DHS 101.03(129m)(a)(a) A pregnant woman for MA coverage of ambulatory prenatal care and other services, as determined under s. 49.465 (2), Stats. DHS 101.03(129m)(c)(c) A woman diagnosed with breast or cervical cancer or precancerous conditions for MA coverage, as defined under s. 49.473 (3), Stats. DHS 101.03(130)(130) “Preventive or maintenance occupational therapy” means occupational therapy procedures which are provided to forestall deterioration of the patient’s condition or to preserve the patient’s current status. Preventive or maintenance occupational therapy makes use of the procedures and techniques of minimizing further deterioration in areas including, but not limited to, the treatment of arthritic conditions, multiple sclerosis, upper extremity contractures, chronic or recurring mental illness and intellectual disability. DHS 101.03(131)(131) “Preventive or maintenance physical therapy” means physical therapy modalities and procedures which are provided to forestall the patient’s condition from deteriorating or to preserve the patient’s current physical status. Preventive or maintenance physical therapy makes use of the procedures and techniques of minimizing further deterioration in areas including, but not limited to, daily living skills, mobility, positioning, edema control and other physiological processes. DHS 101.03(133)(133) “Primary provider” means a provider who provides health care service in the area in which the recipient resides and is designated by the recipient, with the concurrence of the designated provider, to be the recipient’s primary provider. DHS 101.03(134)(134) “Prior authorization” means the written authorization issued by the department to a provider prior to the provision of a service. DHS 101.03 NoteNote: Some services are covered only if they are authorized by the department before they are provided. Some otherwise covered services must be prior authorized after certain thresholds have been reached.
DHS 101.03(134m)(134m) “Private duty nursing” means RN or LPN services provided to a recipient who requires 8 or more hours of skilled nursing care in a calendar day, as specified in s. DHS 107.12. DHS 101.03(135)(135) “PRO” or “peer review organization” means the organization under contract to the department which makes determinations of medical necessity and reviews quality of services received by recipients of MA, medicare and maternal and child health programs when these recipients are hospitalized. DHS 101.03(136)(136) “Procedure” means a treatment that requires the therapist’s personal attendance on a continuous basis. DHS 101.03(136m)(136m) “Professional services” means the covered services listed in s. DHS 107.08 (4) (d) that are provided by health care professionals to MA recipients who are inpatients of a hospital. DHS 101.03(137)(137) “Provider” means a person who has been certified by the department to provide health care services to recipients and to be reimbursed by MA for those services. DHS 101.03(138)(138) “Provider agreement” means the contract between a provider and the department which sets forth conditions of participation and reimbursement. DHS 101.03(139)(139) “Provider assistant” means a provider whose services must be performed under the supervision of a certified or licensed professional provider. A provider assistant, while required to be certified, is not eligible for direct reimbursement from MA. DHS 101.03(140)(140) “Provider certification” means the process of approving a provider for participation in the MA program, as specified in s. DHS 105.01. DHS 101.03(141)(141) “Provider handbook” means a publication developed by the department for the use of providers which outlines program policies and includes instructions on claim filing and other aspects of participation in MA. DHS 101.03(142)(142) “Provider’s eligibility date” means the first date on which a provider may begin participation in MA which is no earlier than and may be later than the initial date of a signed written application. The applicant has 30 calendar days within which to complete and return the signed application form to the fiscal agent. DHS 101.03(143)(143) “Provider’s initial date of application” means the earliest of the following: DHS 101.03(143)(a)(a) The date on which the department receives a letter from a person requesting an application to be a provider; DHS 101.03(143)(b)(b) The date on which the department receives an unsolicited application form from a person wishing to become a provider; or DHS 101.03(143)(c)(c) The date on which the department receives a person’s rejected claim which was rejected due to an invalid provider number. DHS 101.03(144)(144) “Psychiatric hospital” or “psychiatric facility” means an institution which is primarily engaged in providing, by or under the supervision of a physician, inpatient psychiatric services for the diagnosis and treatment of mental illness which may include services for the diagnosis and treatment of the abuse of alcohol or other drugs. DHS 101.03(145)(145) “Psychotherapy” means the treatment of an individual who is mentally ill or has medically significant emotional or social dysfunctions by a psychotherapy provider. The treatment is a planned and structured program based on information from a differential diagnostic examination and directed at the accomplishment of specified goals. The treatment goals may include removing, modifying, or retarding existing symptoms, mediating disturbed patterns of behavior, and promoting positive personal growth and development by enhancing the ability to adapt and cope with internal and external stresses. DHS 101.03(146)(146) “Psychotherapy provider” means a person certified by the department to participate in MA who holds the minimum qualifications specified in s. DHS 105.22. DHS 101.03(147)(147) “Public agency” means an agency operated by the state or a local government. DHS 101.03(148)(148) “Public health agency” means an administrative organization established by the state or a local government, the primary function of which is to maintain the health of the population served by providing environmental health services, preventive medical service and, when necessary, therapeutic medical services. DHS 101.03(149)(149) “Public health nurse” means a registered nurse who has completed a baccalaureate degree program approved by the national league for nursing for public health nursing preparation or post-registered nurse study which includes content approved by the national league for nursing for public health nursing preparation. DHS 101.03(149m)(149m) “Qualified provider” means a provider who is qualified to determine presumptive eligibility of children, women with breast or cervical cancer or precancerous conditions, and pregnant women for MA coverage, as ascertained by the department in accordance with 42 USC 1396a (a) (47). DHS 101.03(150)(150) “Recipient” means a natural person who is entitled to receive benefits under MA. DHS 101.03(151)(151) “Registered nurse” or “RN” means a person who holds a current certificate of registration as a registered nurse under ch. 441, Stats., or, if practicing in another state, is registered with the appropriate licensing agency in that state. DHS 101.03(152)(152) “Rehabilitation agency” means an agency providing an integrated multi-disciplinary program of services designed to upgrade the physical functioning of individuals with disabilities by bringing together as a team specialized rehabilitation personnel to provide these services, the services at a minimum consisting of physical therapy or speech pathology services and a rehabilitation program which, in addition to physical therapy or speech pathology services, includes social or vocational adjustment services. DHS 101.03(152m)(152m) “Remedial expense” means a cost paid by a medicaid purchase plan recipient, an institutionalized person, or someone receiving home and community-based services under 42 USC 1396n that may be considered to be related to that person’s health, employment or disability. The cost is not reimbursable by another source such as medicare, medical assistance, private insurance or an employer. Remedial expenses may be used to expend excess income during a spend-down period. DHS 101.03(153)(153) “Resident” means an individual who resides as an inpatient in a skilled nursing facility (SNF), intermediate care facility (ICF) or other medical institution. DHS 101.03(154)(154) “Resident recipient” or “patient recipient” means a person who resides in a nursing home and is eligible to receive or is receiving benefits under MA. DHS 101.03(155)(155) “Resource” means a recipient’s homestead and all other personal and real property in which the recipient has a legal interest. DHS 101.03(155m)(155m) “Respiratory care” means the treatment of a person who receives mechanically assisted respiration. DHS 101.03(156)(156) “Restorative occupational therapy” means the application of procedures and techniques to achieve maximum reduction of a physical disability or the establishment of a patient at the best possible functional level, including but not limited to techniques which improve motor skills, sensory integrative functioning, cognitive skills, the ability to engage in activities of daily living, social interpersonal skills and psychological intrapersonal skills, and those procedures provided to relieve pain, improve cardio-pulmonary function, and adapt orthotic, prosthetic, assistive and adaptive appliances or devices and train the patient in their use. DHS 101.03(157)(157) “Restorative physical therapy” means physical therapy modalities and procedures which are provided for the purpose of achieving maximum reduction of a physical disability or the establishment of the recipient at the best possible functional level. Restorative physical therapy includes but is not limited to exercises to increase range-of-motion, strength, tolerance, coordination and the ability to engage in activities of daily living. Restorative physical therapy also includes those physical therapy modalities and procedures provided to relieve pain, promote wound healing, improve cardio-pulmonary function and adapt orthotic, prosthetic, assistive and adaptive appliances or devices and train the patient in their use. DHS 101.03(158)(158) “Rural health clinic” means an outpatient health clinic located in a rural area designated by the federal department of health and human services as a rural shortage area, which is not a rehabilitation agency or a facility primarily for the care and treatment of mental diseases but which complies with all other appropriate federal, state and local laws. DHS 101.03(159)(159) “Rural shortage area” means a defined geographic area that is not delineated as an urbanized area by the U.S. bureau of the census and that is designated by the federal department of health and human services as having either: DHS 101.03(159)(a)(a) A shortage of personal health services under section 1302 (7) of the public health service act; or DHS 101.03(160)(160) “Schedule” means, in reference to drugs, those drugs listed in schedules II, III, IV and V of the controlled substances act, ss. 961.16, 961.18, 961.20 and 961.22, Stats., and additions made to these schedules by ch. CSB 2. DHS 101.03(160m)(160m) “Screener” means a person certified by the department and employed at a screening agency to review employment plans. DHS 101.03(160r)(160r) “Screening agency” means an agency certified by the department to review employment plans. DHS 101.03(161)(161) “Semi-private room” means the lowest cost, multiple-bed accommodation in the section of the hospital appropriate for treatment of the recipient’s condition, which is available at the time of admission. DHS 101.03(163)(163) “Skilled nursing services” means those professional nursing services furnished pursuant to a physician’s orders which require the skills of a registered nurse or licensed practical nurse and which are provided either directly by or under the supervision of the registered nurse or licensed practical nurse. DHS 101.03 NoteNote: Examples of services which would qualify as skilled nursing services are:
DHS 101.03(163)(a)(a) Intravenous, intramuscular, or subcutaneous injections and hypodermoclysis or intravenous feeding; DHS 101.03(163)(e)(e) Application of dressings involving prescription medications and aseptic techniques; DHS 101.03(163)(f)(f) Treatment of extensive decubitus ulcers or other widespread skin disorder; DHS 101.03(163)(g)(g) Heat treatments which have been specifically ordered by a physician as part of active treatment and which require observation by nurses to adequately evaluate the patient’s progress; DHS 101.03(163)(h)(h) Initial phases of a regimen involving administration of medical gases; and DHS 101.03(163)(i)(i) Rehabilitation nursing procedures, including the related teachings and adaptive aspects of nursing that are part of active treatment, e.g., the institution and supervision of bowel and bladder training programs. DHS 101.03(164)(164) “Skilled nursing services for individuals age 21 or older”means skilled nursing services that are: DHS 101.03(164)(a)(a) Needed on a daily basis and required to be provided on an inpatient basis; DHS 101.03(164)(c)(c) Ordered by and to be administered under the direction of a physician. DHS 101.03(164m)(164m) “Skilled nursing services provided primarily in the home” means nursing services requiring the skills of a licensed professional nurse or a licensed practical nurse supervised by a registered nurse according to the requirements of ch. N 6 and directly provided as specified by a written plan of care. DHS 101.03(165)(165) “Skilled rehabilitation services” means those services furnished pursuant to a physician’s orders which require the skills of a physical therapist, occupational therapist, speech pathologist or audiologist and which are provided either directly by or under the supervision of the professional personnel. DHS 101.03 NoteNote: Skilled rehabilitation services include:
DHS 101.03 Note(a) Ongoing assessment of rehabilitation needs and potential, including tests and measurements of range of motion, strength, balance, coordination, endurance, functional ability, activities of daily living, perceptual deficits, speech and language or hearing disorders and sensory integrative abilities;
DHS 101.03 Note(b) Therapeutic exercises or activities which, because of the type of exercises employed or the condition of the patient, must be performed by or under the supervision of a qualified physical therapist or occupational therapist to ensure the safety of the patient and the effectiveness of the treatment;
DHS 101.03 Note(c) Gait evaluation and training furnished to restore function in a patient whose ability to walk has been impaired by neurological, muscular, or skeletal abnormality;
DHS 101.03 Note(d) Range of motion exercises which are part of the active treatment of a specific disease state which has resulted in loss or restriction of mobility as evidenced by a therapist’s notes showing the degree of motion lost and the degree to be restored;
DHS 101.03 Note(e) Sensory integrative evaluation and training which, because of the type of training or the condition of the patient, must be performed by or under the supervision of a qualified occupational therapist or physical therapist or other appropriate licensed health care provider to ensure the safety of the patient and the effectiveness of the treatment;
DHS 101.03 Note(f) Preventive therapy utilizing the principles or techniques of minimizing further debilitation in the areas of energy preservation, joint protection, edema control, positioning, etc., which requires the specialized knowledge and judgment of a qualified occupational or physical therapist;
DHS 101.03 Note(g) Maintenance therapy, when the specialized knowledge and judgment of a qualified therapist is required to design and establish a maintenance program based on an initial evaluation and periodic reassessment of the patient’s needs, and consistent with the patient’s capacity and tolerance;
DHS 101.03 Note(h) Ultrasound, shortwave, and microwave therapy treatments by a qualified physical therapist;
DHS 101.03 Note(i) Hot pack, hydrocollator, infra-red treatments, paraffin baths, and whirlpool in particular cases where the patient’s condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications, and where the skills, knowledge, and judgment of a qualified physical therapist are required;
DHS 101.03 Note(j) Therapeutic adaptations, including orthotics, splinting, prosthetics and assistive or adaptive equipment prescribed by a physician and provided by a qualified occupational or physical therapist are required; and
DHS 101.03 Note(k) Services of a speech pathologist or audiologist when necessary for the restoration of function in speech or hearing.
DHS 101.03(166)(166) “Specialized medical vehicle” or “SMV” means a non-emergency vehicle used to transport a recipient who is confined to a wheelchair or whose condition contraindicates transportation by common carrier, and whose physician has prescribed specialized medical vehicle transportation to a facility at which the recipient primarily receives medical services. DHS 101.03(167)(167) “Spell of illness” means, in relationship to physical therapy, occupational therapy, and speech pathology services, a condition characterized by a demonstrated loss of functional ability to perform daily living skills, caused by a new disease, injury or medical condition or by an increase in the severity of a pre-existing medical condition. For a condition to be classified as a new spell of illness, the recipient must display the potential to reachieve the skill level that he or she had previously. DHS 101.03(168)(168) “Spend-down period” means the period during which excess income may be expended or obligations to expend excess income may be incurred for the purpose of obtaining MA eligibility, as described under s. DHS 103.08 (2) (a). DHS 101.03(169)(169) “SSI” means supplemental security income, the assistance program under Title XVI of the Social Security Act of 1935, as amended, and s. 49.77, Stats. DHS 101.03(170m)(170m) “State employees health plan” means family or individual coverage under a group health insurance plan offered by a unit of state government to its employees. DHS 101.03(171)(171) “Stepparent case” means an MA case consisting of a family in which a legal parent, a stepparent and a child under age 18 reside in the home. DHS 101.03(172)(172) “Sterilization” means any medical procedure, treatment, or operation for the purpose of rendering an individual permanently incapable of reproducing.
