2015 - 2016 LEGISLATURE
January 13, 2016 - Introduced by Representatives VanderMeer, Tittl, Ballweg,
Horlacher, Knodl, Kremer, Murphy, A. Ott, Quinn, Rohrkaste, Sanfelippo,
Zepnick, Novak and Kitchens, cosponsored by Senator Harsdorf. Referred to
Committee on Health.
1An Act to create
49.45 (29w) (a) 3. to 7., 49.45 (29w) (c) and 49.45 (29w) (d) of 2
the statutes; relating to: access to and prior authorization for mental health
3services under the Medical Assistance program.
Analysis by the Legislative Reference Bureau
This bill sets limitations on what is required for prior authorizations for mental
health treatment under the Medical Assistance (MA) program. Specifically, the bill
limits the information that may be collected on a prior authorization form, requires
the Department of Health Services (DHS) to allow 24 mental health therapy visits
before requiring prior authorization for additional visits, requires DHS to allow 15
days of adolescent day treatment services before requiring prior authorization for
additional days, and creates a preferred provider status for purposes of processing
prior authorization requests. The bill also requires a health maintenance
organization that provides mental health services under the MA program to use
uniform application, provider recertification, and prior authorization forms and
processes prescribed by DHS and to allow mental health agencies to replace a
departing mental health professional on the provider panel with another mental
health professional of similar qualifications who agrees to abide by the health
maintenance organization's policies.
For further information see the state fiscal estimate, which will be printed as
an appendix to this bill.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
49.45 (29w) (a) 3. to 7. of the statutes are created to read:
(a) 3. Allow 24 mental health therapy visits before requiring prior 3
authorization for additional mental health visits.
4. Allow 15 days of adolescent day treatment services before requiring prior 5
authorization for additional days of adolescent day treatment services.
5. Limit the collection of information on the prior authorization form for mental 7
health services to the following elements:
a. Diagnostic criteria and symptoms.
b. Patient and mental health services provider identification.
c. Modality and frequency of treatment for which prior authorization is 11
d. Goals and discharge criteria for treatment for which prior authorization is 13
6. Limit the collection of information on prior authorization forms and by 15
reviewers for prior authorization of mental health services to the information that 16
is within the scope of practice of the mental health service provider requesting prior 17
authorization to provide treatment.
7. Limit the collection of information for prior authorization renewals to 19
measures of progress on treatment goals and to new information on the individual's 20
condition for which prior authorization for treatment is being requested.
49.45 (29w) (c) of the statutes is created to read:
(c) 1. For purposes of reviewing requests for prior authorization 2
for mental health services provided under this subchapter, the department shall 3
recognize a preferred provider status which is a mental health service provider that 4
meets all of the following criteria:
a. The mental health service provider has a minimum of 5 years of experience 6
as a certified provider under the Medical Assistance program under this subchapter.
b. The mental health service provider has had no instances of substantiated 8
fraud in the 5 years previous to requesting preferred provider status.
c. The mental health service provider has a history of having 90 percent of prior 10
authorization requests approved, regardless of whether the department requested 11
additional information before approval, for the 3 years previous to requesting 12
preferred provider status.
2. In providing mental health benefits under this subchapter, the department 14
shall process prior authorization requests from a mental health service provider with 15
preferred provider status under subd. 1. automatically, without delay, in a manner 16
similar to claims for services that do not require prior authorization.
3. A mental health service provider may appeal denial of or termination of 18
preferred provider status under subd. 1. under ch. 227.
49.45 (29w) (d) of the statutes is created to read:
(d) A health maintenance organization that provides mental 21
health services under this subchapter shall do all of the following:
1. Use uniform application, provider recertification, and prior authorization 23
forms and processes prescribed by the department for use by all health maintenance 24
organizations providing mental health services under this subchapter.
2. Allow a mental health agency that is certified to provide mental health 2
service under the Medical Assistance program under this subchapter to replace a 3
departing mental health professional on the health maintenance organization's 4
provider panel with another mental health professional of similar qualifications who 5
agrees to abide by the policies of the health maintenance organization.