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Authorizations

Authorizations

Many services in the Family Care, Partnership, SSI, and Medicare Dual Advantage benefit plans are covered and do not need prior authorization. Prior authorization is the process by which Care Wisconsin gives prior written approval for coverage of specified services, treatment, equipment, and supplies. The purpose of prior authorization is to determine member eligibility, benefit coverage, medical necessity, location, and appropriateness of services. Prior authorization will determine and authorize payment of:

  • The specific item or service as medically necessary
  • The number of visits/units and the period of time during which the service will be provided
  • The name of the provider rendering the service

 

Prior authorization is not:

  • A guarantee the service or supply will be covered. Coverage is determined by the member's benefit plan and is subject to contract agreement
  • Unlimited. Prior authorization approvals may be limited by visits and/or time span

Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Providers are encouraged to confirm member’s program eligibility prior to each encounter. For a comprehensive list of prior authorization requirements for Family Care, Partnership, SSI, and Medicare Advantage Plans, see the Care Wisconsin Prior Authorizations Reference Document.

 

Quick links:

Provider Resources for Prior Authorizations

Additional Resources:

Prior Authorization Forms

All requests for Prior Authorization for acute and primary services and Medicaid State Plan must be made by faxing the approved forms below along with supporting documentation to 608-210-4050.

See the Care Wisconsin Prior Authorization Reference Document for more information on services that require Prior Authorization. Please note that Home and Community-based Waiver Services in the Family Care and Partnership benefit package require prior authorization directly from the member’s Care Team.

 

Home and Community-Based Waiver Services in Family Care

The Home and Community-based Waiver Services in the Family Care and Partnership benefit package require prior authorization from the Care Team. These services are available to meet the needs of people who prefer to get long-term care services and supports in their home or community, rather than in an institutional setting and have enrolled in Family Care or Partnership. Care Teams work with members to determine the most effective and cost effective services to promote independence and meet long term care outcomes. For information on specific services included in the Home and Community-based Waiver Services, please see the Care Wisconsin Prior Authorizations Reference Document. All Home and Community-based Waiver Services require prior authorization from the member’s Care Team. To reach the member’s Care Team, call us at 800-963-0035.

 

NEW! Provider Authorization Portal

Access Our New Provider Portal - June 1, 2017!

 The Provider Authorization Portal allows providers convenient access to search, view and print Home and Community-Based Waiver Service authorizations on the web, 24/7. To register for access to the Provider Portal, pleaseThis email address is being protected from spambots. You need JavaScript enabled to view it.and include your:

  • Tax Identification Number
  • User First and Last Name 

 

 Provider Authorization Portal FAQ

Provider Authorization Portal User Guide 


 

Disposable Medical Supply Order Forms

Care Wisconsin contracts with several providers of Disposable Medical Supplies found in our Provider Directory. For your convenience, DMS may be ordered from Medline or McKesson using the following FAX order forms

 

  New Provider Authorization Portal Training Webinar



pdfProvider Authorization Portal Training Transcript (0.9 MB)

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 Non-Covered Services

Care Wisconsin administers Wisconsin Medicaid health care benfits through our SSI Medicaid, Family Care, and Partnership programs and complies with Wisconsin Administrative code outlined in DHS 107.03.

Care Wisconsin provides Medicare benefits to members in our Dual Advantage program, as well as dual eligible members in our Partnership program. Care Wisconsin administers the benefits consistent with original Medicare. Items and services not covered under Medicare.

The Family Care and Partnership programs include Home and Community-based Waiver benefits in addition to traditional Medicaid coverage.

 

Retroactive Authorization Requests

Care Wisconsin will accept a request for retroactive authorization if the request meets the following requirements:

  • The request is received by Care Wisconsin within 14 calendar days of the start of the provision of services;
  • The request precedes a bill for services; and
  • The request includes justification for beginning the service prior to receiving authorization:
    • The member was not able to tell the provider about their insurance coverage prior to rendering services, or
    • The provider verified different insurance coverage prior to rendering services

Please note: All authorization requests are subject to member eligibility, benefit plan coverage and medical necessity.

Please see the Claims Information page for more information on filing a claim.

 

Coordination of Benefits - Prior Authorization

Care Wisconsin does not require prior authorization for outpatient services for in-network, outpatient services for secondary coverage, when Medicare or other commercial insurance is providing primary coverage consistent with DHS 107.02.

NOTE: If Medicare or other primary insurance does not cover a service and you are seeking primary coverage from Care Wisconsin, all prior authorization requirements apply.

For more information on coordination of benefits, visit our Claims Information page.