• 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

Requesting Spell of Illness

Physical therapy (PT), occupational therapy (OT), and speech and language pathology (SLP) providers should submit the Prior Authorization/Spell of Illness Attachment (PA/SOIA), HCF 11039 (fillable PDF, 54 KB), when requesting approval for SOI.

The completion instructions and PA/SOIA are located in Appendix 31 and Appendix 32 of this handbook for photocopying and may also be downloaded and printed from the Medicaid Web site.

After the initial SOI, any new disease, injury, medical condition, or increased severity of a pre-existing medical condition that requires PT, OT, or SLP services is called a subsequent SOI. A subsequent SOI always requires PA.

When submitting the PA/SOIA, providers are required to provide the appropriate primary International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code or the appropriate ICD-9-CM surgical procedure code and answer “yes” or “no” to seven statements about the recipient’s diagnosis or condition. The answers to these statements are used to determine if the SOI request will be approved. If the PA request is approved, Wisconsin Medicaid uses the combination of the ICD-9-CM code and the answers to these statements to assign the maximum allowable treatment days for the SOI.

A PA request for an SOI may be approved if all of the following are true:

• The recipient has incurred a demonstrated functional loss of ability to perform daily living skills within the past six weeks, and there is measurable evidence to support this.
• There is a reasonable expectation that the recipient will return to his or her previous level of function by the end of this SOI or sooner.
• Only one of statements “A” through “F” from Element 11 of the PA/SOIA (fillable PDF, 54 KB) would be marked “yes.” If the recipient’s condition could be categorized by more than one of statements “A” through “F,” providers should choose the statement that best describes the reason for the SOI. Examples of situations covered in statements “A” through “F” are provided on the back of the PA/SOIA.

If these conditions are not met, Wisconsin Medicaid will return the PA request and instruct the provider to use the Prior Authorization/Therapy Attachment (PA/TA), HCF 11008 (fillable PDF, 134 KB).

Next — Requesting Spell of Illness, Maximum Allowable Treatment Days
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