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.h.
h. Via telehealth when the provider is in a location that ensures privacy and confidentiality of recipient information and communications.
DHS 107.13(2)(a)5.
5. The provider who performs psychotherapy 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 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)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.e.
e. 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(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)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)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)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
