Medicine and Surgery Section - Wisconsin.gov

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Contacting Wisconsin Medicaid Web Site dhfs.wisconsin.gov/ The Web site contains information for providers and recipients about the following: • Program requirements. • Publications. • Forms. • Maximum allowable fee schedules. • Professional relations representatives. • Certification packets. Available 24 hours a day, seven days a week Automated Voice Response System (800) 947-3544 (608) 221-4247 The Automated Voice Response system provides computerized voice responses about the following: • Recipient eligibility. • Prior authorization (PA) status. • Claim status. • Checkwrite information. Available 24 hours a day, seven days a week Provider Services (800) 947-9627 (608) 221-9883 Correspondents assist providers with questions about the following: • Clarification of program requirements. • Recipient eligibility. Division of Health Care Financing Electronic Data Interchange Helpdesk • Resolving claim denials. • Provider certification. Available: 8:30 a.m. - 4:30 p.m. (M, W-F) 9:30 a.m. - 4:30 p.m. (T) Available for pharmacy services: 8:30 a.m. - 6:00 p.m. (M, W-F) 9:30 a.m. - 6:00 p.m. (T) (608) 221-9036 e-mail: wiedi@dhfs.state.wi.us Correspondents assist providers with technical questions about the following: Available 8:30 a.m. - 4:30 p.m. (M-F) • Electronic transactions. • Companion documents. • Provider Electronic Solutions software. Web Prior Authorization Technical Helpdesk (608) 221-9730 Correspondents assist providers with Web PA-related technical questions about the following: • User registration. • Submission process. • Passwords. Available 8:30 a.m. - 4:30 p.m. (M-F) Recipient Services (800) 362-3002 (608) 221-5720 Correspondents assist recipients, or persons calling on behalf of recipients, with questions about the following: • Recipient eligibility. • General Medicaid information. • Finding Medicaid-certified providers. • Resolving recipient concerns. Available 7:30 a.m. - 5:00 p.m. (M-F)
T Table of Contents Preface ........................................................................................................................................ 7 General Information ...................................................................................................................... 9 Certification ............................................................................................................................. 9 Physicians and Residents .................................................................................................... 9 Physician Assistants............................................................................................................9 Nurse Practitioners .............................................................................................................9 Nurse Midwives ..................................................................................................................9 HealthCheck Certification ..................................................................................................... 9 Presumptive Eligibility for Pregnant Women Benefit ............................................................. 10 Presumptive Eligibility for the Family Planning Waiver Program.............................................. 10 Prenatal Care Coordination Certification .............................................................................. 10 Durable Medical Equipment ............................................................................................... 10 Provider Numbers .................................................................................................................. 10 Billing Performing Provider Numbers (Issued to Physicians and Residents) ............................ 11 Group Billing Numbers (Issued to Clinics) ........................................................................... 11 Nonbilling Performing Provider Numbers (Issued to Physician Assistants) ............................. 11 Covered Physician Services .................................................................................................... 11 Procedure Codes and Modifiers ......................................................................................... 11 Place of Service Codes ..................................................................................................... 12 Reimbursement Not Available ................................................................................................. 12 Recipient Eligibility ................................................................................................................... 12 Retroactive Eligibility .......................................................................................................... 12 Non-U.S. Citizens — Emergency Services .......................................................................... 13 Recipient Copayment ............................................................................................................. 13 Copayment for Physician Services ..................................................................................... 14 Documentation Requirements ................................................................................................. 14 Prior Authorization .................................................................................................................. 14 Physician Services Requiring Prior Authorization ................................................................... 14 Prior Authorization Request Forms and Attachments........................................................... 15 Experimental Services ............................................................................................................ 15 Specialized Medical Vehicle Services ......................................................................................... 16 Evaluation and Management Services........................................................................................... 17 Concurrent Care .................................................................................................................... 17 Consultations......................................................................................................................... 17 Covered Consultations ...................................................................................................... 17 Critical Care and Prolonged Services ........................................................................................ 17 Ambulance Services ......................................................................................................... 18 Emergency Department Services ............................................................................................ 18 Evaluation and Management Services Provided with Surgical Procedures ................................... 18 Family Planning Services ......................................................................................................... 18 Hospital Services ................................................................................................................... 18 Nursing Home Visits ............................................................................................................... 19 Observation Care .................................................................................................................. 19 PHC 1357-C
Page 1: Physician Services Medicine and Sur
Page 5 and 6: Telemedicine ......................
Page 7: Health Professional Shortage Areas
Page 10 and 11: Legal Framework The following laws
Page 12 and 13: General Information Treatment (EPSD
Page 14 and 15: General Information Category III Co
Page 16 and 17: General Information collecting the
Page 18 and 19: General Information • The current
Page 20 and 21: Evaluation and Management reimburse
Page 22 and 23: Evaluation and Management in an out
Page 24 and 25: Evaluation and Management 22 Wiscon
Page 26 and 27: Medicine Services System [HCPCS] co
Page 28 and 29: Medicine Services In cases where mo
Page 30 and 31: Medicine Services documentation in
Page 32 and 33: Medicine Services Providers of ment
Page 34 and 35: Medicine Services Substance Abuse S
Page 36 and 37: Surgery Services Appendix 10 of thi
Page 38 and 39: Surgery Services Cataract Surgery W
Page 40 and 41: Surgery Services and the insertion
Page 42 and 43: Surgery Services Note: A telephone
Page 44 and 45: Surgery Services • Sterilization.
Page 46 and 47: Surgery Services live with her sinc
Page 48 and 49: Surgery Services by a multi-discipl
Page 50 and 51: Prescription Requirements Prescribe
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Prescription Requirements Approval
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Prescription Requirements prescribe
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Prescription Requirements 54 Wiscon
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Claims Submission adjustment reques
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Claims Submission 58 Wisconsin Medi
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Reimbursement • Confirming or rev
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Reimbursement about whether a speci
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Reimbursement 64 Wisconsin Medicaid
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Appendix 66 Wisconsin Medicaid and
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Appendix Surgery Services Appendix
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Appendix Medicine Services (Continu
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Appendix Other Services Appendix 1
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Appendix Appendix 4 (Continued) If
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Appendix Appendix 4 (Continued) Ele
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Appendix Appendix 4 (Continued) Ele
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Appendix (This page was intentional
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ABORTION CERTIFICATION STATEMENTS P
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STERILIZATION INFORMED CONSENT FORM
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DEPARTMENT OF HEALTH AND FAMILY SER
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Appendix Appendix 15 (Continued) Pe
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Appendix Category Musculoskeletal S
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Appendix Category Musculoskeletal S
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Appendix Category Female Genital Sy
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Appendix SECTION II — RECIPIENT I
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Appendix PRIOR AUTHORIZATION / PHYS
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PRIOR AUTHORIZATION / PHYSICIAN ATT
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PRIOR AUTHORIZATION / “J” CODE
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PRIOR AUTHORIZATION / “J” CODE
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PRIOR AUTHORIZATION / PHYSICIAN OTO
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Appendix Health Professional Shorta
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Appendix HPSA Name County ZIP Codes
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Appendix Appendix 26 (Continued) ma
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Appendix The following table lists
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DECLARATION OF SUPERVISION FOR NONB
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Appendix HCPCS Code* Drug Name Diag
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Index Organ Transplants, 44 Provide
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