• 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"

Prior Authorization

To receive PA for HealthCheck “Other Services,” providers are required to submit the following:

• A completed Prior Authorization Request Form (PA/RF), HCF 11018 (or Prior Authorization Dental Request Form [PA/DRF], HCF 11035, or Prior Authorization Request for Hearing Instrument Audiological Services [PA/HIAS1], HCF 11020).
  • The provider should write “HealthCheck Other Services” in red ink at the top of the form.
  • The provider may omit the procedure code if he or she is uncertain what it is. The Medicaid consultant will assign one for approved services.
• The appropriate service-specific PA attachment.
• Verification that a comprehensive HealthCheck screening has been provided within 365 days prior to Wisconsin Medicaid’s receipt of the PA request. The date and provider of the screening must be indicated.
• Necessary supporting documentation.

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

Next — Appendix 1 — Services Not Covered by Wisconsin Medicaid
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