• Certification and Ongoing Responsibilities
  • Introduction
  • Other Facilities
  • Responsibilities
  • Supervision Requirements
    • Introduction
    • Declaration of Supervision
    • Supervision Waiver
  • Durable Medical Equipment and Disposable Medical Supplies
• Provider Communication
  • Introduction
  • Coordination with School-Based Services Providers
  • Coordination with County Birth to 3 Programs
  • Therapy Services for Children Brochure
  • Guide to Obtaining Augmentative Communication Devices and Accessories
  • Directory of Used Medical Equipment
• Documentation Requirements
  • Introduction
  • Prescriptions
  • Evaluations
  • Plan of Care
  • Daily Entries
• Services and Requirements
  • Introduction
  • Initial Spell of Illness
  • Daily Limitations
  • Duplicate Services
  • Evaluations
  • Group Therapy
  • Natural Environments
  • Durable Medical Equipment and Disposable Medical Supplies
  • HealthCheck "Other Services"
  • Services Not Separately Reimbursable
  • Reimbursement Not Available
• Codes
  • Procedure Codes
    • Introduction
    • Unit of Service
  • Modifiers
  • Place of Service Codes
  • Diagnosis Codes
• Prior Authorization
  • Introduction
  • Prior Authorization Forms and Attachments
  • Medical Necessity
    • Introduction
    • Relationship of Medical Necessity to Clinical Practice Principles
  • Flexibility of Approved Services
    • Introduction
    • Plan of Care Must Reflect Flexibility of Approved Services
    • Duration of Approved Services
    • Coordinating Multiple Prior Authorization Requests
• Requesting Extension of Therapy, Maintenance Therapy, and Services That Always Require Prior Authorization
  • Introduction
  • Approval Criteria
  • Extension of Therapy
  • Maintenance Therapy
    • Introduction
    • Direct Maintenance
    • Monitoring Maintenance
    • Discontinuing Maintenance
  • Services That Always Require Prior Authorization
    • Introduction
    • Cotreatment
    • Dual Treatment
    • Unlisted Procedure Codes
    • Decubitus Ulcers
• Requesting Spell of Illness
  • Introduction
  • Maximum Allowable Treatment Days
    • Introduction
    • Unused Treatment Days
• Extension of Therapy vs. Spell of Illness
• Requesting Services for Birth to 3 Participants
  • Introduction
  • Situations That Do Not Qualify for Birth to 3
• Requesting Amendments
  • Introduction
  • Approval Criteria
  • Reasons for Denial
• Claims
  • Introduction
  • 837 Health Care Claim: Professional
  • CMS 1500
  • Provider Numbers
    • Individual Providers
    • Groups, Clinics, and Nursing Homes
    • Rehabilitation Agencies
    • Hospitals
  • Referring Provider
  • Evaluations
  • Services Provided Beyond Daily Limits
  • Unlisted Procedure Codes
  • Multiple Services During One Session
  • Submitting Claims for Birth to 3 Services
• Reimbursement
  • Maximum Allowable Fees
  • Reimbursement Methods
    • Introduction
    • Natural Environment Enhanced Reimbursement
  • Copayment
    • Introduction
    • Annual Copayment Maximum
• Appendix
• PDF

Services and Requirements

A covered service is a service, item, or supply for which Medicaid reimbursement is available when all program requirements are met. 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 Covered and Noncovered Services section of the All-Provider Handbook for more information about covered services, medical necessity, services that are not separately reimbursable, services that do not meet program requirements, noncovered services, and situations when it is permissible to collect payment from recipients for noncovered services.

Covered physical therapy (PT), occupational therapy (OT), and speech and language pathology (SLP) services are identified by the procedure codes listed in Appendices 8,  9, and 10 of this handbook.

To receive Medicaid reimbursement for a covered service, all Medicaid requirements must be met. For PT, OT, and SLP services, the following statements must be true:

• Professional skills of a PT, OT, or SLP provider are required to meet the recipient’s therapy treatment needs.
• Services are cost-effective when compared with other services that meet the recipient’s needs.
• Services are established in a written plan of care (POC) before they are provided.
• Services are medically necessary as defined under HFS 101.03(96m), Wis. Admin. Code.
• Services are performed by a qualified provider and supervision requirements are met.
• Services are prescribed by a physician.
• Services are prior authorized by Wisconsin Medicaid, when applicable.

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