General Information
Recipient Information
Wisconsin Medicaid HMO Coverage
Wisconsin Medicaid HMOs are not required to cover medically necessary chiropractic services. If a Medicaid HMO elects not to cover chiropractic services, the services may be covered under Medicaid fee-for-service.
Medicaid HMOs That Do Not Cover Chiropractic Services
If a Medicaid HMO elects not to cover chiropractic services, chiropractic providers treating these HMO enrollees as fee-for-service recipients are required to follow all Medicaid fee-for-service policies, billing procedures, and PA procedures. This includes collecting the appropriate copayment amount when applicable. Providers should bill Wisconsin Medicaid their usual and customary charges.
Medicaid HMOs That Do Cover Chiropractic Services
If a Medicaid HMO covers chiropractic services, the enrollee is required to see an HMO network provider unless the HMO authorizes a non-network provider to provide the service. All non-network chiropractic providers are required to receive PA from the HMO to treat the Medicaid HMO enrollee. If the chiropractic service is covered by the HMO, the recipient is exempt from the copayment requirement.
Checking Eligibility, HMO Enrollment, and HMO Chiropractic Coverage
Providers should always verify the eligibility of any recipient they are serving. The Wisconsin Medicaid EVS will indicate if the recipient is enrolled in an HMO and if the HMO covers chiropractic services. For more information on the EVS, refer to the Provider Resources section of the All-Provider Handbook.
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Chiropractic Services Handbook
PHC 1306, October 2004