Chapter DHS 107

DHS 107.13(2)(c) (c) Other limitations.

DHS 107.13(2)(c)1. 1. Collateral interviews shall be limited to members of the recipient’s immediate family. These are parents, spouse and children or, for children in foster care, foster parents.

DHS 107.13(2)(c)2. 2. No more than one provider may be reimbursed for the same psychotherapy session, unless the session involves a couple, family group or is a group therapy session. In this subdivision, “group therapy session” means a session not conducted in a hospital for an inpatient recipient at which there are more than one but not more than 10 individuals receiving psychotherapy services together from one or 2 providers. Under no circumstances may more than 2 providers be reimbursed for the same session.

DHS 107.13(2)(c)3. 3. Emergency psychotherapy may be performed by a provider for a recipient without a prescription for treatment or prior authorization when the provider has reason to believe that the recipient may immediately injure himself or herself or any other person. A prescription for the emergency treatment shall be obtained within 48 hours of the time the emergency treatment was provided, excluding weekends and holidays. Services shall be incorporated within the limits described in par. (b) and this paragraph, and subsequent treatment may be provided if par. (b) is followed.

DHS 107.13(2)(c)4. 4. Strength-based assessment, including a differential diagnostic evaluation for mental health, day treatment and substance abuse services shall be limited to 8 hours every calendar year per recipient as a unique procedure before prior authorization is required.

DHS 107.13(2)(c)5. 5. 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).

DHS 107.13(2)(c)6. 6. Professional psychotherapy services provided to hospital inpatients in general hospitals, other than group therapy and medication management, are not considered inpatient services. Reimbursement shall be made to the psychiatrist, psychologist, or advanced practice nurse prescriber billing providers certified under s. DHS 105.22 (1) (a), (b), or (bm) who provide mental health professional services to hospital inpatients in accordance with requirements of this subsection.

DHS 107.13(2)(d) (d) Non-covered services. All of the following services are not covered services:

DHS 107.13(2)(d)1. 1. Collateral interviews with persons not stipulated in par. (c) 1., and consultations, except as provided in s. 49.45 (29y), Stats., and s. DHS 107.06 (4) (d).

DHS 107.13(2)(d)2. 2. Psychotherapy for individuals with the primary diagnosis of developmental disabilities, including intellectual disabilities, except when they experience psychological problems that necessitate psychotherapeutic intervention.

DHS 107.13(2)(d)3. 3. For individuals age 21 and over, psychotherapy provided in a person’s home.

DHS 107.13 Note Note: Section 49.45 (45), Stats., provides for in-home community mental health and alcohol and other drug abuse (AODA) services for individuals age 21 and over. However, these services are available to an individual only if the county, city, town or village in which the individual resides elects to make the services available and agrees to pay the non-federal share of the cost of those services.

DHS 107.13(2)(d)4. 4. Self-referrals. For purposes of this paragraph, “self-referral” means that a provider refers a recipient to an agency in which the provider has a direct financial interest, or to himself or herself acting as a practitioner in private practice.

DHS 107.13(2)(d)5. 5. Court appearances except when necessary to defend against commitment.

DHS 107.13 Note Note: For more information on non-covered services, see s. DHS 107.03.

DHS 107.13(2m) (2m) The goals of psychotherapy and specific objectives to meet those goals shall be documented in the recipient’s recovery and treatment plan that is based on the strength-based assessment. In the recovery and treatment plan, the signs of improved functioning that will be used to measure progress towards specific objectives at identified intervals, agreed upon by the provider and recipient shall be documented. A mental health diagnosis and medications for mental health issues used by the recipient shall be documented in the recovery and treatment plan.

DHS 107.13(3) (3) Alcohol and other drug abuse outpatient treatment services.

DHS 107.13(3)(a) (a) Covered services. Outpatient alcohol and drug abuse treatment services shall be covered when prescribed by a physician, provided by a provider who meets the requirements of s. DHS 105.23, and when the following conditions are met:

DHS 107.13(3)(a)1. 1. The treatment services furnished are AODA treatment services;

DHS 107.13(3)(a)2. 2. Before being enrolled in an alcohol or drug abuse treatment program, the recipient receives a complete medical evaluation, including diagnosis, summary of present medical findings, medical history and explicit recommendations by the physician for participation in the alcohol or other drug abuse treatment program. A medical evaluation performed for this purpose within 60 days prior to enrollment shall be valid for reenrollment;

DHS 107.13(3)(a)3. 3. The supervising physician or psychologist develops a treatment plan which relates to behavior and personality changes being sought and to the expected outcome of treatment;

DHS 107.13(3)(a)5. 5. AODA treatment services are performed only in the office of the provider, a hospital or hospital outpatient clinic, an outpatient facility, a nursing home or a school or by telehealth when functionally equivalent to services provided in person;

DHS 107.13(3)(a)6. 6. The provider who performs AODA treatment services shall engage in contact with the recipient in person, via real-time interactive audio-visual telehealth, or real-time interactive audio-only telehealth for at least 5/6 of the time for which reimbursement is claimed.

DHS 107.13(3)(c) (c) Other limitations.

DHS 107.13(3)(c)1. 1. No more than one provider may be reimbursed for the same AODA treatment session, unless the session involves a couple, a family group or is a group session. In this paragraph,“group session” means a session not conducted in a hospital for an inpatient recipient at which there are more than one but not more than 10 recipients receiving services together from one or 2 providers. No more than 2 providers may be reimbursed for the same session. No recipient may be held responsible for charges for services in excess of MA coverage under this paragraph.

DHS 107.13(3)(c)2. 2. Services under this subsection are not reimbursable if the recipient is receiving community support program services under sub. (6).

DHS 107.13(3)(c)3. 3. Professional AODA treatment services other than group therapy and medication management provided to hospital inpatients in general or to inpatients in IMDs are not considered inpatient services. Reimbursement shall be made to the psychiatrist or psychologist billing provider certified under s. DHS 105.22 (1) (a) or (b) or 105.23 who provides AODA treatment services to hospital inpatients in accordance with requirements under this subsection.

DHS 107.13(3)(c)4. 4. Medical detoxification services are not considered inpatient services if provided outside an inpatient general hospital or IMD.

DHS 107.13(3)(d) (d) Non-covered services. The following services are not covered services:

DHS 107.13(3)(d)1. 1. Collateral interviews and consultations, except as provided in s. DHS 107.06 (4) (d);

DHS 107.13(3)(d)2. 2. Court appearances except when necessary to defend against commitment; and

DHS 107.13(3)(d)3. 3. Detoxification provided in a social setting, as described in s. DHS 75.58, is not a covered service.

DHS 107.13 Note Note: For more information on non-covered services, see s. DHS 107.03.

DHS 107.13(3m) (3m) Alcohol and other drug abuse day treatment services.

DHS 107.13(3m)(a) (a) Covered services. Alcohol and other drug abuse day treatment services shall be covered when prescribed by a physician, provided by a provider certified under s. DHS 105.25 and performed according to the recipient’s treatment program in a non-residential, medically supervised setting, and when the following conditions are met:

DHS 107.13(3m)(a)1. 1. An initial assessment is performed by qualified medical professionals under s. DHS 75.24 (11) for a potential participant. Services under this section shall be covered if the assessment concludes that AODA day treatment is medically necessary and that the recipient is able to benefit from treatment;

DHS 107.13(3m)(a)2. 2. A treatment plan based on the initial assessment is developed by the interdisciplinary team in consultation with the medical professionals who conducted the initial assessment and in collaboration with the recipient;

DHS 107.13(3m)(a)3. 3. The supervising physician or psychologist approves the recipient’s written treatment plan;

DHS 107.13(3m)(a)4. 4. The treatment plan includes measurable individual goals, treatment modes to be used to achieve these goals and descriptions of expected treatment outcomes; and

DHS 107.13(3m)(a)5. 5. The interdisciplinary team monitors the recipient’s progress, adjusting the treatment plan as required.

DHS 107.13(3m)(b) (b) Prior authorization.

DHS 107.13(3m)(b)1. 1. All AODA day treatment services except the initial assessment shall be prior authorized.

DHS 107.13(3m)(b)2. 2. Any recommendation by the county human services department under s. 46.23, Stats., or the county community programs department under s. 51.42, Stats., shall be considered in review and approval of the prior authorization request.

DHS 107.13(3m)(b)3. 3. Department representatives who review and approve prior authorization requests shall meet the same minimum training requirements as those mandated for AODA day treatment providers under s. DHS 105.25.

DHS 107.13(3m)(c) (c) Other limitations.

DHS 107.13(3m)(c)1. 1. AODA day treatment services in excess of 5 hours per day are not reimbursable under MA.

DHS 107.13(3m)(c)2. 2. AODA day treatment services may not be billed as psychotherapy, AODA outpatient treatment, case management, occupational therapy or any other service modality except AODA day treatment.

DHS 107.13(3m)(c)3. 3. Reimbursement for AODA day treatment services may not include time devoted to meals, rest periods, transportation, recreation or entertainment.

DHS 107.13(3m)(c)4. 4. Reimbursement for AODA day treatment assessment for a recipient is limited to 3 hours in a calendar year. Additional assessment hours shall be counted towards the mental health outpatient dollar or hour limit under sub. (2) (a) 6. before prior authorization is required or the AODA outpatient dollar or hour limit under sub. (3) (a) 4. before prior authorization is required.

DHS 107.13(3m)(d) (d) Non-covered services. The following are not covered services:

DHS 107.13(3m)(d)1. 1. Collateral interviews and consultations, except as provided in s. DHS 107.06 (4) (d);

DHS 107.13(3m)(d)2. 2. Time spent in the AODA day treatment setting by affected family members of the recipient;

DHS 107.13(3m)(d)3. 3. AODA day treatment services which are primarily recreation-oriented or which are provided in non-medically supervised settings. These include but are not limited to sports activities, exercise groups, and activities such as crafts, leisure time, social hours, trips to community activities and tours;

DHS 107.13(3m)(d)4. 4. Services provided to an AODA day treatment recipient which are primarily social or only educational in nature. Educational sessions are covered as long as these sessions are part of an overall treatment program and include group processing of the information provided;

DHS 107.13(3m)(d)5. 5. Prevention or education programs provided as an outreach service or as case-finding; and

DHS 107.13(3m)(d)6. 6. AODA day treatment provided in person in the recipient’s home.

DHS 107.13(4) (4) Mental health day treatment or day hospital services.

DHS 107.13(4)(a) (a) Covered services. Day treatment or day hospital services are covered services when prescribed by a physician, when provided by a provider who meets the requirements of s. DHS 105.24, and when the following conditions are met:

DHS 107.13(4)(a)1. 1. Before becoming involved in a day treatment program, the recipient is evaluated through the use of the functional assessment scale provided by the department to determine the medical necessity for day treatment and the person’s ability to benefit from it;

DHS 107.13(4)(a)2. 2. The supervising psychiatrist approves, signs and dates a written treatment plan for each recipient and reviews and signs the plan no less frequently than once every 60 days. The treatment plan shall be based on the initial evaluation and shall include the individual goals, the treatment modalities including identification of the specific group or groups to be used to achieve these goals and the expected outcome of treatment;

DHS 107.13(4)(a)3. 3. Up to 90 hours of day treatment services in a calendar year may be reimbursed without prior authorization. Psychotherapy services or occupational therapy services provided as component parts of a person’s day treatment package may not be billed separately, but shall be billed and reimbursed as part of the day treatment program;

DHS 107.13(4)(a)4. 4. Day treatment or day hospital services provided to recipients with inpatient status in a hospital are limited to 20 hours per inpatient admission and shall only be available to patients scheduled for discharge to prepare them for discharge;

DHS 107.13(4)(a)5. 5. Reimbursement is not made for day treatment services provided in excess of 5 hours in any day or in excess of 120 hours in any month;

DHS 107.13(4)(a)6. 6. Day treatment services are covered only for the chronically mentally ill and acutely mentally ill who have a need for day treatment and an ability to benefit from the service, as measured by the functional assessment scale provided by the department; and

DHS 107.13(4)(a)7. 7. Billing for day treatment is submitted by the provider. Day treatment services shall be billed as such, and not as psychotherapy, occupational therapy or any other service modality.

DHS 107.13(4)(a)8. 8. The groups shall be led by a qualified professional staff member, as defined under s. DHS 105.24 (1) (b) 4. a., and the staff member shall be present throughout the group sessions and shall perform or direct the service.

DHS 107.13(4)(b) (b) Services requiring prior authorization.

DHS 107.13(4)(b)1. 1. Providers shall obtain authorization from the department before providing the following services, as a condition for coverage of these services:

DHS 107.13(4)(b)1.a. a. Day treatment services provided beyond 90 hours of service in a calendar year;

DHS 107.13(4)(b)1.b. b. All day treatment or day hospital services provided to recipients with inpatient status in a nursing home. Only those patients scheduled for discharge are eligible for day treatment. No more than 40 hours of service in a calendar year may be authorized for a recipient residing in a nursing home;

DHS 107.13(4)(b)1.c. c. All day treatment services provided to recipients who are concurrently receiving psychotherapy, occupational therapy or AODA services;

DHS 107.13(4)(b)1.d. d. All day treatment services in excess of 90 hours provided to recipients who are diagnosed as acutely mentally ill.

DHS 107.13(4)(b)2. 2. The prior authorization request shall include:

DHS 107.13(4)(b)2.a. a. The name, address, and MA number of the recipient;

DHS 107.13(4)(b)2.b. b. The name, address, and provider number of the provider of the service and of the billing provider;

DHS 107.13(4)(b)2.c. c. A photocopy of the physician’s original prescription for treatment;

DHS 107.13(4)(b)2.d. d. A copy of the treatment plan and the expected outcome of treatment;

DHS 107.13(4)(b)2.e. e. A statement of the estimated additional dates of service necessary and total cost; and

DHS 107.13(4)(b)2.f. 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.

DHS 107.13(4)(b)3. 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.

DHS 107.13(4)(c) (c) Other limitations.

DHS 107.13(4)(c)1. 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.

DHS 107.13(4)(c)2. 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.

DHS 107.13(4)(c)3. 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.

DHS 107.13(4)(c)4. 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).

DHS 107.13(4)(d) (d) Non-covered services. The following services are not covered services:

DHS 107.13(4)(d)1. 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;

DHS 107.13(4)(d)2. 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;

DHS 107.13(4)(d)3. 3. Consultation with other providers or service agency staff regarding the care or progress of a recipient;