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;

DHS 107.13(4)(d)4. 4. Prevention or education programs provided as an outreach service, case-finding, and reading groups;

DHS 107.13(4)(d)5. 5. Aftercare programs, provided independently or operated by or under contract to boards;

DHS 107.13(4)(d)6. 6. Medical or AODA day treatment for recipients with a primary diagnosis of alcohol or other drug abuse;

DHS 107.13(4)(d)7. 7. Day treatment provided in person in the recipient’s home; and

DHS 107.13(4)(d)8. 8. 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(6) (6) Community support program (CSP) services.

DHS 107.13(6)(a) (a) Covered services. Community support program (CSP) services shall be covered services when prescribed by a physician and provided by a provider certified under s. DHS 105.255 for recipients who can benefit from the services. These non-institutional services make medical treatment and related care and rehabilitative services available to enable a recipient to better manage the symptoms of his or her illness, to increase the likelihood of the recipient’s independent, effective functioning in the community and to reduce the incidence and duration of institutional treatment otherwise brought about by mental illness. Services covered are as follows: