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;