DHS 107.13(1)(b)5.d. d. The development and review of the plan of care under this subdivision shall satisfy the utilization control requirements for physician certification and establishment and periodic review of the plan of care.
DHS 107.13(1)(b)6. 6. `Evaluation.'
DHS 107.13(1)(b)6.a.a. Before a recipient is admitted to a psychiatric hospital or before payment is authorized for a patient who applies for MA, the attending physician or staff physician shall make a medical evaluation of each applicant's or recipient's need for care in the hospital, and appropriate professional personnel shall make a psychiatric and social evaluation of the applicant's or recipient's need for care.
DHS 107.13(1)(b)6.b. b. Each medical evaluation shall include a diagnosis, a summary of present medical findings, medical history, the mental and physical status and functional capacity, a prognosis, and a recommendation by a physician concerning admission to the psychiatric hospital or concerning continued care in the psychiatric hospital for an individual who applies for MA while in the hospital.
DHS 107.13(1)(b)7. 7. `Physician certification.'
DHS 107.13(1)(b)7.a.a. A physician shall certify and recertify for each applicant or recipient that inpatient services in a psychiatric hospital are or were needed.
DHS 107.13(1)(b)7.b. b. The certification shall be made at the time of admission or, if an individual applies for assistance while in a psychiatric hospital, before the agency authorizes payment.
DHS 107.13(1)(b)7.c. c. Recertification shall be made at least every 60 days after certification.
DHS 107.13(1)(b)8. 8. `Physician's plan of care.'
DHS 107.13(1)(b)8.a.a. Before a recipient is admitted to a psychiatric hospital or before payment is authorized, the attending physician or staff physician shall document and sign a written plan of care for the recipient or applicant. The physician's plan of care shall include diagnosis, symptoms, complaints and complications indicating the need for admission; a description of the functional level of the individual; objectives; any orders for medications, treatments, restorative and rehabilitative services, activities, therapies, social services, diet or special procedures recommended for the health and safety of the patient; plans for continuing care, including review and modification to the plan of care; and plans for discharge.
DHS 107.13(1)(b)8.b. b. The attending or staff physician and other personnel involved in the recipient's care shall review each plan of care at least every 30 days.
DHS 107.13(1)(b)9. 9. `Record entries.' A written report of each evaluation under subd. 6. and the plan of care under subd. 8. shall be entered in the applicant's or recipient's record at the time of admission or, if the individual is already in the facility, immediately upon completion of the evaluation or plan.
DHS 107.13(1)(c) (c) Eligibility for non-institutional services. Recipients under age 22 or over age 64 who are inpatients in a hospital IMD are eligible for MA benefits for services not provided through that institution and reimbursed to the hospital as hospital services under s. DHS 107.08 and this subsection.
DHS 107.13(1)(d) (d) Patient's account. Each recipient who is a patient in a state, county, or private psychiatric hospital shall have an account established for the maintenance of earned or unearned money payments received, including social security and SSI payments. The account for a patient in a state mental health institute shall be kept in accordance with s. 46.07, Stats. The payee for the account may be the recipient, if competent, or a legal representative or bank officer except that a legal representative employed by a county department of social services or the department may not receive payments. If the payee of the resident's account is a legally authorized representative, the payee shall submit an annual report on the account to the U.S. social security administration if social security or SSI payments have been paid into the account.
DHS 107.13(1)(e) (e) Professional services provided to hospital IMD inpatients. In addition to meeting the conditions for provision of services listed under s. DHS 107.08 (4), including separate billing, the following conditions apply to professional services provided to hospital IMD inpatients:
DHS 107.13(1)(e)1. 1. Diagnostic interviews with the recipient's immediate family members shall be covered services. In this subdivision, “immediate family members" means parents, guardian, spouse and children or, for a child in a foster home, the foster parents;
DHS 107.13(1)(e)2. 2. The limitations specified in s. DHS 107.08 (3) shall apply; and
DHS 107.13(1)(e)3. 3. Electroconvulsive therapy shall be a covered service only when provided by a certified psychiatrist in a hospital setting.
DHS 107.13(1)(f) (f) Non-covered services. The following services are not covered services:
DHS 107.13(1)(f)1. 1. Activities which are primarily diversional in nature such as services which act as social or recreational outlets for the recipient;
DHS 107.13(1)(f)2. 2. Mild tranquilizers or sedatives provided solely for the purpose of relieving the recipient's anxiety or insomnia;
DHS 107.13(1)(f)3. 3. Consultation with other providers about the recipient's care;
DHS 107.13(1)(f)4. 4. Conditional leave, convalescent leave or transfer days from psychiatric hospitals for recipients under the age of 21;
DHS 107.13(1)(f)5. 5. Psychotherapy or AODA treatment services when separately billed and performed by masters level therapists or AODA counsellors certified under s. DHS 105.22 or 105.23;
DHS 107.13(1)(f)6. 6. Group therapy services or medication management for hospital inpatients whether separately billed by an IMD hospital or by any other provider as an outpatient claim for professional services;
DHS 107.13(1)(f)7. 7. Court appearances, except when necessary to defend against commitment; and
DHS 107.13(1)(f)8. 8. Inpatient services for recipients between the ages of 21 and 64 when provided by a hospital IMD, except that services may be provided to a 21 year old resident of a hospital IMD if the person was a resident of that institution immediately prior to turning 21 and continues to be a resident after turning 21. A hospital IMD patient who is 21 to 64 years of age may be eligible for MA benefits while on convalescent leave from a hospital IMD.
DHS 107.13 Note Note: Subdivision 8 applies only to services for recipients 21 to 64 years of age who are actually residing in a psychiatric hospital or an IMD. Services provided to a recipient who is a patient in one of these facilities but temporarily hospitalized elsewhere for medical treatment or temporarily residing at a rehabilitation facility or another type of medical facility are covered services.
DHS 107.13 Note Note: For more information on non-covered services, see ss. DHS 107.03 and 107.08 (4).
DHS 107.13(2) (2)Outpatient psychotherapy services.
DHS 107.13(2)(a)(a) Covered services. Except as provided in par. (b), outpatient psychotherapy services shall be covered services when provided by a provider certified under s. DHS 105.22, and when the following conditions are met:
DHS 107.13(2)(a)1. 1. A strength-based assessment, including differential diagnostic examination, is performed by a certified psychotherapy provider. A physician's prescription is not necessary to perform the assessment. The assessment shall include:
DHS 107.13(2)(a)1.a. a. The recipient's presenting problem.
DHS 107.13(2)(a)1.b. b. Diagnosis established from the current Diagnostic and Statistical Manual of Mental Disorders including all 5 axes or, for children up to age four, the current Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood.
DHS 107.13(2)(a)1.c. c. The recipient's symptoms which support the given diagnosis.
DHS 107.13(2)(a)1.d. d. The recipient's strengths, and current and past psychological, social, and physiological data; information related to school or vocational, medical, and cognitive function; past and present trauma; and substance abuse.
DHS 107.13(2)(a)1.e. e. The recipient's unique perspective and own words about how he or she views his or her recovery, experience, challenges, strengths, needs, recovery goals, priorities, preferences, values and lifestyle, areas of functional impairment, and family and community support.
DHS 107.13(2)(a)1.f. f. Barriers and strengths to the recipient's progress and independent functioning.
DHS 107.13(2)(a)1.g. g. Necessary consultation to clarify the diagnosis and treatment.
DHS 107.13(2)(a)3. 3. Psychotherapy is furnished by:
DHS 107.13(2)(a)3.a. a. A provider who is a licensed physician, licensed psychologist, or a licensed and certified advanced practice nurse prescriber who is individually certified under s. DHS 105.22 (1) (a), (b), or (bm) and who is working in an outpatient mental health clinic certified under s. DHS 105.22 or in private practice.
DHS 107.13(2)(a)3.b. b. A provider under s. DHS 105.22 (3) who is working in an outpatient mental health clinic that is certified under s. DHS 105.22 to participate in MA.
DHS 107.13(2)(a)4. 4. Psychotherapy is performed only in any of the following:
DHS 107.13(2)(a)4.a. a. The office of a provider for providers who may bill directly.
DHS 107.13(2)(a)4.b. b. A hospital outpatient mental health clinic on the hospital's physical premises.
DHS 107.13(2)(a)4.c. c. An outpatient mental health clinic.
DHS 107.13(2)(a)4.d. d. A nursing home.
DHS 107.13(2)(a)4.e. e. A school.
DHS 107.13(2)(a)4.f. f. A hospital.
DHS 107.13(2)(a)4.g. g. The home.
DHS 107.13(2)(a)5. 5. The provider who performs psychotherapy shall engage in face-to-face contact with the recipient for at least 5/6 of the time for which reimbursement is claimed under MA;
DHS 107.13(2)(a)6. 6. Outpatient psychotherapy services of up to $825 per recipient, per provider in a calendar year for hospital outpatient mental health clinic providers billing on the hospital claim form, or 15 hours or $825 per recipient, per provider, in a calendar year for non-hospital outpatient mental health clinic providers, whichever limit is reached first, may be provided without prior authorization by the department;
DHS 107.13(2)(a)7. 7. If reimbursement is also made to the same provider for substance abuse treatment services under sub. (3) during the same year for the same recipient, the hours reimbursed for these services shall be considered part of the $825 or 15-hour psychotherapy treatment services limit before prior authorization is required. For hospital outpatient mental health clinic providers billing on the hospital claim form, these services shall be included in the $825 limit before prior authorization is required. If a recipient is hospitalized as an inpatient in an acute care general hospital or IMD with a diagnosis of, or for a procedure associated with, a psychiatric or substance abuse condition, reimbursement for any inpatient psychotherapy or substance abuse treatment services is not included in the $825, 15-hour limit before prior authorization is required for outpatient psychotherapy or substance abuse treatment services. For hospital inpatients, the strength-based assessment, including differential diagnostic examination for psychotherapy and the medical evaluation for substance abuse treatment services also are not included in the limit before prior authorization is required.
DHS 107.13(2)(b) (b) Prior authorization.
DHS 107.13(2)(b)1.1. Reimbursement may be claimed for treatment services beyond 15 hours or $825, whichever limit is attained first, after receipt of prior authorization from the department.
DHS 107.13(2)(b)2. 2. The department may authorize reimbursement for a specified number of additional hours of non-hospital outpatient care or visits for hospital outpatient services to be provided to a recipient with the calendar year. The department shall require periodic progress reports and subsequent prior authorization requests in instances where additional services are approved.
DHS 107.13(2)(b)3. 3. Persons who review prior authorization requests for the department shall meet the same minimum training that providers are expected to meet.
DHS 107.13(2)(b)4. 4. A prior authorization request shall include the following information:
DHS 107.13(2)(b)4.a. a. The names, addresses and MA provider or identifier numbers of the providers conducting the strength-based assessment, including diagnostic examination or medical evaluation and performing psychotherapy services.
DHS 107.13(2)(b)4.c. c. A detailed summary of the strength-based assessment, including differential diagnostic examination, setting forth the elements of an assessment in s. DHS 107.13 (2) (a) 1.
DHS 107.13(2)(b)4.d. d. A copy of the treatment plan and setting forth the elements required in s. DHS 107.13 (2m).
DHS 107.13(2)(b)4.e. e. A statement of the estimated frequency of treatment sessions, the estimated cost of treatment and the anticipated location of treatment.
DHS 107.13(2)(b)5. 5. The department's decision on a prior authorization request shall be communicated to the provider in writing.
DHS 107.13(2)(c) (c) Other limitations.
DHS 107.13(2)(c)1.1. Collateral interviews shall be limited to members of the recipient's immediate family. These are parents, spouse and children or, for children in foster care, foster parents.
DHS 107.13(2)(c)2. 2. No more than one provider may be reimbursed for the same psychotherapy session, unless the session involves a couple, family group or is a group therapy session. In this subdivision, “group therapy session" means a session not conducted in a hospital for an inpatient recipient at which there are more than one but not more than 10 individuals receiving psychotherapy services together from one or 2 providers. Under no circumstances may more than 2 providers be reimbursed for the same session.
DHS 107.13(2)(c)3. 3. Emergency psychotherapy may be performed by a provider for a recipient without a prescription for treatment or prior authorization when the provider has reason to believe that the recipient may immediately injure himself or herself or any other person. A prescription for the emergency treatment shall be obtained within 48 hours of the time the emergency treatment was provided, excluding weekends and holidays. Services shall be incorporated within the limits described in par. (b) and this paragraph, and subsequent treatment may be provided if par. (b) is followed.
DHS 107.13(2)(c)4. 4. Strength-based assessment, including a differential diagnostic evaluation for mental health, day treatment and substance abuse services shall be limited to 8 hours every calendar year per recipient as a unique procedure before prior authorization is required.
DHS 107.13(2)(c)5. 5. Services under this subsection are not reimbursable if the recipient is receiving community support program services under sub. (6) or psychosocial services provided through a community-based psychosocial service program under sub. (7).
DHS 107.13(2)(c)6. 6. Professional psychotherapy services provided to hospital inpatients in general hospitals, other than group therapy and medication management, are not considered inpatient services. Reimbursement shall be made to the psychiatrist, psychologist, or advanced practice nurse prescriber billing providers certified under s. DHS 105.22 (1) (a), (b), or (bm) who provide mental health professional services to hospital inpatients in accordance with requirements of this subsection.
DHS 107.13(2)(d) (d) Non-covered services . All of the following services are not covered services:
DHS 107.13(2)(d)1. 1. Collateral interviews with persons not stipulated in par. (c) 1., and consultations, except as provided in s. DHS 107.06 (4) (d).
DHS 107.13(2)(d)2. 2. Psychotherapy for individuals with the primary diagnosis of developmental disabilities, including intellectual disabilities, except when they experience psychological problems that necessitate psychotherapeutic intervention.
DHS 107.13(2)(d)3. 3. For individuals age 21 and over, psychotherapy provided in a person's home.
DHS 107.13 Note Note: Section 49.45 (45), Stats., provides for in-home community mental health and alcohol and other drug abuse (AODA) services for individuals age 21 and over. However, these services are available to an individual only if the county, city, town or village in which the individual resides elects to make the services available and agrees to pay the non-federal share of the cost of those services.
DHS 107.13(2)(d)4. 4. Self-referrals. For purposes of this paragraph, “self-referral" means that a provider refers a recipient to an agency in which the provider has a direct financial interest, or to himself or herself acting as a practitioner in private practice.
DHS 107.13(2)(d)5. 5. Court appearances except when necessary to defend against commitment.
DHS 107.13 Note Note: For more information on non-covered services, see s. DHS 107.03.
DHS 107.13(2m) (2m)The goals of psychotherapy and specific objectives to meet those goals shall be documented in the recipient's recovery and treatment plan that is based on the strength-based assessment. In the recovery and treatment plan, the signs of improved functioning that will be used to measure progress towards specific objectives at identified intervals, agreed upon by the provider and recipient shall be documented. A mental health diagnosis and medications for mental health issues used by the recipient shall be documented in the recovery and treatment plan.
DHS 107.13(3) (3)Alcohol and other drug abuse outpatient treatment services.
DHS 107.13(3)(a)(a) Covered services. Outpatient alcohol and drug abuse treatment services shall be covered when prescribed by a physician, provided by a provider who meets the requirements of s. DHS 105.23, and when the following conditions are met:
DHS 107.13(3)(a)1. 1. The treatment services furnished are AODA treatment services;
DHS 107.13(3)(a)2. 2. Before being enrolled in an alcohol or drug abuse treatment program, the recipient receives a complete medical evaluation, including diagnosis, summary of present medical findings, medical history and explicit recommendations by the physician for participation in the alcohol or other drug abuse treatment program. A medical evaluation performed for this purpose within 60 days prior to enrollment shall be valid for reenrollment;
DHS 107.13(3)(a)3. 3. The supervising physician or psychologist develops a treatment plan which relates to behavior and personality changes being sought and to the expected outcome of treatment;
DHS 107.13(3)(a)4. 4. Outpatient AODA treatment services of up to $500 or 15 hours per recipient in a calendar year, whichever limit is reached first, may be provided without prior authorization by the department;
DHS 107.13(3)(a)5. 5. AODA treatment services are performed only in the office of the provider, a hospital or hospital outpatient clinic, an outpatient facility, a nursing home or a school;
DHS 107.13(3)(a)6. 6. The provider who provides alcohol and other drug abuse treatment services engages in face-to-face contact with the recipient for at least 5/6 of the time for which reimbursement is claimed; and
DHS 107.13(3)(a)7. 7. If reimbursement is also made to any provider for psychotherapy or mental health services under sub. (2) during the same year for the same recipient, the hours reimbursed for these services shall be considered part of the $500 or 15-hour AODA treatment services limit before prior authorization is required. For hospital outpatient service providers billing on the hospital claim form, these services shall be included in the $500 limit before prior authorization is required. If several psychotherapy or AODA treatment service providers are treating the same recipient during the year, all the psychotherapy or AODA treatment services shall be considered in the $500 or 15-hour total limit before prior authorization is required. However, if a recipient is hospitalized as an inpatient in an acute care general hospital or IMD with a diagnosis of, or for a procedure associated with, a psychiatric or alcohol or other drug abuse condition, reimbursement for any inpatient psychotherapy or AODA treatment services is not included in the $500, 15-hour limit before prior authorization is required. For hospital inpatients, the differential diagnostic examination for psychotherapy or AODA treatment services and the medical evaluation for psychotherapy or other mental health treatment or AODA treatment services are also not included in the limit before prior authorization is required.
DHS 107.13(3)(b) (b) Prior authorization.
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Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.