• 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

Select a section » Certification and Ongoing Responsibilities Claims Information Coordination of Benefits Covered and Noncovered Services Informational Resources Managed Care Prior Authorization Recipient Eligibility

 

 

Covered and Noncovered Services

Covered Services

Definition

Program Requirements

For a covered service to meet program requirements, the service must be provided by a qualified Medicaid-certified provider to an eligible recipient. In addition, the service must meet 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 handbook and to service-specific publications for more information about program requirements.

Medical Necessity

Wisconsin Medicaid reimburses only for services that are medically necessary as defined under HFS 101.03(96m), Wis. Admin. Code. Wisconsin Medicaid may deny or recoup payment if a service fails to meet Medicaid medical necessity requirements.

Services defined as “medically necessary” meet the following:

1. Required to prevent, identify, or treat a recipient’s illness, injury, or disability; and
2. Meets the following standards:
1. Is consistent with the recipient’s symptoms or with prevention, diagnosis, or treatment of the recipient’s illness, injury, or disability;
2. Is provided consistent with standards of acceptable quality of care applicable to the type of service, the type of provider, and the setting in which the service is provided;
3. Is appropriate with regard to generally accepted standards of medical practice;
4. Is not medically contraindicated with regard to the recipient’s diagnoses, the recipient’s symptoms, or other medically necessary services being provided to the recipient;
5. Is of proven medical value or usefulness and, consistent with s. HFS 107.035, Wis. Admin. Code, is not experimental in nature;
6. Is not duplicative with respect to other services being provided to the recipient;
7. Is not solely for the convenience of the recipient, the recipient’s family, or a provider;
8. With respect to PA of a service and to other prospective coverage determinations made by the Department of Health and Family Services (DHFS), is cost-effective compared to an alternative medically necessary service that is reasonably accessible to the recipient; and
9. Is the most appropriate supply or level of service that can be safely and effectively provided to the recipient.

Prior Authorization

About 4 percent of Medicaid services require PA. In most cases, providers are required to obtain PA for those services before providing them.

Services that require PA are identified in HFS 107, Wis. Admin. Code, and in service-specific publications. Refer to the Prior Authorization section of this handbook and to service-specific publications for more information about PA requirements.

Services That Do Not Meet Program Requirements

As stated in HFS 107.02(2), Wis. Admin. Code, Wisconsin Medicaid may deny or recoup payment for covered services that fail to meet program requirements.

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

• Services for which records or other documentation were not prepared or maintained.
• Services for which the provider fails to meet any or all of the requirements of HFS 106.03, Wis. Admin. Code, including, but not limited to, the requirements regarding timely submission of claims.
• Services that fail to comply with Medicaid requirements or state and federal statutes, rules, and regulations.
• Services that the DHFS, the Peer Review Organization review process, or Wisconsin Medicaid determines to be inappropriate, in excess of accepted standards of reasonableness or less costly alternative services, or of excessive frequency or duration.
• Services provided by a provider who fails or refuses to meet and maintain any of the certification requirements under HFS 105, Wis. Admin. Code.
• Services provided by a provider who fails or refuses to provide access to records.
• Services provided inconsistent with an intermediate sanction or sanctions imposed by the DHFS.

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