need for health care services that are not otherwise covered by Wisconsin Medicaid or that exceed Medicaid limitations. These services are called HealthCheck “Other Services.” Federal law requires that these services be reimbursed by Wisconsin Medicaid through HealthCheck “Other Services” if they are medically necessary and prior authorized. The purpose of HealthCheck “Other Services” is to assure that medically necessary medical services are available to recipients under 21 years of age.

For a service to be reimbursed through HealthCheck “Other Services,” the following requirements must be met:

• The condition being treated is identified in a HealthCheck screening that occurred within 365 days of the prior authorization (PA) request for the service.
• The service is provided to a recipient who is under 21 years of age.
• The service may be covered under federal Medicaid law.
• The service is medically necessary and reasonable.
• The service is prior authorized by Wisconsin Medicaid before it is provided.
• Services currently covered by Wisconsin Medicaid are not considered acceptable to treat the identified condition.

Wisconsin Medicaid has the authority to do all of the following:

• Review the medical necessity of all requests.
• Establish criteria for the provision of such services.
• Determine the amount, duration, and scope of services as long as limitations are reasonable and maintain the preventive intent of the HealthCheck program.

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