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)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 or by telehealth when functionally equivalent to services provided in person;
DHS 107.13(3)(a)6.
6. The provider who performs AODA treatment services shall engage in contact with the recipient in person, via real-time interactive audio-visual telehealth, or real-time interactive audio-only telehealth 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)1.1. Reimbursement beyond 15 hours or $500 of service may be claimed for treatment services furnished after receipt of prior authorization from the department. Services reimbursed by any third-party payer shall be included when calculating the 15 hours or $500 of service.
DHS 107.13(3)(b)2.
2. The department may authorize reimbursement for a specified additional number of hours of outpatient AODA treatment services or visits for hospital outpatient services to be provided to a recipient in a calendar year. The department shall require periodic progress reports and subsequent prior authorization requests in instances where additional services are approved.
DHS 107.13(3)(b)3.
3. Persons who review prior authorization requests for the department shall meet the same minimum training requirements that providers are expected to meet.
DHS 107.13(3)(b)4.
4. A prior authorization request shall include the following information:
DHS 107.13(3)(b)4.a.
a. The names, addresses and MA provider or identifier numbers of the providers conducting the medical evaluation and performing AODA services;
DHS 107.13(3)(b)4.c.
c. A copy of the treatment plan which shall relate to the findings of the medical evaluation and specify behavior and personality changes being sought; and
DHS 107.13(3)(b)4.d.
d. A statement of the estimated frequency of treatment sessions, the estimated cost of treatment and the anticipated place of service of treatment.
DHS 107.13(3)(b)5.
5. The department's decision on a prior authorization request shall be communicated to the provider in writing.
DHS 107.13(3)(c)1.1. No more than one provider may be reimbursed for the same AODA treatment session, unless the session involves a couple, a family group or is a group session. In this paragraph,“group 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 recipients receiving services together from one or 2 providers. No more than 2 providers may be reimbursed for the same session. No recipient may be held responsible for charges for services in excess of MA coverage under this paragraph.
DHS 107.13(3)(c)2.
2. Services under this subsection are not reimbursable if the recipient is receiving community support program services under sub.
(6).
DHS 107.13(3)(c)3.
3. Professional AODA treatment services other than group therapy and medication management provided to hospital inpatients in general or to inpatients in IMDs are not considered inpatient services. Reimbursement shall be made to the psychiatrist or psychologist billing provider certified under s.
DHS 105.22 (1) (a) or
(b) or
105.23 who provides AODA treatment services to hospital inpatients in accordance with requirements under this subsection.
DHS 107.13(3)(c)4.
4. Medical detoxification services are not considered inpatient services if provided outside an inpatient general hospital or IMD.
DHS 107.13(3)(d)
(d) Non-covered services. The following services are not covered services:
DHS 107.13(3)(d)2.
2. Court appearances except when necessary to defend against commitment; and
DHS 107.13 Note
Note: For more information on non-covered services, see s.
DHS 107.03.
DHS 107.13(3m)
(3m)
Alcohol and other drug abuse day treatment services. DHS 107.13(3m)(a)(a) Covered services. Alcohol and other drug abuse day treatment services shall be covered when prescribed by a physician, provided by a provider certified under s.
DHS 105.25 and performed according to the recipient's treatment program in a non-residential, medically supervised setting, and when the following conditions are met:
DHS 107.13(3m)(a)1.
1. An initial assessment is performed by qualified medical professionals under s.
DHS 75.24 (11) for a potential participant. Services under this section shall be covered if the assessment concludes that AODA day treatment is medically necessary and that the recipient is able to benefit from treatment;
DHS 107.13(3m)(a)2.
2. A treatment plan based on the initial assessment is developed by the interdisciplinary team in consultation with the medical professionals who conducted the initial assessment and in collaboration with the recipient;
DHS 107.13(3m)(a)3.
3. The supervising physician or psychologist approves the recipient's written treatment plan;
DHS 107.13(3m)(a)4.
4. The treatment plan includes measurable individual goals, treatment modes to be used to achieve these goals and descriptions of expected treatment outcomes; and
DHS 107.13(3m)(a)5.
5. The interdisciplinary team monitors the recipient's progress, adjusting the treatment plan as required.
DHS 107.13(3m)(b)1.1. All AODA day treatment services except the initial assessment shall be prior authorized.
DHS 107.13(3m)(b)2.
2. Any recommendation by the county human services department under s.
46.23, Stats., or the county community programs department under s.
51.42, Stats., shall be considered in review and approval of the prior authorization request.
DHS 107.13(3m)(b)3.
3. Department representatives who review and approve prior authorization requests shall meet the same minimum training requirements as those mandated for AODA day treatment providers under s.
DHS 105.25.
DHS 107.13(3m)(c)1.1. AODA day treatment services in excess of 5 hours per day are not reimbursable under MA.
DHS 107.13(3m)(c)2.
2. AODA day treatment services may not be billed as psychotherapy, AODA outpatient treatment, case management, occupational therapy or any other service modality except AODA day treatment.
DHS 107.13(3m)(c)3.
3. Reimbursement for AODA day treatment services may not include time devoted to meals, rest periods, transportation, recreation or entertainment.
DHS 107.13(3m)(c)4.
4. Reimbursement for AODA day treatment assessment for a recipient is limited to 3 hours in a calendar year. Additional assessment hours shall be counted towards the mental health outpatient dollar or hour limit under sub.
(2) (a) 6. before prior authorization is required or the AODA outpatient dollar or hour limit under sub.
(3) (a) 4. before prior authorization is required.
DHS 107.13(3m)(d)2.
2. Time spent in the AODA day treatment setting by affected family members of the recipient;
DHS 107.13(3m)(d)3.
3. AODA day treatment services which are primarily recreation-oriented or which are provided in non-medically supervised settings. These include but are not limited to sports activities, exercise groups, and activities such as crafts, leisure time, social hours, trips to community activities and tours;
DHS 107.13(3m)(d)4.
4. Services provided to an AODA day treatment recipient which are primarily social or only educational in nature. Educational sessions are covered as long as these sessions are part of an overall treatment program and include group processing of the information provided;
DHS 107.13(3m)(d)5.
5. Prevention or education programs provided as an outreach service or as case-finding; and
DHS 107.13(4)
(4)
Mental health day treatment or day hospital services. DHS 107.13(4)(a)(a) Covered services. Day treatment or day hospital services are covered services when prescribed by a physician, when provided by a provider who meets the requirements of s.
DHS 105.24, and when the following conditions are met:
DHS 107.13(4)(a)1.
1. Before becoming involved in a day treatment program, the recipient is evaluated through the use of the functional assessment scale provided by the department to determine the medical necessity for day treatment and the person's ability to benefit from it;
DHS 107.13(4)(a)2.
2. The supervising psychiatrist approves, signs and dates a written treatment plan for each recipient and reviews and signs the plan no less frequently than once every 60 days. The treatment plan shall be based on the initial evaluation and shall include the individual goals, the treatment modalities including identification of the specific group or groups to be used to achieve these goals and the expected outcome of treatment;
DHS 107.13(4)(a)3.
3. Up to 90 hours of day treatment services in a calendar year may be reimbursed without prior authorization. Psychotherapy services or occupational therapy services provided as component parts of a person's day treatment package may not be billed separately, but shall be billed and reimbursed as part of the day treatment program;
DHS 107.13(4)(a)4.
4. Day treatment or day hospital services provided to recipients with inpatient status in a hospital are limited to 20 hours per inpatient admission and shall only be available to patients scheduled for discharge to prepare them for discharge;
DHS 107.13(4)(a)5.
5. Reimbursement is not made for day treatment services provided in excess of 5 hours in any day or in excess of 120 hours in any month;
DHS 107.13(4)(a)6.
6. Day treatment services are covered only for the chronically mentally ill and acutely mentally ill who have a need for day treatment and an ability to benefit from the service, as measured by the functional assessment scale provided by the department; and
DHS 107.13(4)(a)7.
7. Billing for day treatment is submitted by the provider. Day treatment services shall be billed as such, and not as psychotherapy, occupational therapy or any other service modality.
DHS 107.13(4)(a)8.
8. The groups shall be led by a qualified professional staff member, as defined under s.
DHS 105.24 (1) (b) 4. a., and the staff member shall be present throughout the group sessions and shall perform or direct the service.
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.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.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)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;
