DHS 107.12(4)(4) Non-covered services. The following services are not covered services: DHS 107.12(4)(c)(c) Skilled nursing services performed by a recipient’s spouse or parent if the recipient is under age 21; DHS 107.12(4)(e)(e) Any service that fails to meet the recipient’s medical needs or places the recipient at risk for a negative treatment outcome. DHS 107.12(4)(f)1.1. Except as provided in subd. 2., services provided by an individual nurse under this section that, when combined with services provided to all recipients and other patients under the nurse’s care, exceed either of the following limitations: DHS 107.12(4)(f)2.2. Services may exceed the limitations in subd. 1. when both of the following conditions are met: DHS 107.12(4)(f)2.a.a. The services are approved by the department on a case-by-case basis for circumstances that could not reasonably have been predicted. DHS 107.12(4)(f)2.b.b. Failure to provide skilled nursing services likely would result in serious impairment of the recipient’s health. DHS 107.12(4)(g)1.1. Except as provided in subd. 2., services provided during any 24-hour period during which the nurse who performs the services has less than 8 continuous and uninterrupted hours off duty. DHS 107.12(4)(g)2.2. Services may exceed the limitations in subd. 1. when both of the following conditions are met: DHS 107.12(4)(g)2.a.a. The services are approved by the department on a case-by-case basis for circumstances that could not reasonably have been predicted. DHS 107.12(4)(g)2.b.b. Failure to provide skilled nursing services likely would result in serious impairment of the recipient’s health. DHS 107.12 HistoryHistory: Cr. Register, February, 1986, No. 362, eff. 3-1-86; emerg. r. and recr. eff. 7-1-90; r. and recr. Register, January, 1991, No. 421, eff. 2-1-91; emerg. r. and recr. eff. 7-1-92; r. and recr. Register, February, 1993, No. 446, eff. 3-1-93; CR 03-033: am. (1) (e) Register December 2003 No. 576, eff. 1-1-04; corrections in (1) (b) made under s. 13.93 (2m) (b) 7., Stats., Register December 2003 No. 576; CR 05-052: r. (2) (b) and (3) (d), cr. (4) (f) and (g) Register June 2007 No. 618, eff. 7-1-07; corrections in (1) (a) and (3) (a) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 23-046: am. (1) (b), (c), (d) 1. (intro.), 2., (e) 1., (4) (a) Register April 2024 No. 820, eff. 5-1-24. DHS 107.121(1)(1) Covered services. Covered services provided by a certified nurse-midwife may include the care of mothers and their babies throughout the maternity cycle, including pregnancy, labor, normal childbirth and the immediate postpartum period, provided that the nurse-midwife services are provided within the limitations established in s. 441.15 (2), Stats., and ch. N 4. DHS 107.121(2)(2) Limitation. Coverage for nurse-midwife services for management and care of the mother and newborn child shall end after the sixth week of postpartum care. DHS 107.121 HistoryHistory: Cr. Register, January, 1991, No. 421, eff. 2-1-91. DHS 107.122DHS 107.122 Independent nurse practitioner services. DHS 107.122(1)(1) Covered services. Services provided by a nurse practitioner, including a clinical nurse specialist, which are covered by the MA program are those medical services delegated by a licensed physician by a written protocol developed with the nurse practitioner pursuant to the requirements set forth in s. N 6.03 (2) and guidelines set forth by the medical examining board and the board of nursing. General nursing procedures are covered services when performed by a certified nurse practitioner or clinical nurse specialist in accordance with the requirements of s. N 6.03 (1). These services may include those medically necessary diagnostic, preventive, therapeutic, rehabilitative or palliative services provided in a medical setting, the recipient’s home or elsewhere. Specific reimbursable delegated medical acts and nursing services are the following: DHS 107.122(1)(a)1.1. Obtaining a recipient’s complete health history and recording the findings in a systematic, organized manner; DHS 107.122(1)(a)3.3. Performing a complete physical assessment using techniques of observation, inspection, auscultation, palpation and percussion, ordering appropriate laboratory and diagnostic tests and recording findings in a systematic manner; DHS 107.122(1)(a)4.4. Performing and recording a developmental or functional status evaluation and mental status examination using standardized procedures; and DHS 107.122(1)(a)5.5. Identifying and describing behavior associated with developmental processes, aging, life style and family relationships; DHS 107.122(1)(b)1.1. Discriminating between normal and abnormal findings associated with growth and development, aging and pathological processes; DHS 107.122(1)(b)2.2. Discriminating between normal and abnormal patterns of behavior associated with developmental processes, aging, life style, and family relationships as influenced by illness; DHS 107.122(1)(b)3.3. Exercising clinical judgment in differentiating between situations which the nurse practitioner can manage and those which require consultations or referral; and DHS 107.122(1)(c)1.1. Providing preventive health care and health promotion for adults and children; DHS 107.122(1)(c)2.2. Managing common self-limiting or episodic health problems in recipients according to protocol and other guidelines; DHS 107.122(1)(c)3.3. Managing stabilized illness problems in coloration with physicians and other health care providers according to protocol; DHS 107.122(1)(c)4.4. Prescribing, regulating and adjusting medications as defined by protocol; DHS 107.122(1)(c)6.6. Counseling recipients and their families about the process of growth and development, aging, life crises, common illnesses, risk factors and accidents; DHS 107.122(1)(c)7.7. Helping recipients and their families assume greater responsibility for their own health maintenance and illness care by providing instruction, counseling and guidance; DHS 107.122(1)(c)8.8. Arranging referrals for recipients with health problems who need further evaluation or additional services; and DHS 107.122(1)(c)9.9. Modifying the therapeutic regimen so that it is appropriate to the developmental and functional statuses of the recipient and the recipient’s family; DHS 107.122(1)(d)2.2. Collecting systematic data for evaluating the response of a recipient and the recipient’s family to a therapeutic regimen; DHS 107.122(1)(d)5.5. Utilizing an epidemiological approach in examining the health care needs of recipients in the nurse practitioner’s caseload; DHS 107.122(2)(b)(b) Requests for prior authorization shall be accompanied by the written protocol. DHS 107.122(3)(a)(a) No services under this section may be reimbursed without a written protocol developed and signed by the nurse practitioner and the delegating physician, except for general nursing procedures described under s. N 6.03 (1). The physician shall review a protocol according to the requirements of s. 448.03 (2) (e), Stats., and guidelines established by the medical examining board and the board of nursing, but no less than once each calendar year. A written protocol shall be organized as follows: DHS 107.122(3)(b)(b) Prescriptions for drugs are limited to those drugs allowed under protocol for prescription by a nurse practitioner, except that controlled substances may not be prescribed by a nurse practitioner. DHS 107.122(4)(b)(b) Services provided to nursing home residents or hospital inpatients which are included in the daily rates for a nursing home or hospital; DHS 107.122(4)(e)(e) Medical acts for which the nurse practitioner or clinical nurse specialist does not have written protocols as specified in this section. In this paragraph, “medical acts” means acts reserved by professional training and licensure to physicians, dentists and podiatrists. DHS 107.122 HistoryHistory: Emerg. cr. eff. 7-1-90; cr. Register, January, 1991, No. 421, eff. 2-1-91; correction in (1) (e) made under s. 13.93 (2m) (b) 7., Stats., Register, April, 1999, No. 520. DHS 107.13(1)(a)(a) Covered services. Inpatient hospital mental health and AODA care shall be covered when prescribed by a physician and when provided within a hospital institution for mental disease (IMD) which is certified under ss. DHS 105.07 and 105.21, except as provided in par. (b). DHS 107.13(1)(b)(b) Conditions for coverage of recipients under 21 years of age. DHS 107.13(1)(b)1.1. ‘Definition.’ In this paragraph, “individual plan of care”or “plan of care” means a written plan developed for each recipient under 21 years of age who receives inpatient hospital mental health or AODA care in a hospital IMD for the purpose of improving the recipient’s condition to the extent that inpatient care is no longer necessary. DHS 107.13(1)(b)2.2. ‘General conditions.’ Inpatient hospital mental health and AODA services provided in a hospital IMD for recipients under age 21 shall be provided under the direction of a physician and, if the recipient was receiving the services immediately before reaching age 21, coverage shall extend to the earlier of the following: DHS 107.13(1)(b)3.a.a. For recipients under age 21 receiving services in a hospital IMD, a team specified in subd. 3. b. shall certify that ambulatory care resources do not meet the treatment needs of the recipient, proper treatment of the recipient’s psychiatric condition requires services on an inpatient basis under the direction of a physician, and the services can reasonably be expected to improve the recipient’s condition or prevent further regression so that the services will be needed in reduced amount or intensity or no longer be needed. The certification specified in this subdivision satisfies the requirement for physician certification in subd. 7. In this subparagraph, “ambulatory care resources” means any covered service except hospital inpatient care or care of a resident in a nursing home. DHS 107.13(1)(b)3.b.b. Certification under subd. 3. a. shall be made for a recipient when the person is admitted to a facility or program by an independent team that includes a physician. The team shall have competence in diagnosis and treatment of mental illness, preferably in child psychology, and have knowledge of the recipient’s situation. DHS 107.13(1)(b)3.c.c. For a recipient who applies for MA eligibility while in a facility or program, the certification shall be made by the team described in subd. 5. b. and shall cover any period before application for which claims are made.
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Department of Health Services (DHS)
Chs. DHS 101-109; Medical Assistance
administrativecode/DHS 107.122(1)(a)4.
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