Wisconsin.gov home page State agency directory State-wide subject directory

 

 

Provider Menu
Contacts
Fee Schedules
Forms
Handbooks
EDI
National Provider Identifier
Service-Specific
R/S Messages
Training
Updates
Web PA
Provider Home
Provider Home Wisconsin Medicaid Home Search Wisconsin Medicaid What's New Wisconsin Medicaid, Provider Area

Part Y, Nursing Home

Issued: 01/96

Nursing Facilities Updates
All-Provider Updates

Please click on the appropriate PDF file below to view and download Part Y, Nursing Home Services Handbook pages. The pages have been broken down into sections for easy downloading. You can view the entire handbook in one file (8138 kb) or, if you prefer, you can download sections which are listed below in a smaller file format.

The file size is listed next to each item in parentheses. Please use the chart to the right as a guide to estimate the time it may take for a chapter to download. The download time is an estimate, based on an average user downloading the product using a 28.8 modem. Using a faster or slower modem increases or decreases download time.

You will need Acrobat Reader 3.01 or higher to view these PDF files.

Learn about PDF files.

Additional publications may have been issued for this provider type after this handbook was issued. For updated information, view the nursing facilities publication list for this provider type. In addition to these service-specific publications, please view the All-Provider Updates.
File Size Download Time
4300 kb 21 minutes
3600 kb 18 minutes
2800 kb 14 minutes
1800 kb 10 minutes
1100 kb 6 minutes
154 kb 2 minutes
50 kb 1 minute

Handbook Section or Appendix Description
[service-specific] Handbook, Part Y
[service-specific] Handbook, Part Y
Please Note: If you have a higher speed modem, you can download larger files sizes found at the bottom of this table.

 Page Numbers PDF File for downloading

  • Letter to nursing home providers.

  • Cover of handbook.

  • Introduction to the handbook.

  • Transmittal log.

  • Table of contents for sections and appendices.

   

PDF
(433 kb)
Section I - General Information Y1-001 to Y1-009

PDF
(1260 kb)
Section II - Covered Services & Related Limitations Y2-001 to Y2-010

PDF
(1041 kb)
Section III - Prior Authorization Y3-001 to Y3-003

PDF
(239 kb)
Section IV - Billing Information. Y4-001 to Y4-004

PDF
(370 kb)
Appendix 1: UB-92 Claim Form Instructions Y5-003 to Y5-009

PDF
PDF
(527 kb)
Appendix 2a: UB-92 Claim Form Sample Straight Wisconsin Medicaid with Medicare Coinsurance Days Claim Y5-011 PDF
(75 kb)
Appendix 2b: UB-92 Claim Form Sample Medicare Part A Coinsurance Days Claim Y5-013 PDF
(78 kb)
Appendix 2c: UB-92 Claim Form Sample Straight Wisconsin Medicaid Claim with Bedhold Days - Ancillaries Y5-015 PDF
(74 kb)
Appendix 2d: UB-92 Claim Form Sample Straight Wisconsin Medicaid Claim with Bedhold Days Y5-017 PDF
(75 kb)
Appendix 2e: UB-92 Claim Form Sample Straight Wisconsin Medicaid Claim - Recipient Death Y5-019 PDF
(70 kb)
Appendix 3: HCFA 1500 Claim Form Instructions Y5-021 to Y5-026 PDF
(474 kb)
Appendix 4: Sample HCFA 1500 Claim Form Y5-027 PDF
(116 kb)
Appendix 5: Prior Authorization Request Form (PA/RF) - AIDS Y5-029 PDF
(72 kb)
Appendix 6: Sample Prior Authorization Physician Attachment (PA/PA) Form | Revised form (PDF, 66 KB) | Revised instructions (PDF, 12 KB) Y5-031 to Y5-032  
Appendix 7: Prior Authorization Request Form (PA/RF) Instructions Y5-033 to Y5-035 PDF
(216 kb)
Appendix 8: Prior Authorization Durable Medical Equipment Attachment (PA/DMEA) Instructions | Revised instructions (23 KB) | Revised form (PDF, 146 KB) Y5-037 to Y5-038  
Appendix 9: Sample Prior Authorization Request Form (PA/RF) - Oxygen Y5-039 PDF
(146 kb)
Appendix 10: Sample Prior Authorization Durable Medical Equipment Attachment (PA/DMEA) Form | Revised form (PDF, 146 KB) Y5-041 to Y5-042  
Appendix 11: Requesting Nursing Home Rate Administrative Review Instructions Y5-043 PDF
(72 kb)
Appendix 12: Nursing Home Rate Administrative Review Request Form Y5-045 PDF
(31 kb)
Appendix 13: Eligibility/Authorization Report Y5-047 PDF
(22 kb)
Appendix 14: Reading the Eligibility/Authorization Report Y5-049 PDF
(61 kb)
Appendix 15: Nursing Home Level of Care/Accommodation Codes Y5-051 PDF
(42 kb)
Appendix 16: Request for Reimbursement for OBRA Level I Screening Form Y5-053 PDF
(50 kb)
Appendix 17: Request for Reimbursement for OBRA Level I Screening Instructions Y5-055 PDF
(50 kb)
Appendix 18: Nurses Aide Training and Competency Evaluation Reimbursement Request Form Y5-057 PDF
(65 kb)
Appendix 19: Nurses Aide Y5-059 PDF
(82 kb)
Appendix 20: Allowable Wisconsin Medicaid Nursing Home Ancillary Codes Y5-061 PDF
(26 kb)
Appendix 21: Bureau of Health Care Financing District Offices Y5-063 PDF
(32 kb)
Appendix 22: Bureau of Quality Compliance District Offices Y5-065 PDF
(35 kb)
Appendix 23: Minimum Data Set (MDS) - Part A Y5-067 to Y5-072 PDF
(707 kb)
Appendix 24: Minimum Data Set (MDS) - Part B Y5-073 to Y5-080 PDF
(897 kb)
Appendix 25: Preadmission Screen/Annual Resident Review Level I Screen Y5-081 to Y5-084 PDF
(393 kb)
Appendix 26: PASAAR Roster Claim form Y5-085 PDF
(80 kb)
Appendix 27: Estate Recovery Affidavit Y5-087 PDF
(33 kb)
Appendix 28: Estate Recovery Program Notification of Death Form Y5-089 PDF
(41 kb)
Entire Part Y, Nursing Home Services Handbook

All

 PDF
(8138 kb)
All Handbook Sections (except Appendices). Includes Table of Contents and Section I, II, III, and IV. Everything except Appendices PDF
(3060 kb)
All Appendices. Includes Appendix Table of Contents as well as Appendix 1 to Appendix 28 Appendices only PDF
(41 kb)

DHFS home page

Back to top  |  About  |  Contact  |  Disclaimer  |  Privacy Notice  |  Feedback

Wisconsin Department of Health Services
Protecting and promoting the health and safety of the people of Wisconsin