Handbook Section or Appendix Description
Wisconsin Medicaid Mental Health & Alcohol and Other Drug Abuse Services, Part H, Division II
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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
(424 kb)

Section I - General Information

2H1-001
to
2H1-005

PDF
(606 kb)

Section II - Covered Services & Related Limitations

2H2-001
to
2H2-010

PDF
(1404 kb)

Section III - Prior Authorization

2H3-001
to
2H3-005

PDF
(604 kb)

Section IV - Billing Information.

2H4-001
to
2H4-004

PDF
(396 kb)

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

2H5-003
to
2H5-007

PDF
(467 kb)

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

2H5-009

PDF
(121 kb)

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

2H5-011

PDF
(120 kb)

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

2H5-013
to
2H5-014

PDF
(106 kb)

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

2H5-015
to
2H5-016

PDF
(215 kb)

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

2H5-017

PDF
(79 kb)

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

2H5-019

PDF
(78 kb)

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

2H5-021

PDF
(79 kb)

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

Appendix 7: Sample Prior Authorization Psychotherapy Attachment (PA/PSYA) | Revised Form (PDF, 44 KB)

2H5-027
to
2H5-028

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

2H5-029

PDF
(106 kb)

Appendix 9: Instructions for the Completion of the Prior Authorization AODA Attachment (PA/AA) | (New PA/SAA Completion Instructions,  for use in place of the PA/AA after HIPAA implementation)

2H5-031
to
2H5-032

Appendix 10: Sample Prior Authorization AODA Attachment (PA/AA) | (New PA/SAA,  for use in place of the PA/AA after HIPAA implementation)

2H5-033
to
2H5-036

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

2H5-037
to
2H5-038

PDF
(175 kb)

Appendix 12: Instructions for the Completion of the Prior Authorization Evaluation and Testing Attachment (PA/ETA) | Revised Instructions (PDF, 62 KB)

2H5-039
to
2H5-040

Appendix 13: Sample Prior Authorization Evaluation and Testing Attachment (PA/ETA) | Revised Form (PDF, 91 KB)

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

2H5-043

PDF
(75 kb)

Appendix 15: Copayment Schedule for Psychotherapy and AODA Services

2H5-045

PDF
(38 kb)

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

2H5-047

PDF
(43 kb)

Appendix 17: Rounding Guidelines

2H5-049

PDF
(31 kb)

Appendix 18: Billing Hints for Mental Health Services Billed on the HCFA 1500 Claim Form

2H5-051
to
2H5-052

PDF
(128 kb)

Appendix 19: Billing Hints for Mental Health Services Sample Claim Form

2H5-053

PDF
(119 kb)

Appendix 20: Paperless Claims Request Form

2H5-055
to
2H5-056

PDF
(209 kb)

Appendix 21: Wisconsin Peer Review Organization (WIPRO) Review Process

2H5-057
to
2H5-058

PDF
(148 kb)

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

All

PDF
(7077 kb)

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

Everything except Appendices

PDF
(3319 kb)

All Appendices. Includes Appendix Table of Contents as well as Appendix 1 to Appendix 21

Appendices only

PDF
(3759 kb)