Caring Starts with Speedy Service

We know that a simple authorization process and getting paid promptly is important to you. To help facilitate this, we:

  • Streamline steps where we can, even eliminating the pre-authorization process in some situations.
  • Have authorization and claims experts on hand to offer speedy responses via phone, email or fax.
  • Keep you informed when we roll out new policies, through email notifications, in-person forums and webinars.
  • Have Provider Service team members located at our “hub” offices throughout the state.

In the library below, you will find links to our claims and authorization-specific documents. To search for or view all of our resources for provider, check out our Resources Library. There, you’ll find instructions, training documents, and forms you need to make the authorization and claims process run smoothly.

For your convenience, our most commonly referenced documents are:

  1. Prior Authorization Reference Document – Requirements By Program
  2. Provider Quick Reference Guide
  3. Prior Authorization Request Form (DME/DMS)
  4. Prescription Drug Coverage Determination Form (Medicare)

Where to Send Claims and Authorizations 
See our Contacts for Providers page. Please allow up to 30 days from claim submission date to receive payment.

Claims Electronic Data Interchange
Care Wisconsin accepts standard electronic billing for Professional and Institutional claims (837P or 837I as appropriate) using Payer ID 27004. Please contact our vendor Change Healthcare at 800-845-6592 for additional information on this billing option.

Non-Covered Services
Care Wisconsin administers Wisconsin Medicaid health care benefits 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. Please see Items and Services Not Covered Under Medicare for more information. The Family Care and Partnership programs include Home and Community-based Waiver benefits in addition to traditional Medicaid coverage.

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.

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.

Resource Downloads For Claims & Authorizations

Resources are listed in alphabetical order. You will need Adobe Acrobat Reader to view and print PDF files. Download A Free Copy. If you need materials in other formats or languages, visit Help In Other Languages.

Chiropractic Prior Authorization Request Form

July 19, 2018 | pdf (199.22 KB) | Authorizations

Use this form to request prior authorization for chiropractic medicine.

DME/DMS Prior Authorization Request Form

July 18, 2018 | pdf (144.25 KB) | Authorizations

Use this form to request prior authorization for DME or DMS.

Home Health Prior Authorization Request Form

July 18, 2018 | pdf (156.58 KB) | Authorizations

Use this form to request prior authorization for a home health service.

Hospice Prior Authorization Request Form

April 30, 2018 | pdf (533.41 KB) | Authorizations

Use this form to request prior authorization for hospice treatment.

Inpatient Admission Prior Authorization Form

April 27, 2018 | pdf (143.48 KB) | Authorizations

Use this form to request authorization for an inpatient admission.

Inpatient Behavioral Health Treatment and Services Prior Authorization Form

April 27, 2018 | pdf (146.44 KB) | Authorizations

Use this form to notify Care Wisconsin of an inpatient stay for behavioral health.

Out-of-Network Provider Prior Authorization Form

April 27, 2018 | pdf (522.38 KB) | Authorizations

Use this form to request authorization for a service outside of the Care Wisconsin provider network.

Outpatient Behavioral Health Treatment and Services Prior Authorization Form

July 18, 2018 | pdf (187.72 KB) | Authorizations

Use this prior authorization form to request behavioral health treatment or services.

Physician-Administered Medication Prior Authorization Request Form

April 30, 2018 | pdf (547.88 KB) | Authorizations

Use this form to request prior authorization for physician-administered medicine.

Prior Authorization Reference Document (Requirements by Program)

September 18, 2018 | pdf (427.26 KB) | Authorizations

Reference this chart for info regarding which programs require prior authorizations for certain services.

Procedure and Imaging Prior Authorization Form

April 27, 2018 | pdf (127.75 KB) | Authorizations

Use this form to request authorization of imaging or another procedure.

Therapy/Cardiac/Pulmonary Rehab Prior Authorization Request Form

July 18, 2018 | pdf (145.97 KB) | Authorizations

Use this form to request authorization for cardiac or pulmonary rehab, physical therapy, occupational therapy, or speech therapy.

Claims Web Portal User Guide

April 30, 2018 | pdf (1.79 MB) | Claims Information

Follow the instructions in this guide to sign up for and navigate the Care Wisconsin claims web portal.

Electronic Funds Transfer Authorization Form

April 30, 2018 | pdf (117.39 KB) | Claims Information

Complete this form to enroll in electronic funds transfer (EFT).

General Services Claim Form

April 30, 2018 | pdf (53.70 KB) | Claims Information

Use this form to submit a claim for any non-residential services.

General Services Claim Form Instructions

April 30, 2018 | pdf (109.53 KB) | Claims Information

Refer to this guide if you're having trouble with any part of the general services claim form.

How to Obtain a Copy of Your Explanation of Benefits (EOB)

April 30, 2018 | pdf (106.42 KB) | Claims Information

If you submitted a claim via paper, spreadsheet, or electronically, learn how to find your EOB on the Care Wisconsin claims web portal.

Provider Appeal Form

April 30, 2018 | pdf (211.39 KB) | Claims Information

If you believe your claim was denied when it should not have been, use this form to submit an appeal.

Provider Refund Form

April 30, 2018 | pdf (195.72 KB) | Claims Information

If Care Wisconsin overpaid your claim, cut a check payable to Care Wisconsin and complete this form.

​Residential Claim Form

April 30, 2018 | pdf (217.32 KB) | Claims Information

Use this form to submit a residential claim.

​Residential Claim Form Instructions

April 30, 2018 | pdf (127.95 KB) | Claims Information

Refer to this guide if you're having trouble with any part of the residential claim form.

Dental Procedures Prior Authorization List

April 30, 2018 | pdf (11.46 KB) | Authorizations, Provider Manuals & Policies

Reference this chart to determine whether a dental procedure needs prior authorization.

Outpatient Procedure Prior Authorization Exception List

April 30, 2018 | pdf (290.21 KB) | Authorizations

Many outpatient procedures do not require prior authorization. Check this list before submitting a prior authorization.

Medicaid SSI – Personal Care Prior Authorization Resource

November 8, 2018 | pdf (285.98 KB) | Authorizations

Use this guide to determine when and how to request prior authorization for Medicaid personal care services.

Medicare Home Health Services Prior Authorization Resource

November 8, 2018 | pdf (287.99 KB) | Authorizations

Use this guide to determine when and how to request prior authorization for Medicare home health services.

Medicare-Medicaid Physician Home Visit Prior Authorization Resource

November 8, 2018 | pdf (288.62 KB) | Authorizations

Use this guide to determine when and how to request prior authorization for Medicare and Medicaid physician home visits.

Medicare Diabetes Prevention Program Prior Authorization Resource

November 8, 2018 | pdf (327.24 KB) | Authorizations

Use this guide to determine when and how to request prior authorization for the Medicare Diabetes Prevention Program.

Medicaid Crisis Stabilization Program Prior Authorization Resource

November 8, 2018 | pdf (285.23 KB) | Authorizations

Use this guide to determine when and how to request prior authorization for a Crisis Stabilization Program.

Medicare-Medicaid Enteral Nutrition Prior Authorization Resource

April 30, 2018 | pdf (319.02 KB) | Authorizations, Provider Manuals & Policies

Use this guide to determine when and how to request prior authorization for enteral and parenteral nutrition therapy.

Medicaid Home Health Services Prior Authorization Resource

November 8, 2018 | pdf (287.08 KB) | Authorizations

Use this guide to determine when and how to request prior authorization for Medicaid home health services.

Medicaid Personal Care Worker Prior Authorization Form

November 14, 2018 | pdf (130.14 KB) | Authorizations

Use this form to request prior authorization for personal care service.

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