• Certification and Ongoing Responsibilities
  • Introduction
  • Other Facilities
  • Responsibilities
  • Supervision Requirements
    • Introduction
    • Declaration of Supervision
    • Supervision Waiver
  • Durable Medical Equipment and Disposable Medical Supplies
• Provider Communication
  • Introduction
  • Coordination with School-Based Services Providers
  • Coordination with County Birth to 3 Programs
  • Therapy Services for Children Brochure
  • Guide to Obtaining Augmentative Communication Devices and Accessories
  • Directory of Used Medical Equipment
• Documentation Requirements
  • Introduction
  • Prescriptions
  • Evaluations
  • Plan of Care
  • Daily Entries
• Services and Requirements
  • Introduction
  • Initial Spell of Illness
  • Daily Limitations
  • Duplicate Services
  • Evaluations
  • Group Therapy
  • Natural Environments
  • Durable Medical Equipment and Disposable Medical Supplies
  • HealthCheck "Other Services"
  • Services Not Separately Reimbursable
  • Reimbursement Not Available
• Codes
  • Procedure Codes
    • Introduction
    • Unit of Service
  • Modifiers
  • Place of Service Codes
  • Diagnosis Codes
• Prior Authorization
  • Introduction
  • Prior Authorization Forms and Attachments
  • Medical Necessity
    • Introduction
    • Relationship of Medical Necessity to Clinical Practice Principles
  • Flexibility of Approved Services
    • Introduction
    • Plan of Care Must Reflect Flexibility of Approved Services
    • Duration of Approved Services
    • Coordinating Multiple Prior Authorization Requests
• Requesting Extension of Therapy, Maintenance Therapy, and Services That Always Require Prior Authorization
  • Introduction
  • Approval Criteria
  • Extension of Therapy
  • Maintenance Therapy
    • Introduction
    • Direct Maintenance
    • Monitoring Maintenance
    • Discontinuing Maintenance
  • Services That Always Require Prior Authorization
    • Introduction
    • Cotreatment
    • Dual Treatment
    • Unlisted Procedure Codes
    • Decubitus Ulcers
• Requesting Spell of Illness
  • Introduction
  • Maximum Allowable Treatment Days
    • Introduction
    • Unused Treatment Days
• Extension of Therapy vs. Spell of Illness
• Requesting Services for Birth to 3 Participants
  • Introduction
  • Situations That Do Not Qualify for Birth to 3
• Requesting Amendments
  • Introduction
  • Approval Criteria
  • Reasons for Denial
• Claims
  • Introduction
  • 837 Health Care Claim: Professional
  • CMS 1500
  • Provider Numbers
    • Individual Providers
    • Groups, Clinics, and Nursing Homes
    • Rehabilitation Agencies
    • Hospitals
  • Referring Provider
  • Evaluations
  • Services Provided Beyond Daily Limits
  • Unlisted Procedure Codes
  • Multiple Services During One Session
  • Submitting Claims for Birth to 3 Services
• Reimbursement
  • Maximum Allowable Fees
  • Reimbursement Methods
    • Introduction
    • Natural Environment Enhanced Reimbursement
  • Copayment
    • Introduction
    • Annual Copayment Maximum
• Appendix
• PDF

Certification and Ongoing Responsibilities

Responsibilities

The following laws and regulations provide the legal framework for the program requirements in this handbook:

• Section 15, Wis. Stats., gives general powers to examining boards that license PT, OT, and SLP providers.
• Section 227, Wis. Stats., gives an agency the authority to promulgate rules.
• Section 448, Wis. Stats., outlines the qualifications for licensure or certification of PT or OT providers.
• Section 459, Wis. Stats., outlines the qualifications for licensure of SLP providers.
• Section 448, Wis. Stats., and Ch. PT, Wis. Admin. Code, define the scope of practice for PT providers.
• Section 448, Wis. Stats., and Ch. OT, Wis. Admin. Code, define the scope of practice for OT providers.
• Section 459, Wis. Stats., and Ch. HAS, Wis. Admin. Code, define the scope of practice for SLP providers.

To participate in Wisconsin Medicaid, providers are required to be certified by Wisconsin Medicaid as described in HFS 105, Wis. Admin. Code. Medicaid-certified providers have responsibilities that include, but are not limited to, the following:

• Providing the same level and quality of care to Medicaid recipients as private-pay patients.
• Billing only for services that were actually provided.
• Complying with all state and federal laws related to Wisconsin Medicaid.
• Obtaining prior authorization for certain services, when applicable.
• Notifying recipients in advance if a service is not Medicaid covered.
• Maintaining accurate medical and billing records.
• Allowing a recipient access to his or her records.
• Monitoring contracted staff.
• Accepting Medicaid reimbursement as payment in full for covered services.
• Keeping provider information (e.g., address, business name, business ownership) current.
• Responding to Medicaid recertification notifications.
• Safeguarding recipient confidentiality.
• Verifying recipient eligibility.
• Keeping up-to-date with changes in program requirements as published in Medicaid publications.

Providers are required to refer to the All-Provider Handbook for more information on these and other topics. Providers should also refer to the Certification and Ongoing Responsibilities section of the All-Provider Handbook for information about certification, provider rights, and recertification.

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