• 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

Prior Authorization

Prior authorization (PA) is required for certain services before they are provided. Wisconsin Medicaid does not reimburse providers for services provided either before the grant date or after the expiration date indicated on the approved Prior Authorization Request Form (PA/RF), HCF 11018. If the provider delivers a service either before the grant date or after the expiration date of an approved PA, or provides a service that requires PA without obtaining PA, the provider is responsible for the cost of the service. In these situations, providers may not collect payment from the recipient. Providers should refer to HFS 107.02(3), Wis. Admin. Code, for more information about Medicaid PA requirements.

Prior authorization does not guarantee payment. To receive Medicaid reimbursement, provider and recipient eligibility on the date of service, as well as all other Medicaid requirements, must be met.

For more information about general PA requirements, obtaining PA forms, submitting PA requests, and PA decisions, refer to the Prior Authorization section of the All-Provider Handbook.

Wisconsin Medicaid requires PA for the following:

• Physical therapy (PT), occupational therapy (OT), and speech and language pathology (SLP) services provided subsequent to the recipient’s initial spell of illness (SOI).
• Physical therapy, OT, and SLP services that require PA starting with the first day of treatment. (Refer to the Requesting Extension of Therapy, Maintenance Therapy, and Services That Always Require Prior Authorization chapter of this handbook for information about services that always require PA.)

To avoid potential claim denials, providers are encouraged to request PA when they are unsure whether the recipient has received, or is currently receiving, PT, OT, or SLP services from another provider.

Prior authorization requests for PT, OT, and SLP services must be received by Wisconsin Medicaid within two weeks of performing the initial evaluation. This allows the PA request to be backdated to the date the evaluation was performed.

Next — Prior Authorization, Prior Authorization Forms and Attachments
Previous — Codes, Diagnosis Codes