Children’s Long-Term Support: HealthCheck FAQs for Counties

Member Services is for members or people calling on behalf of a member. If CWA staff are calling on behalf of a member and the question relates to personally identifiable information or personal health information, the member or their guardian must be on the call as well. (If the question is about general program information, this may not be necessary.)

Member Services representatives can help with:

• Member benefits
• General program information and requirements
• Answering member questions

Phone number: 880-362-3002
Hours: Monday–Friday, 8 a.m.–6 p.m.

Provider Services is for providers with a National Provider Identifier (NPI).

Provider Services representatives can help with questions about topics like:

• Provider and member enrollment
• Billing and claim submission
• Policy clarification
• Help completing forms

Phone number: 800-947-9627
Hours: Monday–Friday, 7 a.m.–6 p.m., virtual agents available 24 hours/day, 7 days/week

ForwardHealth Online Handbook Topic #474 has more information about how Provider Services can help. It also lists the information you should have ready (including your provider name and NPI) before making a call.

Professional field representatives help providers and CWA staff with more complex questions than Provider Services can address.

Professional field representatives can help CWA staff by:

• Locating Medicaid-enrolled providers
• Answering questions about coverage policy

Professional field representatives can help providers with:

• Prior authorization (PA) questions
• Complex billing and claims processing questions

Find the professional field representative for your area of the state using the Professional Field Representative Map (PDF).

ForwardHealth Topic #473 has more information about how professional field representatives can help. It also lists the information you should have ready before making a call.

Medicaid will only reimburse Medicaid-enrolled providers for services or supplies. You can find Medicaid-enrolled providers in a few different ways:

• CWA staff can:
  • Use the Find a Provider tool on the ForwardHealth Portal.
  • Call Provider Services at 800-947-9627, Monday–Friday, 7 a.m.–6 p.m. for help.
  • Call your field representative for help. Find your professional field representative using the Professional Field Representative Map (PDF).
• Members can:
  • Use the Find a Provider tool on the ForwardHealth Portal.
  • Call Member Services at 800-362-3002, Monday – Friday, 8am – 6pm for help.

HealthCheck is Wisconsin’s name for what the federal government calls the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit. It provides preventive services for Medicaid members under age 21. The goal of HealthCheck is to prevent illness and find and treat health issues early.

HealthCheck covers well-child checks per the American Academy of Pediatrics’ Preventive Care Schedule guidelines. It includes:

• Dental checks
• Growth and development checks
• Head-to-toe physical exams
• Hearing and vision checks
• Immunizations
• Lab tests
• Nutrition checks

HealthCheck also covers follow-up visits and special appointments if the doctor finds things that should be looked at further. For example:

• Dental concerns
• Ear or eye concerns
• Issues related to growth and developmental milestones
• Mental, emotional, or substance use concerns
• Needed tests or vaccines
• Other medical concerns

HealthCheck Other Services is coverage of services or items for members under 21 that Medicaid typically doesn’t cover. This includes:

• Needing a type of service or item that isn’t typically covered
• Needing a higher number of services or items than what is typically covered

As part of the federal EPSDT benefit, Medicaid in Wisconsin must provide any medically necessary services or items to treat, correct, or reduce illnesses and conditions for members under 21, even if Medicaid typically does not cover the services or items in amount or type.

HealthCheck Other Services covers services or items that are:

• Prescribed by the member’s provider.
• Able to be covered according to federal Medicaid law.
• Approved by Wisconsin Medicaid, based on information submitted by the member’s health care provider.

Wisconsin Medicaid determines medical necessity of services and items under the HealthCheck Other Services benefit on a case-by-case basis based on the member’s medical needs and circumstances.

The HealthCheck Other Services benefit includes coverage for the following services and items:

• Behavioral and mental health treatment
• Disposable medical supplies
• Durable medical equipment
• Orthodontia
• Over-the-counter items
• Personal care services

HealthCheck Other Services is limited to 1905(a) services. Find more information in the Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents (PDF) from the Centers for Medicare & Medicaid Services (see section 4.B.e. Other Services)

Almost all services and items covered under HealthCheck Other Services require prior authorization (PA). Medicaid-enrolled providers typically submit PA requests. If a provider has questions about the PA process, CWA staff should encourage the provider to get help from:

• Provider Services at 800-947-9627, 7 a.m.–6 p.m. CST Monday–Friday.
• Their field representative. They can find their professional field representative using the Professional Field Representative Map (PDF).

Find more information about the PA process in the Prior Authorization section of these FAQs.

BadgerCare Plus, Medicaid, and HealthCheck Other Services cover many over-the-counter items, including medications, vitamins, and minerals.

Members can get some over-the-counter items without prior authorization (PA). Even if PA is not required, the pharmacist will need to see the member’s ForwardHealth card and a prescription from the member’s provider for the item to be covered. The ForwardHealth Pharmacy page lists over-the-counter drugs that do not require PA:

• Over-the-Counter Drugs Covered by BadgerCare Plus and Medicaid (PDF): over-the-counter drugs members of all ages can get without PA
• Over-the-Counter Drugs Covered by HealthCheck Other Services (PDF): over-the-counter drugs members under 21 can get without PA

If the member needs an item that is not included on the lists above, their provider can work with the pharmacist to submit a PA request for coverage under HealthCheck Other Services. Use the ForwardHealth Drug Search Tool to find out specific coverage information for over-the-counter drugs.

Find more information under ForwardHealth Topic #23377.

Based on federal law, Medicaid cannot reimburse for the following services and items:

• Structural or home modifications (such as ramps, stair lifts, fences, permanent fixtures for ceiling lifts)
• Vehicles and vehicle modifications (such as vehicle lifts or carriers)
• Items already purchased by the family or another funding source (Medicaid does not directly reimburse members)
• Experimental services and items

Note: A list of noncovered durable medical equipment and supplies does not exist for HealthCheck Other Services.

Medicaid-enrolled providers typically submit PA requests. Many providers can use the ForwardHealth Interactive Max Fee Search or the ForwardHealth DME or DMS Indexes to decide if a service or item covered under Medicaid or HealthCheck needs PA. Pharmacy providers will need to follow the process outlined in the question, “Does the HealthCheck benefit apply to over-the-counter medications and specialized supplements?”

Almost all services or items requested under HealthCheck Other Services need a PA request since HealthCheck Other Services covers services and items Medicaid doesn’t typically cover. The PA process allows Wisconsin Medicaid to determine if the requested service or item is medically necessary.

For emergency requests, CWA staff should encourage the provider to request an expedited review by contacting either:

• Provider Services at 800-947-9627, 7 a.m.–6 p.m. CST Monday–Friday, or
• Their field representative. They can find their professional field representative using the Professional Field Representative Map (PDF).

The PA request process for HealthCheck Other Services is the same as the usual PA process for many services and items. However, PA requests for HealthCheck Other Services must include documentation from the provider that describes:

• Why the member’s needs are not met by the services or items typically covered or limited by Wisconsin Medicaid.
• Why the requested service or item is needed and how it supports or sustains the member’s highest level of function, prevents a condition from worsening, or makes a condition more tolerable.

Some Medicaid benefit areas, such as pharmacy, could require additional forms and/or supporting documentation. Find more information about pharmacy and over-the-counter drugs under ForwardHealth Topic #23377. More details about other benefit areas are provided in the ForwardHealth Online Handbook.

PA determines if a requested service or item is medically necessary. Medicaid-enrolled providers typically submit PA requests. The forms and supporting documentation they submit for a PA request depends on the service or item requested.

Wisconsin Medicaid reviews PA requests and makes one of several possible decisions:

• Approved: The requested service or item is medically necessary for the member. Wisconsin Medicaid informs the provider of the approval, and they can then deliver the service or item to the member and make a claim for reimbursement.
• Approved with Modifications: The request is approved but something has been changed or modified from the provider’s original request. Modifications are made in alignment with DHS 107.02(3)(b). Common modifications include changes in the frequency or intensity of the service requested, changes in the duration of the treatment period, or changes to the reimbursement rate for products. When Wisconsin Medicaid modifies a PA request, they notify both the provider and the member, and the member has the right to appeal the decision.
• Returned: More information is needed from the provider. This could include additional forms, correcting inconsistent information, and/or additional clinical information to support medical necessity. A return is not a denial. When Wisconsin Medicaid returns a PA, the return message details the additional information needed from the providers. Providers should read the message and submit the appropriate materials to support the request.
• Denied: The requested service or item did not meet medical necessity criteria. When Wisconsin Medicaid denies a PA request, they notify both the provider and the member. The member has the right to appeal the decision.

1. Confirm with the member that their provider submitted the PA request.
2. Confirm the member received a decision letter that indicates a modification or denial.
   • Both the member and provider will get a letter from Wisconsin Medicaid when a PA request is modified or denied.
   • If the member did not get a letter, there may be a misunderstanding about the PA decision. Some providers think a returned PA is a denial. A returned PA is not a denial, it is a request for more information. Members do not receive letters when a PA request is returned to the provider for more information.
3. Encourage the member to connect with their provider to understand why the request was modified or denied.
   • CWA staff can help members connect with their provider to understand the final PA decision.
   • The decision letter includes an explanation for the modification or denial.
     • Members get a letter with a more generic message.
     • Providers get a letter with a more detailed explanation.
4. Make sure the member knows they can appeal the decision if they disagree.
   • The letter will include a Notice of Appeal Rights that provides information about how to request a fair hearing.
   • Find more information about how to appeal with Medicaid decisions in ForwardHealth Online Handbook Topic #425.

If a member cannot get a particular service or item through Medicaid, it could be funded through the CLTS Program. You’ll need to know Healthcare Common Procedure Coding System (HCPCS) procedure codes for the CLTS One Time High-Cost Notification, F-21353.

Find HCPCS procedure codes and their descriptions in the DME and DMS Indexes on the ForwardHealth Portal. Keep in mind, the provider chooses the HCPCS codes on the letter the family gets when a PA request is approved with modifications or denied. The HCPCS codes chosen by a provider may not accurately represent the service or item requested.

We recommend you call Provider Services at 800-947-9627, Monday–Friday, 7 a.m.–6 p.m. for help understanding the proper use of HCPCS procedure codes and for help using the DME and DMS Indexes.