• 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

Claims

Submitting Claims for Birth to 3 Services

Federal regulations allow a Birth to 3 (B-3) participant’s parents or guardians to refuse consent to bill their commercial health insurance (34 CFR Part 303) if it would result in a cost to the family, such as:

• Reaching the lifetime limit on a policy.
• An increase in premiums, copayments, or deductibles.

Birth to 3 agencies may reimburse the commercial health insurance liability when both of the following occur:

• The Medicaid recipient participates in the B-3 Program and is receiving B-3 services.
• The parents or guardians do not allow their Medicaid provider or Medicaid HMO to bill their commercial health insurance first.

Refer to Appendix 39 of this handbook for procedures to follow when the B-3 agency reimburses the commercial health insurance liability.

When a child’s parents or guardians give consent to billing their commercial health insurance (or when the child has no commercial health insurance coverage), federal and state regulations require the provider to submit claims in the following order:

1. Bill the commercial health insurance with the informed, written consent of the child’s parents or guardians if applicable.
2. Submit claims to Wisconsin Medicaid.
3. Bill the county B-3 agency (according to the agency’s requirements) if Wisconsin Medicaid does not cover the services.

Next — Reimbursement, Maximum Allowable Fees
Previous — Claims, Multiple Services During One Session