A Prior Authorization (PA) Request is an approval process used by health plans and Wisconsin Medicaid to decide if a medical service, device or treatment will be covered. It’s sometimes also called an authorization request or prior approval. In most cases, health plans and Medicaid approve PA requests based on their decision that the treatment or service is medically necessary.

Completing a PA

In most cases the provider, such as the medical provider or therapist, is responsible for completing the PA request. This must be submitted and approved before the service or treatment is provided.

The health plan or Wisconsin Medicaid approves services for a specific period and the type and quantity of service allowed. For example, the health plan might say that they will cover the cost of six physical therapy visits over the next three months and require that a new PA be submitted before more visits are approved.

Review and Approval of PA Requests

Designated staff members at the Department of Health Services (DHS) review all Medicaid PA requests. Health plans (HMOs, PPOs or other private insurance companies) also have designated staff members who review all PA requests. If reviewers have questions about whether the service is medically necessary, they will send the PA request back to the provider to ask for more documentation or details.

Families Being Part of the PA Process

Families can be actively involved in the PA process, if needed. This may ensure that the PA includes all relevant information and provides a complete picture of why the service or treatment is needed.

Families can:

• • • offer to review the PA for accuracy before it is submitted.
    • provide additional documentation or background information.
    • request letters from other professionals who work with the child.

Defining Medical Necessity for Wisconsin Medicaid Coverage

The Department of Health Services defines a medically necessary service as “a service that is required to prevent, identify, or treat a recipient’s illness, injury, or disability.” In addition, it looks at other requirements, including the value of the treatment, that it meets medical standards, is not experimental, does not duplicate other treatments or services, is the most appropriate, and can be safely and effectively provided.

DHS states, “Wisconsin Medicaid reimburses only for services that are medically necessary as defined under HFS 101.03(96m), Wis. Admin. Code.” “Medicaid may deny or recoup payment if a service fails to meet Medicaid medical necessity requirements.”

Reviewers think about the following:

• • • Is an item or service is medically necessary and appropriate
    • The cost of the item, service or treatment
    • If it is likely to be effective, of high quality and prescribed at the right time for the person
    • Whether there is a less expensive or more appropriate alternative
    • Whether the provider or recipient has overused or misused services in the past

Reasons Why PA Requests Are Denied

A health plan, insurance company or Medicaid may deny a PA request if they feel the provider does not adequately document that the service or item is medically necessary. In other instances, providers who are not familiar with completing PA requests may submit the PA without all the necessary information.

Avoiding Duplication of Services 

Families who are seeking physical, occupational or speech therapy services for their children outside of the school environment sometimes receive a denial from Wisconsin Medicaid due to duplication of services.

When reviewing a PA request for therapy services, Wisconsin Medicaid will likely request a copy of the child’s Individualized Education Program (IEP) and the long-term support service plan (CLTS ISP) to see if they receive the same therapies at school and in the community. Medicaid will not cover a service that is already being provided at school or should be provided at school. This is because schools often bill Medicaid for medically-related services and supports.

To learn more about duplication of services see Department of Public Instruction’s billing Medicaid information

How to Avoid Denials and Appealing Denials 

If the PA is for community-based therapy services, your family can work with the provider to make sure the therapy goals are related to functioning at home or in the community and are not education or school related.

If Medicaid denies the PA request, the provider can re-submit the PA with additional details or documentation. If this is not successful, your family can appeal the denial. To appeal a denial from Wisconsin Medicaid, you must submit a request for a Fair Hearing and participate in a phone call with an Administrative Law Judge to explain why the service should be covered. See the Family Voices fact sheet on appealing a denial. and School and Community-Based Therapy Services for more information on this process

Children’s Long-Term Support and Medicaid PAs

If your child is enrolled in the Children’s Long-Term Support Program (CLTS), there may be times when your Support and Service Coordinator will request that a PA be submitted to Wisconsin Medicaid before CLTS will consider covering the cost of an item or service. By law, CLTS cannot pay for something if it can be covered by insurance, so a Medicaid denial may be needed first. If you have questions, contact the CLTS Program. 

INFORMATION AND RESOURCES

Wisconsin Wayfinder: Children’s Resource Network, 877-WiscWay (877-947-2929): Wisconsin Wayfinder offers families one name and phone number to find services for children with special health care needs. Wayfinder connects you to a resource guide at one of the five Children’s Resource Centers in your area.

If you need this fact sheet as a pdf or other format contact Lynn at lynn@fvofwi.org.