Handbook Section or Appendix Description
Wisconsin Medicaid Mental Health & Alcohol and Other Drug Abuse Services, Part H, Division I:
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Page Numbers

PDF File for downloading

• Cover of handbook.

• Transmittal log.

• Introduction to the handbook.

• Table of contents for sections and appendices.

PDF
(113 kb)

Section I - General Information

1H1-001
to
1H1-005

PDF
(631 kb)

Section II - Covered Services & Related Limitations

1H2-001
to
1H2-011

PDF
(1500 kb)

Section III - Prior Authorization

1H3-001
to
1H3-005

PDF
(616 kb)

Section IV - Billing Information.

1H4-001
to
1H4-003

PDF
(368 kb)

Appendix 1: National HCFA 1500 Claim Form Instructions for Non-51.42 Board Operated Psychotherapy/Alcohol and Other Drug Abuse Services

1H5-003
to

1H5-007

PDF
(487 kb)

Appendix 2a: Sample HCFA 1500 Claim Form Sample - Non-51.42 Board Psychotherapy Services

1H5-009

PDF
(122 kb)

Appendix 2b: Sample HCFA 1500 Claim Form Sample - Non-51.42 Board AODA Services

1H5-011

PDF
(121 kb)

Appendix 3: Wisconsin Medicaid Allowable Procedure Codes for Non-51.42 Board Providers

1H5-013
to
1H5-014

PDF
(118 kb)

Appendix 4: Instructions for the Completion of the Prior Authorization Request Form (PA/RF) for Psychotherapy/Alcohol and Other Drug Abuse Services

1H5-015
to
1H5-016

PDF
(223 kb)

Appendix 5a: Sample Prior Authorization Request Form (PA/RF) - Psychotherapy

1H5-017

PDF
(76 kb)

Appendix 5b: Sample Prior Authorization Request Form (PA/RF) - AODA

1H5-019

PDF
(75 kb)

Appendix 5c: Sample Prior Authorization Request Form (PA/RF) - Evaluation and Testing

1H5-021

PDF
(74 kb)

Appendix 6: Instructions for the Completion of the Prior Authorization Psychotherapy Attachment (PA/PSYA) | Revised Instructions (PDF, 36 KB) | Revised Form (PDF, 44 KB)

1H5-023
to
1H5-025

PDF
(326 kb)

Appendix 7: Sample Prior Authorization Psychotherapy Attachment (PA/PSYA)

1H5-027
to
1H5-028

PDF
(202 kb)

Appendix 8: Summary of Outpatient Psychotherapy Prior Authorization Guidelines (for use with the Prior Authorization Psychotherapy Attachment: PA/PSYA)

1H5-029

PDF
(106 kb)

Appendix 9: Instructions for the Completion of the Prior Authorization AODA Attachment (PA/AA)

1H5-031
to
1H5-032

PDF
(167 kb)

Appendix 10: Sample Prior Authorization AODA Attachment (PA/AA)

PDF
(279 kb)

Appendix 11: Summary of Outpatient AODA and AODA Intensive Outpatient Treatment Prior Authorization Guidelines (for use With the Prior Authorization AODA Attachment: PA/AA)

1H5-037
to
1H5-038

PDF
(174 kb)

Appendix 12: Instructions for the Completion of the Prior Authorization Evaluation and Testing Attachment (PA/ETA) | PA/ETA Form (PDF, 91 KB)

1H5-039
to
1H5-040

Appendix 13: Sample Prior Authorization Evaluation and Testing Attachment (PA/ETA)

1H5-041
to
1H5-042

PDF
(125 kb)

Appendix 14: Summary of Prior Authorization Guidelines for the Prior Authorization Evaluation and Testing Attachment (PA/ETA)

1H5-043

PDF
(75 kb)

Appendix 15: Copayment Schedule for Psychotherapy and AODA Services

1H5-045

PDF
(51 kb)

Appendix 16: Wisconsin Medicaid-Allowable Place of Service (POS) and Type of Service (TOS) Codes for Non-51.42 Board-Operated Clinics

1H5-047

PDF
(47 kb)

Appendix 17: Rounding Guidelines

1H5-049

PDF
(31 kb)

Appendix 18: Wisconsin Medicaid-Allowable Procedure Codes for Neuropsychological Testing

1H5-051

PDF
(34 kb)

Appendix 19: Billing Hints for Mental Health Services Billed on the HCFA 1500 Claim Form

1H5-053
to
1H5-054

PDF
(129 kb)

Appendix 20: Billing Hints for Mental Health Services Sample Claim Form

1H5-055

PDF
(121 kb)

Appendix 21: Paperless Claims Request Form

1H5-057
to
1H5-058

PDF
(210 kb)

Appendix 22: Wisconsin Peer Review Organization (WIPRO) Review Process

1H5-059
to
1H5-060

PDF
(148 kb)

Entire Mental Health and Alcohol and Other Drug Abuse Services Handbook, Part H, Division I

All

PDF
(7240 kb)

All Handbook Sections (except Appendices). Includes Table of Contents and Section I, II, III, and IV.

Everything except Appendices

PDF
(3291 kb)

All Appendices. Includes Appendix Table of Contents as well as Appendix 1 to Appendix 22

Appendices only

PDF
(3802 kb)