DHS 107.21(2)(2) Services requiring prior authorization. All sterilization procedures require prior authorization by the medical consultant to the department, as well as the informed consent of the recipient. Informed consent requests shall be in accordance with s. DHS 107.06 (3). DHS 107.21 NoteNote: For more information on prior authorization, see DHS 107.02 (3).
DHS 107.21(3)(3) Non-covered services. The following services are not covered services: DHS 107.21(3)(a)(a) The sterilization of a recipient under the age of 21 or of a recipient declared legally incapable of consenting to such a procedure; DHS 107.21(3)(b)(b) Services and items that are provided for the purpose of enhancing the prospects of fertility in males or females, including but not limited to: DHS 107.21(3)(b)1.1. Artificial insemination, including but not limited to intra-cervical or intra-uterine insemination; DHS 107.21(3)(b)3.3. Infertility testing, including but not limited to tubal patency, semen analysis or sperm evaluation; DHS 107.21(3)(b)4.4. Reversal of female sterilizations, including but not limited to tubouterine implantation, tubotubal anastomoses or fimbrioplasty; DHS 107.21(3)(b)7.7. Office visits, consultations and other encounters to enhance fertility; and DHS 107.21(3)(c)(c) Impotence devices and services, including but not limited to penile prostheses and external devices and to insertion surgery and other related services; DHS 107.21 NoteNote: For more information on non-covered services, see s. DHS 107.03. DHS 107.21 HistoryHistory: Cr. Register, February, 1986, No. 362, eff. 3-1-86; r. and recr. (1) (c) 3., (3), r. (1) (d) 4., renum. (1) (d) 5. to 8. to be (1) (d) 4. to 7; Register, January, 1997, No. 493, eff. 2-1-97. DHS 107.22DHS 107.22 Early and periodic screening, diagnosis and treatment (EPSDT) services. DHS 107.22(1)(1) Covered services. Early and periodic screening and diagnosis to ascertain physical and mental defects, and the provision of treatment as provided in sub. (4) to correct or ameliorate the defects shall be covered services for all recipients under 21 years of age when provided by an EPSDT clinic, a physician, a private clinic, an HMO or a hospital certified under s. DHS 105.37. DHS 107.22(2)(2) EPSDT health assessment and evaluation package. The EPSDT health assessment and evaluation package shall include at least those procedures and tests required by 42 CFR 441.56. The package shall include the following: DHS 107.22(2)(e)(e) Dental assessment and evaluation services furnished by direct referral to a dentist for children beginning at 3 years of age; DHS 107.22(3)(3) Supplemental tests. Selection of additional tests to supplement the health assessment and evaluation package shall be based on the health needs of the target population. Consideration shall be given to the prevalence of specific diseases and conditions, the specific racial and ethnic characteristics of the population, and the existence of treatment programs for each condition for which assessment and evaluation is provided. DHS 107.22(4)(4) Other needed services. In addition to diagnostic and treatment services covered by Wisconsin MA under applicable provisions of this chapter, any services described in the definition of “medical assistance” under federal law, 42 USC 1396d(a), when provided to EPSDT patients, are covered if the EPSDT health assessment and evaluation indicates that they are needed. Prior authorization under s. DHS 107.02 (3) is required for coverage of services under this subsection. DHS 107.22(5)(5) Reasonable standards of practice. Services under this section shall be provided in accordance with reasonable standards of medical and dental practice determined by the department after consultation with the medical society of Wisconsin and the Wisconsin dental association. DHS 107.22(6)(6) Referral. When EPSDT assessment and evaluation indicates that a recipient needs a treatment service not available under MA, the department shall refer the recipient to a provider willing to perform the service at little or no expense to the recipient’s family. DHS 107.22(7)(7) No charge for services. EPSDT services shall be provided without charge to recipients under 18 years of age. DHS 107.22 HistoryHistory: Cr. Register, February, 1986, No. 362, eff. 3-1-86; emerg. am. (4) (intro.), r. (4) (a) and (b) eff. 4-30-07; CR 07-041: am. (4) (intro.), r. (4) (a) and (b) Register December 2007 No. 624, eff. 1-1-08; correction in (1) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636. DHS 107.23(1)(a)(a) Purpose. Transportation by ambulance, specialized medical vehicle (SMV) or county-approved or tribe-approved common carrier as defined under par. (d) 1., is a covered service when provided to a recipient in accordance with this section. DHS 107.23(1)(b)(b) Transport by ambulance. Ambulance transportation shall be a covered service if the recipient is suffering from an illness or injury which contraindicates transportation by other means, but only when provided: DHS 107.23(1)(b)1.1. For emergency care, when immediate medical treatment or examination is needed to deal with or guard against a worsening of the recipient’s condition: DHS 107.23(1)(b)1.a.a. From the recipient’s residence or the site of an illness or accident to a hospital, physician’s office, or emergency care center; DHS 107.23(1)(b)2.2. For non-emergency care when authorized by a physician, physician assistant, nurse midwife or nurse practitioner by written documentation which states the specific medical problem requiring the non-emergency ambulance transport: DHS 107.23(1)(b)2.c.c. From a nursing home to another nursing home, a hospital, a hospice care facility, or a dialysis center; or DHS 107.23(1)(b)2.d.d. From a recipient’s residence or nursing home to a hospital or a physician’s or dentist’s office, if the transportation is to obtain a physician’s or dentist’s services which require special equipment for diagnosis or treatment that cannot be obtained in the nursing home or recipient’s residence. DHS 107.23(1)(c)1.1. In this paragraph,“indefinitely disabled” means a chronic, debilitating physical impairment which includes an inability to ambulate without personal assistance or requires the use of a mechanical aid such as a wheelchair, a walker or crutches, or a mental impairment which includes an inability to reliably and safely use common carrier transportation because of organic conditions affecting cognitive abilities or psychiatric symptoms that interfere with the recipient’s safety or that might result in unsafe or unpredictable behavior. These symptoms and behaviors may include the inability to remain oriented to correct embarkation and debarkation points and times and the inability to remain safely seated in a common carrier cab or coach. DHS 107.23(1)(c)2.2. SMV transportation shall be a covered service if the recipient is legally blind or is indefinitely disabled as documented in writing by a physician, physician assistant, nurse midwife or nurse practitioner. The necessity for SMV transportation shall be documented by a physician, physician assistant, nurse midwife or nurse practitioner. The documentation shall indicate in a format determined by the department why the recipient’s condition contraindicates transportation by a common carrier as defined under par. (d) 1., including accessible mass transit services, or by a private vehicle and shall be signed and dated by a physician, physician assistant, nurse midwife or nurse practitioner. For a legally blind or indefinitely disabled recipient, the documentation shall be rewritten annually. The documentation shall be placed in the file of the recipient maintained by the provider within 14 working days after the date of the physician’s, physician assistant’s, nurse midwife’s or nurse practitioner’s signing of the documentation and before any claim for reimbursement for the transportation is submitted. DHS 107.23(1)(c)3.3. If the recipient has not been declared legally blind or has not been determined by a physician, physician assistant, nurse midwife or nurse practitioner to be indefinitely disabled, the transportation provider shall obtain and maintain a physician’s, physician assistant’s, nurse midwife’s or nurse practitioner’s written documentation for SMV transportation. The documentation shall indicate in a format determined by the department why the recipient’s condition contraindicates transportation by a common carrier, including accessible mass transit services, or by a private vehicle and shall state the specific medical problem preventing the use of a common carrier, as defined under par. (d) 1., and the specific period of time the service may be provided. The documentation shall be signed and dated by a physician, physician assistant’s, nurse midwife or nurse practitioner. The documentation shall be valid for a maximum of 90 days from the date of the physician’s, physician assistant’s, nurse midwife’s or nurse practitioner’s signature. The documentation shall be placed in the file of the recipient maintained by the provider within 14 working days after the date of the physician’s, physician assistant, nurse midwife’s or nurse practitioner’s signing of the documentation and before any claim for reimbursement for the transportation is submitted. DHS 107.23(1)(c)4.4. SMV transportation, including the return trip, is covered only if the transportation is to a location at which the recipient receives an MA-covered service on that day. SMV trips by cot or stretcher are covered if they have been prescribed by a physician, physician assistant, nurse midwife or nurse practitioner. In this subdivision,“cot or stretcher” means a bed-like device used to carry a patient in a horizontal or reclining position. DHS 107.23(1)(c)5.5. Charges for SMV unloaded mileage are reimbursable only when the SMV travels more than 20 miles by the shortest route available to pick up a recipient and there is no other passenger in the vehicle, regardless of whether or not that passenger is an MA recipient. In this subdivision, “unloaded mileage” means the mileage travelled by the vehicle to pick up the recipient for transport to or from MA-covered services. DHS 107.23(1)(c)6.6. When a recipient does not meet the criteria under subd. 2., SMV transportation may be provided under par. (d) to an ambulatory recipient who needs transportation services to or from MA-covered services if no other transportation is available. The transportation provider shall obtain and maintain documentation as to the unavailability of other transportation. Records and charges for the transportation of ambulatory recipients shall be kept separate from records and charges for non-ambulatory recipients. Reimbursement shall be made under the common carrier provisions of par. (d). DHS 107.23(1)(d)(d) Transport by county-approved or tribe-approved common carrier. DHS 107.23(1)(d)1.1. In this paragraph, “common carrier” means any mode of transportation approved by a county or tribal agency or designated agency, except an ambulance or an SMV unless the SMV is functioning under subd. 5. DHS 107.23(1)(d)2.2. Transportation of an MA recipient by a common carrier to a Wisconsin provider to receive MA-covered services shall be a covered service if the transportation is authorized by the county or tribal agency or its designated agency. Reimbursement shall be for the charges of the common carrier, for mileage expenses or a contracted amount the county or tribal agency or its designated agency has agreed to pay a common carrier. A county or tribal agency may develop its own transportation system or may enter into contracts with common carriers, individuals, private businesses, SMV providers and other governmental agencies to provide common carrier services. A county or tribe is limited in making this type of arrangement by sub. (3) (c). DHS 107.23(1)(d)3.3. Transportation of an MA recipient by a common carrier to an out-of-state provider, excluding a border-status provider, to receive MA-covered services shall be covered if the transportation is authorized by the county or tribal agency or its designated agency. The county or tribal agency or its designated agency may approve a request only if prior authorization has been received for the nonemergency medical services as required under s. DHS 107.04. Reimbursement shall be for the charges of the common carrier, for mileage expenses or a contracted amount the county or tribal agency or its designated agency has agreed to pay the common carrier. DHS 107.23(1)(d)4.4. Related travel expenses may be covered when the necessary transportation is other than routine, such as transportation to receive a service that is available only in another county, state or country, and the transportation is prior authorized by the county or tribal agency or its designated agency. These expenses may include the cost of meals and commercial lodging enroute to MA-covered care, while receiving the care and when returning from the care, and the cost of an attendant to accompany the recipient. The necessity for an attendant, except for children under 16 years of age, shall be determined by a physician, physician assistant, nurse midwife or nurse practitioner with that determination documented and submitted to the county or tribal agency. Reimbursement for the cost of an attendant may include the attendant’s transportation, lodging, meals and salary. If the attendant is a relative of the recipient, reimbursed costs are limited to transportation, commercial lodging and meals. Reimbursement for the costs of meals and commercial lodging shall be no greater than the amounts paid by the state to its employees for those expenses. The costs of more than one attendant shall be reimbursed only if the recipient’s condition requires the physical presence of another person. Documentation stating the need for the second attendant shall be from a physician, physician assistant, nurse midwife or nurse practitioner and shall explain the need for the attendant and be maintained by the transportation provider if the provider is not a common carrier. If the provider is a common carrier, the statement of need shall be maintained by the county or tribal agency or its designated agency authorizing the transportation. If the length of attendant care is over 4 weeks in duration, the department shall determine the necessary expenses for the attendant or attendants after the first 4 weeks and at 4-week intervals thereafter. In this subdivision, “attendant” means a person needed by the transportation provider to assist with tasks necessary in transporting the recipient and that cannot be done by the driver or a person traveling with the recipient in order to receive training in the care of the recipient, and “relative” means a parent, grandparent, grandchild, stepparent, spouse, son, daughter, stepson, stepdaughter, brother, sister, half-brother or half-sister, with this relationship either by consanguinity or direct affinity. DHS 107.23(1)(d)5.5. If a recipient for emergency reasons beyond that person’s control is unable to obtain the county or tribal agency’s or designee’s authorization for necessary transportation prior to the transportation, such as for a trip to a hospital emergency room on a weekend, the county or tribal agency or its designee may provide retroactive authorization. The county or tribal agency or its designee may require documentation from the medical service provider or the transportation provider, or both, to establish that the transportation was necessary. DHS 107.23(2)(2) Services requiring prior authorization. The following covered services require prior authorization from the department: DHS 107.23(2)(a)(a) All non-emergency transportation of a recipient by water ambulance to receive MA-covered services; DHS 107.23(2)(b)(b) All non-emergency transportation of a recipient by fixed-wing air ambulance to receive MA-covered services; DHS 107.23(2)(c)(c) All non-emergency transportation of a recipient by helicopter ambulance to receive MA-covered services; DHS 107.23(2)(d)(d) Trips by ambulance to obtain physical therapy, occupational therapy, speech therapy, audiology services, chiropractic services, psychotherapy, methadone treatment, alcohol abuse treatment, other drug abuse treatment, mental health day treatment or podiatry services; DHS 107.23(2)(e)(e) Trips by ambulance from nursing homes to dialysis centers; and DHS 107.23(2)(f)(f) All SMV transportation to receive MA-covered services, except for services to be received out of state for which prior authorization has already been received, that is over 40 miles for a one-way trip in Brown, Dane, Fond du Lac, Kenosha, La Crosse, Manitowoc, Milwaukee, Outagamie, Sheboygan, Racine, Rock and Winnebago counties from a recipient’s residence, and 70 miles for a one-way trip in all other counties from a recipient’s residence. DHS 107.23 NoteNote: For more information on prior authorization, see s. DHS 107.02 (3). DHS 107.23(3)(a)1.1. When a hospital-to-hospital or nursing home-to-nursing home non-emergency transfer is made by ambulance, the ambulance provider shall obtain, before the transfer, written certification from the recipient’s physician, physician assistant, nurse midwife or nurse practitioner explaining why the discharging institution was not an appropriate facility for the patient’s condition and the admitting institution is appropriate for that condition. The document shall be signed by the recipient’s physician, physician assistant, nurse midwife or nurse practitioner and shall include details of the recipient’s condition. This document shall be maintained by the ambulance provider. DHS 107.23(3)(a)2.2. If a recipient residing at home requires treatment at a nursing home, the transportation provider shall obtain a written statement from the provider who prescribed the treatment indicating that transportation by ambulance is necessary. The statement shall be maintained by the ambulance provider. DHS 107.23(3)(a)3.3. For other non-emergency transportation, the ambulance provider shall obtain documentation for the service signed by a physician, physician assistant, nurse midwife, dentist or nurse practitioner. The documentation shall include the recipient’s name, the date of transport, the details about the recipient’s condition that preclude transport by any other means, the specific circumstances requiring that the recipient be transported to the office or clinic to obtain a service, the services performed and an explanation of why the service could not be performed in the hospital, nursing home or recipient’s residence. Documentation of the physician, dentist, physician assistant, nurse midwife or nurse practitioner performing the service shall be signed and dated and shall be maintained by the ambulance provider. Any order received by the transportation provider by telephone shall be repeated in the form of written documentation within 10 working days of the telephone order or prior to the submission of the claim, whichever comes first. DHS 107.23(3)(a)4.4. Services of more than the 2 attendants required under s. 256.15 (4), Stats., are covered only if the recipient’s condition requires the physical presence of more than 2 attendants for purposes of restraint or lifting. Medical personnel not employed by the ambulance provider who care for the recipient in transit shall bill the program separately. DHS 107.23(3)(a)5.a.a. If a recipient is pronounced dead by a legally authorized person after an ambulance is requested but before the ambulance arrives at the pick-up site, emergency service only to the point of pick-up is covered. DHS 107.23(3)(a)5.b.b. If ambulance service is provided to a recipient who is pronounced dead enroute to a hospital or dead on arrival at the hospital by a legally authorized person, the entire ambulance service is covered. DHS 107.23(3)(a)6.6. Ambulance reimbursement shall include payment for additional services provided by an ambulance provider such as for drugs used in transit or for starting intravenous solutions, EKG monitoring for infection control, charges for reusable devices and equipment, charges for sterilization of a vehicle including after carrying a recipient with a contagious disease, and additional charges for services provided at night or on weekends, or on holidays. Separate payments for these charges shall not be made. DHS 107.23(3)(a)7.7. Non-emergency transfers by ambulance that are for the convenience of the recipient or the recipient’s family are reimbursed only when the attending physician documents that the participation of the family in the recipient’s care is medically necessary and the recipient would suffer hardship if the transfer were not made by ambulance. DHS 107.23(3)(b)1.1. Transportation by SMV shall be covered only if the purpose of the trip is to receive an MA-covered service. Documentation of the name and address of the service provider shall be kept by the SMV provider. Any order received by the transportation provider by telephone shall be repeated in the form of written documentation within 10 working days of the telephone order or prior to the submission of the claim, whichever comes first. DHS 107.23(3)(b)2.2. Charges for waiting time are covered charges. Waiting time is allowable only when a to-and-return trip is being billed. Waiting time may only be charged for one recipient when the transportation provider or driver waits for more than one recipient at one location in close proximity to where the MA-covered services are provided and no other trips are made by the vehicle or driver while the service is provided to the recipient. In this subdivision, “waiting time” means time when the transportation provider is waiting for the recipient to receive MA covered services and return to the vehicle. DHS 107.23(3)(b)3.3. Services of a second SMV transportation attendant are covered only if the recipient’s condition requires the physical presence of another person for purposes of restraint or lifting. The transportation provider shall obtain a statement of the appropriateness of the second attendant from the physician, physician assistant, nurse midwife or nurse practitioner attesting to the need for the service and shall retain that statement. DHS 107.23(3)(b)5.5. A trip to a sheltered workshop or other nonmedical facility is covered only when the recipient is receiving an MA-covered service there on the dates of transportation and the medical services are of the level, intensity or extent consistent with the medical need defined in the recipient’s plan of care. DHS 107.23(3)(b)6.6. Trips to school for MA-covered services shall be covered only if the recipient is receiving services on the day of the trip under the Individuals with Disabilities Education Act, 20 USC 33, and the MA-covered services are identified in the recipient’s individual education plan and are delivered at the school.
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Chs. DHS 101-109; Medical Assistance
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