DHS 107.02(3)(b)1.
1. To safeguard against unnecessary or inappropriate care and services;
DHS 107.02(3)(b)4.
4. To determine if less expensive alternative care, services or supplies are usable;
DHS 107.02(3)(b)5.
5. To promote the most effective and appropriate use of available services and facilities; and
DHS 107.02(3)(c)
(c) Penalty for non-compliance. If prior authorization is not requested and obtained before a service requiring prior authorization is provided, reimbursement shall not be made except in extraordinary circumstances such as emergency cases where the department has given verbal authorization for a service.
DHS 107.02(3)(d)
(d) Required information. A request for prior authorization submitted to the department or its fiscal agent shall, unless otherwise specified in chs.
DHS 101 to
108, identify at a minimum:
DHS 107.02(3)(d)1.
1. The name, address and MA number of the recipient for whom the service or item is requested;
DHS 107.02(3)(d)2.
2. The name and provider number of the provider who will perform the service requested;
DHS 107.02(3)(d)4.
4. The attending physician's or dentist's diagnosis including, where applicable, the degree of impairment;
DHS 107.02(3)(d)5.
5. A description of the service being requested, including the procedure code, the amount of time involved, and dollar amount where appropriate; and
DHS 107.02(3)(e)
(e) Departmental review criteria. In determining whether to approve or disapprove a request for prior authorization, the department shall consider:
DHS 107.02(3)(e)6.
6. The extent to which less expensive alternative services are available;
DHS 107.02(3)(e)9.
9. The limitations imposed by pertinent federal or state statutes, rules, regulations or interpretations, including medicare, or private insurance guidelines;
DHS 107.02(3)(e)10.
10. The need to ensure that there is closer professional scrutiny for care which is of unacceptable quality;
DHS 107.02(3)(e)11.
11. The flagrant or continuing disregard of established state and federal policies, standards, fees or procedures; and
DHS 107.02(3)(e)12.
12. The professional acceptability of unproven or experimental care, as determined by consultants to the department.
DHS 107.02(3)(f)
(f) Professional consultants. The department or its fiscal agent may use the services of qualified professional consultants in determining whether requests for prior authorization meet the criteria in par.
(e).
DHS 107.02(3)(g)
(g) Authorization not transferable. Prior authorization, once granted, may not be transferred to another recipient or to another provider. In certain cases the department may allow multiple services to be divided among non-billing providers certified under one billing provider. For example, prior authorization for 15 visits for occupational therapy may be performed by more than one therapist working for the billing provider for whom prior authorization was granted. In emergency circumstances the service may be provided by a different provider.
DHS 107.02(3)(h)
(h) Medical opinion reports. Medical evaluations and written medical opinions used in establishing a claim in a tort action against a third party may be covered services if they are prior-authorized. Prior authorization shall be issued only where:
DHS 107.02(3)(h)1.
1. A recipient has sustained personal injuries requiring medical or other health care services as a result of injury, damage or a wrongful act caused by another person;
DHS 107.02(3)(h)3.
3. The recipient or the recipient's representative has initiated or will initiate a claim or tort action against the negligent third party, joining the department in the action as provided under s.
49.89, Stats.; and
DHS 107.02(3)(h)4.
4. The recipient or the recipient's representative agrees in writing to reimburse the program in whole for all payments made for the prior-authorized services from the proceeds of any judgment, award, determination or settlement on the recipient's claim or action.
DHS 107.02(3)(i)1.1. Approval or modification by the department or its fiscal agent of a prior authorization request, including any subsequent amendments, extensions, renewals, or reconsideration requests:
DHS 107.02(3)(i)1.a.
a. Shall not relieve the provider of responsibility to meet all requirements of federal and state statutes and regulations, provider handbooks and provider bulletins;
DHS 107.02(3)(i)1.b.
b. Shall not constitute a guarantee or promise of payment, in whole or in part, with respect to any claim submitted under the prior authorization; and
DHS 107.02(3)(i)2.
2. Subject to the applicable terms of reimbursement issued by the department, covered services provided consistent with a prior authorization, as approved or modified by the department or its fiscal agent, are reimbursable provided:
DHS 107.02(3)(i)2.a.
a. The provider's approved or modified prior authorization request and supporting information, including all subsequent amendments, renewals and reconsideration requests, is truthful and accurate;
DHS 107.02(3)(i)2.b.
b. The provider's approved or modified prior authorization request and supporting information, including all subsequent amendments, extensions, renewals and reconsideration requests, completely and accurately reveals all facts pertinent to the recipient's case and to the review process and criteria provided under s.
DHS 107.02 (3);
DHS 107.02(3)(i)2.c.
c. The provider complies with all requirements of applicable state and federal statutes, the terms and conditions of the applicable provider agreement pursuant to s.
49.45 (2) (a) 9., Stats., all applicable requirements of chs.
DHS 101 to
108, including but not limited to the requirements of ss.
DHS 106.02,
106.03,
107.02, and
107.03, and all applicable prior authorization procedural instructions issued by the department under s.
DHS 108.02 (4);
DHS 107.02(3)(i)2.e.
e. The provider is MA certified and qualified to provide the service on the date of the service.
DHS 107.02(4)(a)
(a) General policy. The department shall establish cost-sharing provisions for MA recipients, pursuant to s.
49.45 (18), Stats. Cost-sharing requirements for providers are described under s.
DHS 106.04 (2), and services and recipients exempted from cost-sharing requirements are listed under s.
DHS 104.01 (12) (a).
DHS 107.02(4)(b)
(b) Notification of applicable services and rates. All services for which cost-sharing is applicable shall be identified by the department to all recipients and providers prior to enforcement of the provisions.
DHS 107.02(4)(d)
(d) Limitation on copayments for prescription drugs. Providers may not collect copayments in excess of $5 a month from a recipient for prescription drugs if the recipient uses one pharmacy or pharmacist as his or her sole provider of prescription drugs.
DHS 107.02(5)
(5) Services provided via telehealth. The department shall reimburse providers for medically necessary and appropriate health care services listed in this chapter and ss.
49.46 (2) and
49.47 (6) (a), Stats., when provided to currently eligible MA recipients via telehealth. Services provided via telehealth are subject to the same restrictions as services provided in an in-person setting unless otherwise specified in chs.
DHS 101 to
109. Providers shall ensure that the locations from which they provide services via telehealth ensure privacy and confidentiality of recipient information and communications in a functionally equivalent manner to services provided in person. Benefits or services that may not be delivered via telehealth include any of the following:
DHS 107.02(5)(b)
(b) Services that do not meet applicable laws, regulations, licensure requirements, or procedure code definitions if delivered via telehealth.
DHS 107.02(5)(c)
(c) Services when a provider is required to physically touch or examine the recipient and delegation is not appropriate.
DHS 107.02(5)(f)
(f) Services provided by personal care workers, home health aides, private duty nurses, or school based service care attendants.
DHS 107.02 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86; r. and recr. (1) and am. (14) (c) 12. and 13.,
Register, February, 1988, No. 386, eff. 3-1-88; cr. (4) (c) 14.,
Register, April, 1988, No. 388, eff. 7-1-88; r. and recr. (4) (c),
Register, December, 1988, No. 396, eff. 1-1-89; emerg. am. (4) (a), r. (4) (c), eff. 1-1-90; am. (4) (a) r. (4) (c),
Register, September, 1990, No. 417, eff. 10-1-90; am. (2) (b), r. (2) (c), renum. (2) (d) and (e) to be (2) (c) and (d), cr. (2m),
Register, September, 1991, No. 429, eff. 10-1-91; emerg. cr. (3) (i), eff. 7-1-92; am. (2) (c) and (d), cr. (2) (e) to (j) and (3) (i),
Register, February, 1993, No. 446, eff. 3-1-93; r. (2m) (a) 17.,
Register, November, 1994, No. 467, eff. 12-1-94; am. (2) (a),
Register, January, 1997, No. 493, eff. 2-1-97; correction in (4) (a) made under s. 13.93 (2m) (b) 7., Stats.,
Register, April, 1999, No. 520; correction in (3) (h) 3. made under s. 13.93 (2m) (b) 7., Stats.,
Register, October, 2000, No. 538;
CR 03-033: am. (2m) (a) 10. and (c)
Register December 2003 No. 576, eff. 1-1-04; corrections in (2) (e) to (j), (3) (d) (intro.), (i) 1. c., 2. c., and (4) (a) made under s. 13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636;
CR 14-066: r. (2m) (a) 7.
Register August 2015 No. 716, eff. 9-1-15;
CR 21-050: am. (3) (a)
Register April 2022 No. 796, eff. 5-1-22;
CR 22-043: cr. (5)
Register May 2023 No. 809, eff. 6-1-23;
EmR2306: emerg. cr. (1) (am), eff. 5-1-23;
CR 23-045: cr. (1) (am)
Register January 2024 No. 817, eff. 2-1-24.
DHS 107.03
DHS 107.03
Services not covered. The following services are not covered services under MA:
DHS 107.03(4)
(4) Services provided by a particular provider that are considered experimental in nature;
DHS 107.03(5)
(5) Procedures considered by the department to be obsolete, inaccurate, unreliable, ineffectual, unnecessary, imprudent or superfluous;
DHS 107.03(6)
(6) Personal comfort items, such as radios, television sets and telephones, which do not contribute meaningfully to the treatment of an illness;
DHS 107.03(7)
(7) Alcoholic beverages, even if prescribed for remedial or therapeutic reasons;
DHS 107.03(9)
(9) Any service requiring prior authorization for which prior authorization is denied, or for which prior authorization was not obtained prior to the provision of the service except in emergency circumstances;
DHS 107.03(10)
(10) Services subject to review and approval pursuant to s.
150.21, Stats., but which have not yet received approval;
DHS 107.03(11)
(11) Psychiatric examinations and evaluations ordered by a court following a person's conviction of a crime, pursuant to s.
972.15, Stats.;
DHS 107.03(13)
(13) Medical services for adult inmates of the correctional institutions listed in s.
302.01, Stats.;
DHS 107.03(14)
(14) Medical services for a child placed in a detention facility;
DHS 107.03(15)
(15) Expenditures for any service to an individual who is an inmate of a public institution or for any service to a person 21 to 64 years of age who is a resident of an institution for mental diseases (IMD), unless the person is 21 years of age, was a resident of the IMD immediately prior to turning 21 and has been continuously a resident since then, except that expenditures for a service to an individual on convalescent leave from an IMD may be reimbursed by MA.
DHS 107.03(16)
(16) Services provided to recipients when outside the United States, except Canada or Mexico;
DHS 107.03(17)
(17) Separate charges for the time involved in completing necessary forms, claims or reports;
DHS 107.03(18)
(18) Services provided by a hospital or professional services provided to a hospital inpatient are not covered services unless billed separately as hospital services under s.
DHS 107.08 or
107.13 (1) or as professional services under the appropriate provider type. No recipient may be billed for these services as non-covered;
DHS 107.03(19)
(19) Services, drugs and items that are provided for the purpose of enhancing the prospects of fertility in males or females, including but not limited to the following:
DHS 107.03(19)(a)
(a) Artificial insemination, including but not limited to intra-cervical and intra-uterine insemination;
DHS 107.03(19)(c)
(c) Infertility testing, including but not limited to tubal patency, semen analysis or sperm evaluation;
DHS 107.03(19)(d)
(d) Reversal of female sterilization, including but not limited to tubouterine implantation, tubotubal anastomoses or fimbrioplasty;
DHS 107.03(19)(e)
(e) Fertility-enhancing drugs used for the treatment of infertility;
DHS 107.03(19)(g)
(g) Office visits, consultations and other encounters to enhance the prospects of fertility; and
DHS 107.03(20)
(20) Surrogate parenting and related services, including but not limited to artificial insemination and subsequent obstetrical care;
