The Wisconsin Medicaid and BadgerCare Prenatal Care Coordination Services Handbook is issued to prenatal care coordination providers who are Wisconsin Medicaid certified. It contains information that applies to fee-for-service Medicaid providers. The Medicaid information in the handbook applies to both Medicaid and BadgerCare.
Wisconsin Medicaid and BadgerCare are administered by the Department of Health and Family Services (DHFS). Within the DHFS, the Division of Health Care Financing (DHCF) is directly responsible for managing Wisconsin Medicaid and BadgerCare. BadgerCare extends Medicaid coverage to uninsured children and parents with incomes at or below 185% (as of January 2001) of the federal poverty level and who meet other program requirements. BadgerCare recipients receive the same health benefits as Wisconsin Medicaid recipients and their health care is administered through the same delivery system.
Medicaid and BadgerCare recipients enrolled in state-contracted HMOs are entitled to at least the same benefits as fee-for-service recipients; however, HMOs may establish their own requirements regarding prior authorization, billing, etc. If you are an HMO network provider, contact your managed care organization regarding its requirements. Information contained in this and other Medicaid publications is used by the DHCF to resolve disputes regarding covered benefits that cannot be handled internally by HMOs under managed care arrangements.
Verifying Eligibility
Wisconsin Medicaid providers should always verify a recipient’s eligibility before providing services, both to determine eligibility for the current date and to discover any limitations to the recipient’s coverage. Wisconsin Medicaid’s Eligibility Verification System (EVS) provides eligibility information that providers can access a number of ways.
Refer to the Important Telephone Numbers page at the beginning of this handbook for detailed information on the methods of verifying eligibility.
Handbook Organization
The Prenatal Care Coordination Services Handbook consists of the following chapters:
In addition to the Prenatal Care Coordination Services Handbook, each Medicaid-certified provider is issued a copy of the All-Provider Handbook. The All-Provider Handbook includes the following sections:
- Claims Submission.
- Coordination of Benefits.
- Covered and Noncovered Services.
- Prior Authorization.
- Provider Certification.
- Provider Resources.
- Provider Rights and Responsibilities.
- Recipient Rights and Responsibilities.
Legal Framework of Wisconsin Medicaid and BadgerCare
The following laws and regulations provide the legal framework for Wisconsin Medicaid and BadgerCare:
Federal Law and Regulation
- Law: United States Social Security Act; Title XIX (42 US Code ss. 1396 and following) and Title XXI.
- Regulation: Title 42 CFR Parts 430 - 456 -- Public Health.
Wisconsin Law and Regulation
- Law: Wisconsin Statutes: Sections 49.43 - 49.497 and 49.665.
- Regulation: Wisconsin Administrative Code, Chapters HFS 101 - 108.
Handbooks and Wisconsin Medicaid and BadgerCare Updates further interpret and implement these laws and regulations.
Handbooks and Updates, maximum allowable fee schedules, helpful telephone numbers and addresses, and much more information about Wisconsin Medicaid and BadgerCare are available at the following Web sites:
dhs.wisconsin.gov/medicaid
dhfs.wisconsin.gov/badgercareplus/
Medicaid Fiscal Agent
The DHFS contracts with a fiscal agent, which is currently EDS, to provide health claims processing, communications, and other related services.
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