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.