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)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)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(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)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)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.