DHS 107.13(4)(b) (b) Services requiring prior authorization.
DHS 107.13(4)(b)1.1. Providers shall obtain authorization from the department before providing the following services, as a condition for coverage of these services:
DHS 107.13(4)(b)1.a. a. Day treatment services provided beyond 90 hours of service in a calendar year;
DHS 107.13(4)(b)1.b. b. All day treatment or day hospital services provided to recipients with inpatient status in a nursing home. Only those patients scheduled for discharge are eligible for day treatment. No more than 40 hours of service in a calendar year may be authorized for a recipient residing in a nursing home;
DHS 107.13(4)(b)1.c. c. All day treatment services provided to recipients who are concurrently receiving psychotherapy, occupational therapy or AODA services;
DHS 107.13(4)(b)1.d. d. All day treatment services in excess of 90 hours provided to recipients who are diagnosed as acutely mentally ill.
DHS 107.13(4)(b)2. 2. The prior authorization request shall include:
DHS 107.13(4)(b)2.a. a. The name, address, and MA number of the recipient;
DHS 107.13(4)(b)2.b. b. The name, address, and provider number of the provider of the service and of the billing provider;
DHS 107.13(4)(b)2.c. c. A photocopy of the physician's original prescription for treatment;
DHS 107.13(4)(b)2.d. d. A copy of the treatment plan and the expected outcome of treatment;
DHS 107.13(4)(b)2.e. e. A statement of the estimated additional dates of service necessary and total cost; and
DHS 107.13(4)(b)2.f. f. The demographic and client information form from the initial and most recent functional assessment. The assessment shall have been conducted within 3 months prior to the authorization request.
DHS 107.13(4)(b)3. 3. The department's decision on a prior authorization request shall be communicated to the provider in writing. If the request is denied, the department shall provide the recipient with a separate notification of the denial.
DHS 107.13(4)(c) (c) Other limitations.
DHS 107.13(4)(c)1.1. All assessment hours beyond 6 hours in a calendar year shall be considered part of the treatment hours and shall become subject to the relevant prior authorization limits. Day treatment assessment hours shall be considered part of the 6 hour per 2-year mental health evaluation limit.
DHS 107.13(4)(c)2. 2. Reimbursement for day treatment services shall be limited to actual treatment time and may not include time devoted to meals, rest periods, transportation, recreation or entertainment.
DHS 107.13(4)(c)3. 3. Reimbursement for day treatment services shall be limited to no more than 2 series of day treatment services in one calendar year related to separate episodes of acute mental illness. All day treatment services in excess of 90 hours in a calendar year provided to a recipient who is acutely mentally ill shall be prior-authorized.
DHS 107.13(4)(c)4. 4. 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(4)(d) (d) Non-covered services. The following services are not covered services:
DHS 107.13(4)(d)1. 1. Day treatment services which are primarily recreation-oriented and which are provided in non-medically supervised settings such as 24 hour day camps, or other social service programs. These include sports activities, exercise groups, activities such as craft hours, leisure time, social hours, meal or snack time, trips to community activities and tours;
DHS 107.13(4)(d)2. 2. Day treatment services which are primarily social or educational in nature, in addition to having recreational programming. These shall be considered non-medical services and therefore non-covered services regardless of the age group served;
DHS 107.13(4)(d)3. 3. Consultation with other providers or service agency staff regarding the care or progress of a recipient;
DHS 107.13(4)(d)4. 4. Prevention or education programs provided as an outreach service, case-finding, and reading groups;
DHS 107.13(4)(d)5. 5. Aftercare programs, provided independently or operated by or under contract to boards;
DHS 107.13(4)(d)6. 6. Medical or AODA day treatment for recipients with a primary diagnosis of alcohol or other drug abuse;
DHS 107.13(4)(d)7. 7. Day treatment provided in the recipient's home; and
DHS 107.13(4)(d)8. 8. 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(6) (6)Community support program (CSP) services.
DHS 107.13(6)(a)(a) Covered services. Community support program (CSP) services shall be covered services when prescribed by a physician and provided by a provider certified under s. DHS 105.255 for recipients who can benefit from the services. These non-institutional services make medical treatment and related care and rehabilitative services available to enable a recipient to better manage the symptoms of his or her illness, to increase the likelihood of the recipient's independent, effective functioning in the community and to reduce the incidence and duration of institutional treatment otherwise brought about by mental illness. Services covered are as follows:
DHS 107.13(6)(a)1. 1. Initial assessment. At the time of admission, the recipient, upon a psychiatrist's order, shall receive an initial assessment conducted by a psychiatrist and appropriate professional personnel to determine the need for CSP care;
DHS 107.13(6)(a)2. 2. In-depth assessment. Within one month following the recipient's admission to a CSP, a psychiatrist and a treatment team shall perform an in-depth assessment to include all of the following areas:
DHS 107.13(6)(a)2.a. a. Evaluation of psychiatric symptomology and mental status;
DHS 107.13(6)(a)2.b. b. Use of drugs and alcohol;
DHS 107.13(6)(a)2.c. c. Evaluation of vocational, educational and social functioning;
DHS 107.13(6)(a)2.d. d. Ability to live independently;
DHS 107.13(6)(a)2.e. e. Evaluation of physical health, including dental health;
DHS 107.13(6)(a)2.f. f. Assessment of family relationships; and
DHS 107.13(6)(a)2.g. g. Identification of other specific problems or needs;
DHS 107.13(6)(a)3. 3. Treatment plan. A comprehensive written treatment plan shall be developed for each recipient and approved by a psychiatrist. The plan shall be developed by the treatment team with the participation of the recipient or recipient's guardian and, as appropriate, the recipient's family. Based on the initial and in-depth assessments, the treatment plan shall specify short-term and long-term treatment and restorative goals, the services required to meet these goals and the CSP staff or other agencies providing treatment and psychosocial rehabilitation services. The treatment plan shall be reviewed by the psychiatrist and the treatment team at least every 30 days to monitor the recipient's progress and status;
DHS 107.13(6)(a)4. 4. Treatment services, as follows:
DHS 107.13(6)(a)4.a. a. Family, individual and group psychotherapy;
DHS 107.13(6)(a)4.b. b. Symptom management or supportive psychotherapy;
DHS 107.13(6)(a)4.c. c. Medication prescription, administration and monitoring;
DHS 107.13(6)(a)4.d. d. Crisis intervention on a 24-hour basis, including short-term emergency care at home or elsewhere in the community; and
DHS 107.13(6)(a)4.e. e. Psychiatric and psychological evaluations;
DHS 107.13(6)(a)5. 5. Psychological rehabilitation services as follows;
DHS 107.13(6)(a)5.a. a. Employment-related services. These services consist of counseling the recipient to identify behaviors which interfere with seeking and maintaining employment; development of interventions to alleviate problem behaviors; and supportive services to assist the recipient with grooming, personal hygiene, acquiring appropriate work clothing, daily preparation for work, on-the-job support and crisis assistance;
DHS 107.13(6)(a)5.b. b. Social and recreational skill training. This training consists of group or individual counseling and other activities to facilitate appropriate behaviors, and assistance given the recipient to modify behaviors which interfere with family relationships and making friends;
DHS 107.13(6)(a)5.c. c. Assistance with and supervision of activities of daily living. These services consist of aiding the recipient in solving everyday problems; assisting the recipient in performing household tasks such as cleaning, cooking, grocery shopping and laundry; assisting the recipient to develop and improve money management skills; and assisting the recipient in using available transportation;
DHS 107.13(6)(a)5.d. d. Other support services. These services consist of helping the recipient obtain necessary medical, dental, legal and financial services and living accommodations; providing direct assistance to ensure that the recipient obtains necessary government entitlements and services, and counseling the recipient in appropriately relating to neighbors, landlords, medical personnel and other personal contacts; and
DHS 107.13(6)(a)6. 6. Case management in the form of ongoing monitoring and service coordination activities described in s. DHS 107.32 (1) (d).
DHS 107.13(6)(b) (b) Other limitations.
DHS 107.13(6)(b)1.1. Mental health services under s. DHS 107.13 (2) and (4) are not reimbursable for recipients receiving CSP services.
DHS 107.13(6)(b)2. 2. An initial assessment shall be reimbursed only when the recipient is first admitted to the CSP and following discharge from a hospital after a short-term stay.
DHS 107.13(6)(b)3. 3. Group therapy is limited to no more than 10 persons in a group. No more than 2 professionals shall be reimbursed for a single session of group therapy. Mental health technicians shall not be reimbursed for group therapy.
DHS 107.13(6)(b)4. 4. Reimbursement is not available for a person participating in the program under this subsection if the person is also participating in the program under sub. (7).
DHS 107.13(6)(c) (c) Non-covered services. The following CSP services are not covered services:
DHS 107.13(6)(c)1. 1. Case management services provided under s. DHS 107.32 by a provider not certified under s. DHS 105.255 to provide CSP services;
DHS 107.13(6)(c)2. 2. Services provided to a resident of an intermediate care facility, skilled nursing facility or an institution for mental diseases, or to a hospital patient unless the services are performed to prepare the recipient for discharge form the facility to reside in the community;
DHS 107.13(6)(c)3. 3. Services related to specific job-seeking, job placement and work activities;
DHS 107.13(6)(c)4. 4. Services performed by volunteers;
DHS 107.13(6)(c)5. 5. Services which are primarily recreation-oriented; and
DHS 107.13(6)(c)6. 6. Legal advocacy performed by an attorney or paralegal.
DHS 107.13(7) (7)Psychosocial services provided through a community-based psychosocial service program.
DHS 107.13(7)(a) (a) Covered services. Psychosocial services provided through a community-based psychosocial service program shall be covered services when authorized by a mental health professional under s. DHS 36.15 for recipients determined to have a need for the services under s. DHS 36.14. These non-institutional services must fall within the definition of “rehabilitative services" under 42 CFR 440.130 (d) and must be described in a service plan under s. DHS 36.17. Covered services include assessment under s. DHS 36.16 and service planning and review under s. DHS 36.17.
DHS 107.13(7)(b) (b) Other limitations.
DHS 107.13(7)(b)1.1. Mental health services under s. DHS 107.13 (2) and (4) are not reimbursable for recipients receiving services under this subsection.
DHS 107.13(7)(b)2. 2. Group psychotherapy is limited to no more than 10 persons in a group. No more than 2 professionals shall be reimbursed for a single session of group psychotherapy. Mental health technicians shall not be reimbursed for group psychotherapy.
DHS 107.13(7)(b)3. 3. Reimbursement is not available for a person participating in the program under this subsection if the person is also participating in the program under sub. (6).
DHS 107.13(7)(c) (c) Non-covered services. The following are not covered services under this subsection:
DHS 107.13(7)(c)1. 1. Case management services provided under s. DHS 107.32 by a provider not certified under s. DHS 105.257 to provide services under this section.
DHS 107.13(7)(c)2. 2. Services provided to a resident of an intermediate care facility, skilled nursing facility or an institution for mental diseases, or to a hospital patient unless the services are performed to prepare the recipient for discharge from the facility to reside in the community.
DHS 107.13(7)(c)3. 3. Services performed by volunteers, except that out-of-pocket expenses incurred by volunteers in performing services may be covered.
DHS 107.13(7)(c)4. 4. Services that are not rehabilitative, including services that are primarily recreation-oriented.
DHS 107.13(7)(c)5. 5. Legal advocacy performed by an attorney or paralegal.
DHS 107.13 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. (1) (f) 8., Register, February, 1988, No. 386, eff. 3-1-88; emerg. cr. (3m), eff. 3-9-89; cr. (3m), Register, December, 1989, No. 408, eff. 1-1-90; emerg. cr. (2) (c) 5., (3) (c) 2., (4) (c) 4. and (6), eff. 1-1-90; cr. (2) (c) 5., (3) (c) 2., (4) (c) 4. and (6), Register, September, 1990, No. 417, eff. 10-1-90; emerg. r. and recr. (1) (b) 3., am. (1) (f) 6., eff. 1-1-91; am. (1) (a), (b) 1. and 2., (c), (f) 5., 6. and 8., (2) (a) 1., 3. a. and b., 4. f., 6., 7., (b) 1. and 2., (c) 2., (3) (a) (intro.), 4., 5., 7., (b) 1. and 2., (c) 1. (3) (d) 1. and 2., (4) (a) 3. and 6. and (d) 6., r. and recr. (1) (b) 3. and (e), r. (4) (b) 1. d., renum. (4) (b) 1. c. to be d., cr. (2) (c) 6., (3) (c) 3. and 4., (3) (d) 3., Register, September, 1991, No. 429, eff. 10-1-91; am. (4) (a) 2., cr. (4) (a) 8., Register, February, 1993, No. 446, eff. 3-1-93; corrections in (3) (d) 3. and (3m) (a) 1. made under s. 13.93 (2m) (b) 7., Stats., Register February 2002 No. 554; emerg. am. (2) (c) 5. and (4) (c) 4., cr. (6) (b) 4. and (7), eff. 7-1-04; CR 04-025: am (2) (c) 5. and (4) (c) 4., cr. (6) (b) 4. and (7) Register October 2004 No. 586, eff. 11-1-04; corrections in (1) (a), (f) 5., (2) (a) (intro.), 3., (c) 6., (3) (a) (intro.), (c) 3., (d) 3., (3m) (a) (intro.), 1., (b) 3., (4) (a) (intro.), 8., (6) (a) (intro.), (c) 1., (7) (a) and (c) 1. made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 06-080: am. (2) (a) (intro.), 1. (intro.), 3. a., b., 4. a. to f., 6., 7., (b) 1., 4. a. to d., (c) 4., 6. and (d) 2., cr. (2) (a) 1. a. to g. and (2m) Register May 2009 No. 641, eff. 6-1-09; CR 14-066: am. (2) (a) (intro.), r. (2) (a) 2., am. (2) (a) 4. (intro.), cr. (2) (a) 4. g., r. (2) (b) 4. b., am. (2) (d) (intro.), 1. to. 4. Register August 2015 No. 716, eff. 9-1-15; 2019 Wis. Act 1: am. (2) (d) 2. Register May 2019 No. 761; eff. 6-1-19.
DHS 107.14 DHS 107.14Podiatry services.
DHS 107.14(1)(1)Covered services.
DHS 107.14(1)(a)(a) Podiatry services covered by medical assistance are those medically necessary services for the diagnosis and treatment of the feet and ankles, within the limitations described in this section, when provided by a certified podiatrist.
DHS 107.14(1)(b) (b) The following categories of services are covered services when performed by a podiatrist:
DHS 107.14(1)(b)1. 1. Office visits;
DHS 107.14(1)(b)2. 2. Home visits;
DHS 107.14(1)(b)3. 3. Nursing home visits;
DHS 107.14(1)(b)4. 4. Physical medicine;
DHS 107.14(1)(b)5. 5. Surgery;
DHS 107.14(1)(b)6. 6. Mycotic conditions and nails;
DHS 107.14(1)(b)7. 7. Laboratory;
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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.