• Provider Information
  • Introduction
  • Scope of Services
  • Services Provided by Registered Nurses
    • Introduction
    • Supervision of Delegated Tasks
  • Services Provided by Licensed Practical Nurses
  • Classification of Nursing Services
  • Wisconsin Medicaid Certification Requirements
  • Requirements for Providing Ventilator-Dependent Services
    • Introduction
    • Demonstration Renewals
    • Age-Specific Requirements
  • Changes in Certification
• Rights and Responsibilities
  • Introduction
  • Universal Precautions
  • Unacceptable Practices
  • Fees Prohibited by Wisconsin Medicaid
  • Private Duty Nursing Requirements
  • Emergency and Back-Up Procedures
  • Verifying Recipient Eligibility
    • Introduction
    • Limited Benefit Categories
  • Distribution of Medicaid Information
  • Written Statement of Recipient Rights
  • Contracts with Recipient and/or Family
  • Terminating Service to a Recipient
  • Recipient Responsibilities
    • Arrangements with Nurses in Independent Practice
    • Scheduling Providers
    • Freedom from Liability for Covered Services
• Covered Services and Related Limitations
  • Introduction
  • Private Duty Nursing Benefit
  • Recipient Eligibility for Private Duty Nursing Services
    • Introduction
    • Ventilator-Dependent Recipients
    • Recipients Who Are Not Eligible for Private Duty Nursing Services
  • Hours of Care That Qualify as Private Duty Nursing Services
  • Private Duty Nursing Services Reimbursement Requirements
  • Place of Service for Private Duty Nursing Recipients
  • Providing Disposable Medical Supplies
  • Coordination Services for Ventilator-Dependent Recipients
    • Introduction
    • Documenting Coordination Services
    • Reimbursable Coordination Responsibilities
    • Change in Coordinators
  • Coordination Services for Recipients Not Ventilator-Dependent
    • Introduction
    • Coordination Services Documentation
    • Coordination Responsibilities
    • Change in Coordinators
  • Case Sharing
    • Introduction
    • Provider Responsibility
    • Case Sharing Documentation
  • Reimbursement Not Available
    • Introduction
    • Travel and Record-Keeping Time
• Documentation Requirements
  • Introduction
  • Required Information for Medical Record
    • Introduction
    • Physician Signature
  • Documentation Requirements of Supervising Nurses
  • Availability of Records to Others
    • Introduction
    • Record Maintenance After Termination as Wisconsin Medicaid Provider
• Plan of Care
  • Introduction
  • Plan of Care Documentation Methods
    • Introduction
    • Submitting Another Format for the Recipient's Plan of Care
  • Obtaining Plan of Care Forms
  • Developing the Plan of Care
  • Physician's Orders and Signature
    • Introduction
    • Start of Care
    • Certification Period
    • Verbal Orders
  • Plan of Care Requirements
  • Medical Necessity and the Plan of Care
  • Changes to the Plan of Care
• Prior Authorization
  • Introduction
  • Responsibility for Prior Authorization
  • Services Requiring Prior Authorization
    • Introduction
    • Limits on Authorized Services
  • Requesting Private Duty Nursing Hours
    • Introduction
    • Hours of Private Duty Nursing for Children
    • Requesting Pro Re Nata Hours
    • Flexible Use of Weekly Hours
  • Required Documentation for Prior Authorization Requests
    • Introduction
    • Prior Authorization Request Form
    • Private Duty Nursing Prior Authorization Acknowledgment
    • Prior Authorization Attachments
  • Submitting Prior Authorization Requests
  • Prior Authorization Effective Dates
  • Prior Authorization Responses
  • Prior Authorization Backdating
    • Introduction
    • Initial Requests
    • Extraordinary Circumstances
    • Subsequent Requests Will Not Be Backdated
    • Returned Requests
    • Amendment Requests
    • Denied Requests
  • Amending an Approved or Modified Prior Authorization Request
  • Enddating a Prior Authorization Request
  • Out-of-State Private Duty Nursing
    • Introduction
    • Out-of-State Prior Authorization Request Requirements
    • Procedure for Obtaining Authorization for Out-of-State Travel
• Claims Submission
  • Introduction
  • Claims Submission Options
    • Introduction
    • Paper Claims Submission
  • Follow-Up to Claims Submission
  • Billing Across Midnight
  • Daylight Savings Time
• Codes for Prior Authorization and Claims
  • Introduction
  • Revenue Codes
  • Date of Service
  • Procedure Codes
  • Modifiers
    • Introduction
    • Start-of-Shift Modifiers
    • Professional Status Modifiers
    • Case Coordination Modifier
  • Units of Service
    • Introduction
    • Rounding Guidelines
  • Prior Authorization Number
  • Diagnosis Code
• Appendix
• PDF

 

 

Prior Authorization

Amending an Approved or Modified Prior Authorization Request

Under certain circumstances, providers may amend an approved or modified PA. Examples of these types of circumstances include, but are not limited to, the following:

• The recipient’s Medicaid identification number changes.
• There is a short-term change in the recipient’s medical condition and the frequency of a service needs to be modified temporarily, regardless of whether it is an increase or decrease in level of care or hours. Physician orders that reflect the change are required.
• A provider reduces the number of hours of service because another provider begins to share the case. Requests for additional services by another provider may be denied if the number of hours on the first PA are not reduced at the same time.
• There is a change in case coordination responsibilities on a ventilator-dependent recipient’s case.

Providers may also submit a reconsideration request in the form of an amendment when a request has been modified. Providers may request reconsideration by submitting an amendment request with additional documentation that supports the original request. The amendment request should be received within 14 calendar days of the adjudication date on the original PA/RF or amendment. If the amendment request is approved, Wisconsin Medicaid will notify the provider of the effective date.

Note:

If there is a significant, long-term change that requires a new POC, then Wisconsin Medicaid recommends that providers enddate the current PA and submit a new PA request.

 The amendment request should include:

• A completed Prior Authorization Amendment Request, HCF 11042 (fillable PDF, 23 KB), describing the specific change requested and the reason for the request. Provide sufficient detail for Wisconsin Medicaid to determine the medical necessity of the requested services.
• A copy of the PA/RF to be amended (not a new PA/RF).
• A copy of the updated PA/HCA (fillable PDF, 139 KB), the recipient’s POC in another format that contains all of the components requested in the completion instructions of the PA/HCA (PDF, 50 KB), or the physician’s orders. If current orders continue to be compatible with the new request, new orders are not necessary.
• Additional supporting materials or medical documentation explaining or justifying the requested changes.

The completion instructions and Prior Authorization Amendment Request are located in Appendix 10 and Appendix 11 of this handbook for photocopying and may also be downloaded and printed from the Medicaid Web site.

Next — Prior Authorization, Enddating a Prior Authorization Request
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