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e. A statement of the estimated additional dates of service necessary and total cost; and
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.
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.
(c) Other limitations.
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.
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.
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.
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).
(d) Non-covered services. The following services are not covered services:
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;
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;
3. Consultation with other providers or service agency staff regarding the care or progress of a recipient;
4. Prevention or education programs provided as an outreach service, case-finding, and reading groups;
5. Aftercare programs, provided independently or operated by or under contract to boards;
6. Medical or AODA day treatment for recipients with a primary diagnosis of alcohol or other drug abuse;
7. Day treatment provided in person in the recipient’s home; and
8. Court appearances except when necessary to defend against commitment.
Note: For more information on non-covered services, see s. DHS 107.03.
(6)Community support program (CSP) services.
(a) Covered services. Community support program (CSP) services shall be covered services when prescribed by a physician and provided by a provider certified under s. DHS 105.255 for recipients who can benefit from the services. These non-institutional services make medical treatment and related care and rehabilitative services available to enable a recipient to better manage the symptoms of his or her illness, to increase the likelihood of the recipient’s independent, effective functioning in the community and to reduce the incidence and duration of institutional treatment otherwise brought about by mental illness. Services covered are as follows:
1. Initial assessment. At the time of admission, the recipient, upon a psychiatrist’s order, shall receive an initial assessment conducted by a psychiatrist and appropriate professional personnel to determine the need for CSP care;
2. In-depth assessment. Within one month following the recipient’s admission to a CSP, a psychiatrist and a treatment team shall perform an in-depth assessment to include all of the following areas:
a. Evaluation of psychiatric symptomology and mental status;
b. Use of drugs and alcohol;
c. Evaluation of vocational, educational and social functioning;
d. Ability to live independently;
e. Evaluation of physical health, including dental health;
f. Assessment of family relationships; and
g. Identification of other specific problems or needs;
3. Treatment plan. A comprehensive written treatment plan shall be developed for each recipient and approved by a psychiatrist. The plan shall be developed by the treatment team with the participation of the recipient or recipient’s guardian and, as appropriate, the recipient’s family. Based on the initial and in-depth assessments, the treatment plan shall specify short-term and long-term treatment and restorative goals, the services required to meet these goals and the CSP staff or other agencies providing treatment and psychosocial rehabilitation services. The treatment plan shall be reviewed by the psychiatrist and the treatment team at least every 30 days to monitor the recipient’s progress and status;
4. Treatment services, as follows:
a. Family, individual and group psychotherapy;
b. Symptom management or supportive psychotherapy;
c. Medication prescription, administration and monitoring;
d. Crisis intervention on a 24-hour basis, including short-term emergency care at home or elsewhere in the community; and
e. Psychiatric and psychological evaluations;
5. Psychological rehabilitation services as follows;
a. Employment-related services. These services consist of counseling the recipient to identify behaviors which interfere with seeking and maintaining employment; development of interventions to alleviate problem behaviors; and supportive services to assist the recipient with grooming, personal hygiene, acquiring appropriate work clothing, daily preparation for work, on-the-job support and crisis assistance;
b. Social and recreational skill training. This training consists of group or individual counseling and other activities to facilitate appropriate behaviors, and assistance given the recipient to modify behaviors which interfere with family relationships and making friends;
c. Assistance with and supervision of activities of daily living. These services consist of aiding the recipient in solving everyday problems; assisting the recipient in performing household tasks such as cleaning, cooking, grocery shopping and laundry; assisting the recipient to develop and improve money management skills; and assisting the recipient in using available transportation;
d. Other support services. These services consist of helping the recipient obtain necessary medical, dental, legal and financial services and living accommodations; providing direct assistance to ensure that the recipient obtains necessary government entitlements and services, and counseling the recipient in appropriately relating to neighbors, landlords, medical personnel and other personal contacts; and
6. Case management in the form of ongoing monitoring and service coordination activities described in s. DHS 107.32 (1) (d).
(b) Other limitations.
1. Mental health services under s. DHS 107.13 (2) and (4) are not reimbursable for recipients receiving CSP services.
2. An initial assessment shall be reimbursed only when the recipient is first admitted to the CSP and following discharge from a hospital after a short-term stay.
3. Group therapy is limited to no more than 10 persons in a group. No more than 2 professionals shall be reimbursed for a single session of group therapy. Mental health technicians shall not be reimbursed for group therapy.
4. Reimbursement is not available for a person participating in the program under this subsection if the person is also participating in the program under sub. (7).
(c) Non-covered services. The following CSP services are not covered services:
1. Case management services provided under s. DHS 107.32 by a provider not certified under s. DHS 105.255 to provide CSP services;
2. Services provided to a resident of an intermediate care facility, skilled nursing facility or an institution for mental diseases, or to a hospital patient unless the services are performed to prepare the recipient for discharge from the facility to reside in the community;
3. Services related to specific job-seeking, job placement and work activities;
4. Services performed by volunteers;
5. Services which are primarily recreation-oriented; and
6. Legal advocacy performed by an attorney or paralegal.
(7)Psychosocial services provided through a community-based psychosocial service program.
(a) Covered services. Psychosocial services provided through a community-based psychosocial service program shall be covered services when authorized by a mental health professional under s. DHS 36.15 for recipients determined to have a need for the services under s. DHS 36.14. These non-institutional services must fall within the definition of “rehabilitative services” under 42 CFR 440.130 (d) and must be described in a service plan under s. DHS 36.17. Covered services include assessment under s. DHS 36.16 and service planning and review under s. DHS 36.17.
(b) Other limitations.
1. Mental health services under s. DHS 107.13 (2) and (4) are not reimbursable for recipients receiving services under this subsection.
2. Group psychotherapy is limited to no more than 10 persons in a group. No more than 2 professionals shall be reimbursed for a single session of group psychotherapy. Mental health technicians shall not be reimbursed for group psychotherapy.
3. Reimbursement is not available for a person participating in the program under this subsection if the person is also participating in the program under sub. (6).
(c) Non-covered services. The following are not covered services under this subsection:
1. Case management services provided under s. DHS 107.32 by a provider not certified under s. DHS 105.257 to provide services under this section.
2. Services provided to a resident of an intermediate care facility, skilled nursing facility or an institution for mental diseases, or to a hospital patient unless the services are performed to prepare the recipient for discharge from the facility to reside in the community.
3. Services performed by volunteers, except that out-of-pocket expenses incurred by volunteers in performing services may be covered.
4. Services that are not rehabilitative, including services that are primarily recreation-oriented.
5. Legal advocacy performed by an attorney or paralegal.
History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. (1) (f) 8., Register, February, 1988, No. 386, eff. 3-1-88; emerg. cr. (3m), eff. 3-9-89; cr. (3m), Register, December, 1989, No. 408, eff. 1-1-90; emerg. cr. (2) (c) 5., (3) (c) 2., (4) (c) 4. and (6), eff. 1-1-90; cr. (2) (c) 5., (3) (c) 2., (4) (c) 4. and (6), Register, September, 1990, No. 417, eff. 10-1-90; emerg. r. and recr. (1) (b) 3., am. (1) (f) 6., eff. 1-1-91; am. (1) (a), (b) 1. and 2., (c), (f) 5., 6. and 8., (2) (a) 1., 3. a. and b., 4. f., 6., 7., (b) 1. and 2., (c) 2., (3) (a) (intro.), 4., 5., 7., (b) 1. and 2., (c) 1. (3) (d) 1. and 2., (4) (a) 3. and 6. and (d) 6., r. and recr. (1) (b) 3. and (e), r. (4) (b) 1. d., renum. (4) (b) 1. c. to be d., cr. (2) (c) 6., (3) (c) 3. and 4., (3) (d) 3., Register, September, 1991, No. 429, eff. 10-1-91; am. (4) (a) 2., cr. (4) (a) 8., Register, February, 1993, No. 446, eff. 3-1-93; corrections in (3) (d) 3. and (3m) (a) 1. made under s. 13.93 (2m) (b) 7., Stats., Register February 2002 No. 554; emerg. am. (2) (c) 5. and (4) (c) 4., cr. (6) (b) 4. and (7), eff. 7-1-04; CR 04-025: am (2) (c) 5. and (4) (c) 4., cr. (6) (b) 4. and (7) Register October 2004 No. 586, eff. 11-1-04; corrections in (1) (a), (f) 5., (2) (a) (intro.), 3., (c) 6., (3) (a) (intro.), (c) 3., (d) 3., (3m) (a) (intro.), 1., (b) 3., (4) (a) (intro.), 8., (6) (a) (intro.), (c) 1., (7) (a) and (c) 1. made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 06-080: am. (2) (a) (intro.), 1. (intro.), 3. a., b., 4. a. to f., 6., 7., (b) 1., 4. a. to d., (c) 4., 6. and (d) 2., cr. (2) (a) 1. a. to g. and (2m) Register May 2009 No. 641, eff. 6-1-09; CR 14-066: am. (2) (a) (intro.), r. (2) (a) 2., am. (2) (a) 4. (intro.), cr. (2) (a) 4. g., r. (2) (b) 4. b., am. (2) (d) (intro.), 1. to. 4. Register August 2015 No. 716, eff. 9-1-15; 2019 Wis. Act 1: am. (2) (d) 2. Register May 2019 No. 761; eff. 6-1-19; CR 20-039: am. (2) (d) 1. Register October 2021 No. 790, eff. 11-1-21; correction in (6) (c) 2. made under s. 35.17, Stats., Register July 2022 No. 799; correction in (3) (d) 3., (3m) (a) 1. made under s. 13.92 (4) (b) 7., Stats., made under s. 13.92 (4) (b) 7., Stats., Register September 2022 No. 801; CR 22-043: cr. (2) (a) 4. h., am. (2) (a) 5., (b) 4. e., (3) (a) 5., 6., (b) 4. d., (3m) (d) 6., (4) (a) 8., (d) 7. Register May 2023 No. 809, eff. 6-1-23; correction in (2) (a) 5., (3) (a) 6. made under s. 35.17, Stats., Register May 2023 No. 809; CR 23-046: r. (2) (a) 6., 7., (b), (3) (a) 4., 7., (b) Register April 2024 No. 820, eff. 5-1-24; correction in (2) (a) 5., (3) (a) 6. made under s. 35.17, Stats., Register April 2024 No. 820.
DHS 107.14Podiatry services.
(1)Covered services.
(a) Podiatry services covered by medical assistance are those medically necessary services for the diagnosis and treatment of the feet and ankles, within the limitations described in this section, when provided by a certified podiatrist.
(b) The following categories of services are covered services when performed by a podiatrist:
1. Office visits;
2. Home visits;
3. Nursing home visits;
4. Physical medicine;
6. Mycotic conditions and nails;
7. Laboratory;
8. Radiology;
9. Plaster or other cast material used in cast procedures and strapping or tape casting for treating fractures, dislocations, sprains and open wounds of the ankle, foot and toes;
10. Unna boots; and
11. Drugs and injections.
(2)Other limitations.
(a) Podiatric services pertaining to the cleaning, trimming and cutting of toenails, often referred to as palliative or maintenance care, shall be reimbursed once per 61 day period only if the recipient is under the active care of a physician and the recipient’s condition is one of the following:
1. Diabetes mellitus;
2. Arteriosclerosis obliterans evidenced by claudication;
3. Peripheral neuropathies involving the feet, which are associated with:
a. Malnutrition or vitamin deficiency;
b. Diabetes mellitus;
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Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.