For Providers: Authorizations–Outpatient Therapy Services Updates

Care Wisconsin has simplified the processing of outpatient therapy prior authorization requests and updated the Outpatient Therapy Prior Authorization Request Form. Under the new process, which goes into effect March 1, 2019, treatment will be authorized per visit using the EVALUATION CODE for the discipline only. This is a change from the previous process that considered each code that might be employed for that specific modality.

There is no change to billing. Please submit your claim for payment as always.

  • Let Us Know Prior Authorization is required for therapy treatment beyond the initial evaluation and 8 sessions per discipline, per episode of care. Fax the New Outpatient Therapy/Cardiac/Pulmonary Rehab Prior Authorization Request Form and supporting clinical documentation, including plan of care and recent progress notes, to 608-210-4050. See definition of “Episode of Care” below.
  • What is an Episode of Care? – Episode of Care is defined as the time that a member is under treatment by an individual discipline for outpatient therapy. A new episode of care may be initiated 30 days following the discharge of the member from services. Treatment within 30 days from a discharge of treatment requires prior authorization. Treatment of multiple distinct conditions during the same time period is considered within the SAME episode of care.
  • When does this new process start? – You can start using the new form NOW! Effective March 1, 2019 Care Wisconsin will process all requests for prior authorization under the new process: per visit using the EVALUATION CODE for the discipline only.
  • Important Benefit Information – There are no changes to our benefit plans. We continue to provide the same benefits as those provided under fee-for-service arrangements for our Medicaid plans and all Part A and Part B original Medicare Services for our Medicare plans.
  • Important Authorization Reminders – Treatment will be authorized PER VISIT using the evaluation code for the discipline. A prior authorization approval letter will reflect the number of visits approved. A denial will indicate the number of visits that are denied.
  • Important Billing Reminders – There is NO CHANGE to billing processes. Continue to submit the appropriate treatment codes based upon the services provided.
  • Questions? – Please reach out to our Customer Service Team at 800-963-0035 with questions.