Medicine and Surgery Section - Wisconsin.gov

Wisconsin
Medicaid
reimburses
physicians the
lesser of the
physician’s billed
amount for a
service or
Wisconsin
Medicaid’s
maximum
allowable fee.
Reimbursement
Maximum Allowable Fees
The maximum allowable fee is the maximum
amount that Wisconsin Medicaid will pay a
provider for an allowable procedure code.
Physician services providers may obtain a
maximum allowable fee schedule that contains
reimbursement rates from one of the following
sources:
• An electronic version on the Medicaid
Web site.
• A paper copy, which may be purchased by
doing either of the following:
Calling Provider Services at
(800) 947-9627 or (608) 221-9883 for
the cost of the fee schedule.
Writing to the following address:
Wisconsin Medicaid
Provider Maintenance
6406 Bridge Rd
Madison WI 53784-0006
Maximum Daily
Reimbursement
A physician services provider’s reimbursement
for all services performed on the same date of
service (DOS) for the same recipient may not
exceed the amount established by Wisconsin
Medicaid. As of July 1, 2002, the maximum
daily reimbursement amount is $2,308.43. The
maximum daily reimbursement amount does
not apply to the following:
• Physician-administered drugs.
• Durable medical equipment.
Medicaid remittance information will indicate
when the maximum daily reimbursement
amount has been met.
Surgery Services Exceeding Six
Hours
A provider may request additional
reimbursement for a surgery exceeding six
hours. A provider in this situation should submit
a claim in the usual manner. Additional
reimbursement may be requested for the
allowed claim by submitting an Adjustment/
Reconsideration Request, HCF 13046, with
clinical documentation. The completion
instructions and Adjustment/Reconsideration
Request are located in the Claims Information
section of the All-Provider Handbook and may
also be downloaded and printed from the
Medicaid Web site.
Reimbursement Amounts
Physicians
Wisconsin Medicaid reimburses physicians the
lesser of the physician’s billed amount for a
service or Wisconsin Medicaid’s maximum
allowable fee.
Supervising Physicians of Interns
and Residents
Wisconsin Medicaid reimburses supervising
physicians in a teaching setting for the services
provided by interns and residents, if those
services are supervised, provided as part of the
training program, and billed under the
supervising physician’s provider number. The
supervising physician must provide personal
and identifiable direction to interns or residents
who are participating in the care of the
recipient. This direction includes any or all of
the following:
• Reviewing the recipient’s medical history
or physical examination.
• Personally examining the recipient within a
reasonable period after admission.
Physician Services Handbook — Medicine and Surgery December 2005 59
Reimbursement