• General Information
  • Introduction
  • Certification
    • Introduction
    • Physicians and Residents
    • Physician Assistants
    • Nurse Practitioners
    • Nurse Midwives
    • HealthCheck Certification
    • Presumptive Eligibility for Pregnant Women Benefit
    • Presumptive Eligibility for the Family Planning Waiver Program
    • Prenatal Care Coordination Certification
    • Durable Medical Equipment
  • Provider Numbers
    • Introduction
    • Billing Performing Provider Numbers (Issued to Physicians and Residents)
    • Group Billing Numbers (Issued to Clinics)
    • Nonbilling Performing Provider Numbers (Issued to Physician Assistants)
  • Covered Physician Services
    • Introduction
    • Procedure Codes and Modifiers
    • Place of Service Codes
  • Reimbursement Not Available
  • Recipient Eligibility
    • Introduction
    • Retroactive Eligibility
    • Non-U.S. Citizens — Emergency Services
  • Recipient Copayment
    • Introduction
    • Copayment for Physician Services
  • Documentation Requirements
  • Prior Authorization
    • Introduction
    • Physician Services Requiring Prior Authorization
    • Prior Authorization Request Forms and Attachments
  • Experimental Services
  • Specialized Medical Vehicle Services
• Evaluation and Management Services
  • Introduction
  • Concurrent Care
  • Consultations
    • Introduction
    • Covered Consultations
  • Critical Care and Prolonged Services
    • Introduction
    • Ambulance Services
  • Emergency Department Services
  • Evaluation and Management Services Provided with Surgical Procedures
  • Family Planning Services
  • Hospital Services
  • Nursing Home Visits
  • Observation Care
  • Office and Other Outpatient Visits
    • Established Patient
    • New Patient
    • Office Visit Daily Limit
    • Office Located in Hospital
    • Office Visits and Counseling
    • Physician Counseling Visits Under s. 253.10, Wis. Stats.
  • Preventive Medicine Services
    • Introduction
    • Annual Physicals
    • HealthCheck Screenings
  • Tobacco Cessation Services
    • Introduction
    • Drugs for Tobacco Cessation
• Medicine Services
  • Introduction
  • Allergy Tests
  • Audiometry
  • Biofeedback
  • Chemotherapy
    • Introduction
    • Anti-Emetic Drugs
  • Clozapine Management
  • Evoked Potentials
  • End-Stage Renal Disease Services
    • Introduction
    • Dialysis Treatment Provided Outside the Recipient's Home
    • Home Dialysis Recipients
    • Home Dialysis Recipients Who are Hospitalized
  • Fluoride — Topical Applications
    • Introduction
    • Coverage
    • Submitting Claims
    • Training Materials
  • Hospital Admissions
    • Introduction
    • Certificate of Need Requirements for Recipients Admitted to an Institution for Mental Disease
  • Immunizations
    • Introduction
    • Vaccines for Children Program
    • Vaccines for Recipients Older than Age 19
    • Synagisฎ Coverage
  • Provider-Administered Drugs
    • Introduction
    • Diagnosis Restrictions
    • Prior Authorization Requirements
    • Unclassified Drugs
    • Reimbursement
  • Laboratory Test Preparation and Handling Fees
    • Introduction
    • Additional Limitations
  • Mental Health Services
  • Psychiatric Medication Checks
  • Screenings
    • Introduction
    • Screening Procedures Coverage
    • Diagnostic Procedures
    • Service-Specific Information
  • Substance Abuse Services
  • Telemedicine
  • Weight Management Services
• Surgery Services
  • Abortions
    • Coverage Policy
    • Covered Services
    • Coverage of Mifeprex
    • Physician Counseling Visits Under s. 253.10, Wis. Stats.
    • Services Incidental to a Noncovered Abortion
  • Anesthesia by Surgeon
  • Bariatric Surgery
  • Breast Reconstruction
  • Cataract Surgery
    • Introduction
    • Surgical Care Only
    • Postoperative Management
    • Preoperative Management
  • Cochlear Implants
  • Contraceptive Implants
    • Introduction
    • Informed Consent Procedure
    • Informed Consent Documentation
  • Co-surgeons/Assistant Surgeons
  • Dilation and Curettage
  • Foot Care
    • Introduction
    • Unna Boots
  • Hysterectomies
  • Intrauterine Devices
  • Obstetric Services
    • Introduction
    • Separate Obstetric Care Components
    • Global Obstetric Care
    • Separately Covered Pregnancy-Related Services
    • Unusual Pregnancies
    • Complications of Pregnancy
    • Unrelated Conditions
    • Health Professional Shortage Area Incentive Reimbursement
    • Other Insurance/Private Pay Prior to Wisconsin Medicaid Eligibility
    • Fee-for-Service Recipients Subsequently Enrolled in a Medicaid HMO or SSI MCO
  • Newborn Reporting
    • Introduction
    • Responsibility for Reporting
    • Newborn Report Submission
    • Newborn Report Procedures
  • Newborn Screenings
  • Organ Transplants
    • Introduction
    • Prior Authorization Requirements
  • Sterilizations
    • General Requirements
    • Sterilization Consent Form
  • Temporomandibular Joint Surgery
    • Introduction
    • Prior Authorization Requirements
  • Vagal Nerve Stimulators
• Prescription Requirements
  • General Prescription Requirements
  • Drugs
    • Introduction
    • Preferred Drug List
    • Diagnosis-Restricted Drugs
    • Brand Medically Necessary Drugs
    • Prior Authorization Requirements for Other Drugs
    • Prescribing Drugs Manufactured by Companies Who Have Not Signed the Rebate Agreement
    • Drug Utilization Review System
    • Drugs with 100-Day Supply Maximum
    • Prescription Mail Delivery
    • Noncovered Drugs
    • SeniorCare
    • Epocrates
  • Disposable Medical Supplies and Durable Medical Equipment
    • Introduction
    • Breast Pumps
  • Specialized Medical Vehicle Trips Exceeding Mileage Limits
• Claims Submission
  • Introduction
  • 837 Health Care Claim: Professional
  • CMS 1500
  • Adjustments
  • Unlisted Procedures
  • ClaimCheck Review
  • Why Was Payment for a Service Denied by ClaimCheck?
• Reimbursement
  • Maximum Allowable Fees
  • Maximum Daily Reimbursement
    • Introduction
    • Surgery Services Exceeding Six Hours
  • Reimbursement Amounts
    • Physicians
    • Supervising Physicians of Interns and Residents
    • Residents
    • Physician Assistants
    • Nurse Practitioners
    • Ancillary Providers
  • Surgical Procedures
    • Introduction
    • Co-surgeons
    • Surgical Assistance
    • Bilateral Surgeries
    • Multiple Surgeries
    • Multiple Births
    • Preoperative and Postoperative Care
  • HealthCheck Services
  • Pediatric Services
  • Health Professional Shortage Areas
    • Introduction
    • Modifier
    • Antepartum Care Visits Performed in a Health Professional Shortage Area
    • Pediatric Services Performed in a Health Professional Shortage Area
    • HealthCheck Services Not Eligible for Health Professional Shortage Area Incentive Payment
• Appendix
  • Appendix 1 — Allowable Procedure Codes and Modifiers for Physician Evaluation and Management, Medicine, and Surgical Services
  • Appendix 2 — Allowable Modifiers for Physician Evaluation and Management, Medicine, and Surgery Services
  • Appendix 3 — Allowable Place of Service Codes for Physician Evaluation and Management, Medicine, and Surgery Services
  • Appendix 4 — CMS 1500 Claim Form Instructions for Physician Services
  • Appendix 5 — Sample CMS 1500 Claim Form — Physician Medical Services (Three Evaluation and Management Visits with Pediatric Modifier)
  • Appendix 6 — Sample CMS 1500 Claim Form — Physician Obstetrical Services (Antepartum Care in a Health Professional Shortage Area)
  • Appendix 7 — Sample CMS 1500 Claim Form — Physician Surgical Services (Bilateral Surgery)
  • Appendix 8 — Sample CMS 1500 Claim Form — End-Stage Renal Disease Services
  • Appendix 9 — Antepartum Care Claims Submission Guide
  • Appendix 10 — Abortion Certification Statements
  • Appendix 11 — Sterilization Informed Consent Instructions and Sample
  • Appendix 12 — Sterilization Informed Consent
  • Appendix 13 — Acknowledgement of Receipt of Hysterectomy Information
  • Appendix 14 — Breast Pump Order
  • Appendix 15 — Physician Services Requiring Prior Authorization
  • Appendix 16 — Prior Authorization Request Form (PA/RF) Completion Instructions for Physician Services
  • Appendix 17 — Sample Prior Authorization Request Form (PA/RF)
  • Appendix 18 — Prior Authorization Physician Attachment (PA/PA) Completion Instructions
  • Appendix 19 — Sample Prior Authorization Physician Attachment (PA/PA)
  • Appendix 20 — Prior Authorization Physician Attachment (PA/PA)
  • Appendix 21 — Prior Authorization "J" Code Attachment (PA/JCA) Completion Instructions
  • Appendix 22 — Prior Authorization/ "J" Code Attachment
  • Appendix 23 — Prior Authorization/ Physician Otological Report (PA/POR) Completion Instructions
  • Appendix 24 — Prior Authorization/ Physician Otological Report (PA/POR)
  • Appendix 25 — Health Professional Shortage Area-Eligible Procedure Codes and ZIP Codes
  • Appendix 26 — Clozapine Management
  • Appendix 27 — Allowable Temporomandibular Joint Surgery and Anesthesia Procedure Codes and Temporomandibular Joint Evaluation Programs
  • Appendix 28 — Certification of Need for Specialized Medical Vehicle Transportation
  • Appendix 29 — Wisconsin Medicaid Newborn Report
  • Appendix 30 — Declaration of Supervision for Nonbilling Providers Instructions
  • Appendix 31 — Declaration of Supervision for Nonbilling Providers
  • Appendix 32 — Diagnosis-Restricted Provider-Administered Drugs
• PDF

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Medicine and Surgery

General Information

Prior Authorization

Prior Authorization Request Forms and Attachments

Physician services providers should use the following Wisconsin Medicaid forms for requesting PA:

• Prior Authorization Request Form.
• Prior Authorization/Physician Attachment (PA/PA), HCF 11016 (fillable PDF, 66 KB).
• Prior Authorization/“J” Code Attachment (PA/JCA), HCF 11034 (fillable PDF, 84 KB).
• Prior Authorization/Physician Otological Report (PA/POR), HCF 11019 (fillable PDF, 93 KB).
• Prescription drug PA forms.

Prior Authorization Request Form

The PA/RF functions as the cover page of the PA request. Providers are required to complete the basic provider, recipient, and service information on the PA/RF. The PA/RF completion instructions for physician services are located in Appendix 16 of this section for photocopying and may also be downloaded and printed from the Medicaid Web site. Refer to Appendix 17 for a sample PA/RF.

Prior Authorization/Physician Attachment

The PA/PA allows a provider to document the clinical information used to determine whether the standards of medical necessity are met for the requested service(s). Physician services providers should use the PA/PA for most services requiring PA. The completion instructions and a sample PA/PA are located in Appendix 18 and Appendix 19 of this section. The PA/PA can be downloaded and printed from the Medicaid Web site or photocopied from Appendix 20 of this section.

Prior Authorization/“J” Code Attachment

The purpose of the PA/JCA is to document the medical necessity of physician-administered drugs requiring PA. The completion instructions and PA/JCA are located in Appendix 21 and Appendix 22 of this section for photocopying and may also be downloaded and printed from the Medicaid Web site.

Prior Authorization/Physician Otological Report

Completion of the PA/POR begins the process by which PA is obtained for a hearing aid by a hearing instrument specialist. The physician gives page one (or a copy) of the completed PA/POR to the recipient and keeps page two (or a copy of it) in the recipient’s medical records. The recipient then takes the PA/POR to any Medicaid-certified hearing instrument specialist to receive a hearing aid. The completion instructions and PA/POR are located in Appendix 23 and Appendix 24 of this section for photocopying and may also be downloaded and printed from the Medicaid Web site.

Prescription Drug Prior Authorization Forms

Prescribers are required to complete prescription drug PA forms for selected drugs and submit them to the pharmacy where the prescription will be filled. Providers may fax or mail the completed drug PA form to the pharmacy or send the completed drug PA form with the recipient. Prescribers should not send prescription drug PA forms directly to Wisconsin Medicaid. Refer to the Prescription Requirements chapter of this section for more information.

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