Authorizations

Family Care Members

• Authorization is required prior to rendering ALL services for Family Care
• Contact the member’s care team to get an authorization
• The member’s care team will enter the authorization. Providers will be able to see and/or print the authorization from the MIDAS portal.
• If you cannot reach the member’s care team, contact our Customer Service team at 1-800-963-0035

SSI, Partnership, and Medicare Dual Advantage Members

• Use the My Choice Wisconsin form appropriate for the service and fax to (608) 210-4050. Forms can be found in the library below or in the Provider Resource Library. 
• You can find which services require prior authorization using the following documents:
  • Prior Authorization Reference Document 
  • Temporary Prior Authorization Changes during COVID-19 Health Emergency
  • Outpatient Procedure Prior Authorization Exception List

Prior authorization is required for all:

• Non-emergent hospital admissions
• Skilled Nursing Facility (SNF) stays
• Sub-acute psychiatric community-based crisis stabilization stays
• Long Term Acute Care (LTAC) stays

For urgent or emergent hospital admissions:

• Notify My Choice Wisconsin within one (1) business day
• Use the My Choice Wisconsin form appropriate for the service and fax to (608) 210-4050. Forms can be found in the library below or in the Provider Resource Library. 

See our resource guides for more information:

• Medicaid SNF Prior Authorization Resource
• Medicare SNF Prior Authorization Resource
• SNF Prior Authorization Resource Guide

Our process:

• Initial Review – Once we have been notified of the admission, the member’s case will be assigned to a Utilization Review RN who will process for medical necessity using InterQual and other evidenced-based clinical standards of care.
• Care Management – The My Choice Wisconsin Care Team staff is also notified of the admission and is available to discuss the member’s discharge needs.
• Certification – We will issue written certification of all stays that meet medical necessity within one business day of receiving pertinent clinical documentation.
• Concurrent Review – Review is completed every two days for all Inpatient hospital stays and sub-acute psychiatric community based crisis stabilization stays. SNF and LTAC stays are reviewed every 7-14 days depending on individual member situation. For prompt authorization, please send updated clinical information to support the continued stay prior to the end of the current certification period. Clinical documentation should be faxed to 608-210-4050.
• Ongoing Communication – My Choice Wisconsin will continue to issue certification letters for additional days meeting medical necessity.
• Secondary Review – If at any time a stay is not meeting medical necessity, it will be reviewed by My Choice Wisconsin’s Medical Director.

Notification of Decision – My Choice Wisconsin will notify the servicing provider within one business day of making a decision to deny a stay deemed not medically necessary. The member, requesting provider, and servicing provider will also be issued written notification within 24 hours of making the decision to deny as not medically necessary. A peer-to-peer may be requested by calling 800-963-0035.

All specialist referrals must be initiated by the Primary Care Physician with a referral form.

• • Complete Prior authorization form with all the requested information
    • Medical Prior Authorization Form 
    • Behavioral Health Prior Authorization Form
  • Fax the form and all pertinent clinical information, including the physician order, plan, and any applicable progress notes to:
    • For Medical authorizations:  414-771-1159.
    • For Behavioral Health authorizations: 608-245-3097
• For Subacute Rehab and Skilled Nursing Facility authorization requests include the therapy evaluation and recommendations for treatment. 
• For acute hospital admissions, an authorization request must be submitted within 48 hours or the next business day. No retroactive authorization outside this period will be considered.
• Once received by the department a Nurse Case Manager reviews the clinical information
• MCG Guidelines, InterQual, Forward Health, and State guidelines are utilized for the review.
• Standard requests are reviewed within 14 business days.
• Urgent requests are reviewed the same day if received before 4 PM. Requests received after 4 PM are reviewed next business day by 12 PM. 
• Nurse Case Manager works closely with the Medical Director.
• The member and requesting provider will be notified of any denials in writing.

Family Care Members
All services rendered through the Family Care program require prior authorization through the care team. Retroactive authorization requests are not permitted for this program and will not be approved. 

SSI, Partnership, and Medicare Dual Advantage Members
All authorization requests are subject to member eligibility, benefit plan coverage, and medical necessity.

A retroactive authorization will be accepted if it meets the following requirements:

• Request is received by My Choice Wisconsin within 14 calendar days of the start of the provision of services
• Request precedes a bill for services
• 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

BadgerCare Plus Members

• For Medical Authorizations:  Backdated referrals are not permitted. Primary Care Providers must submit referral information in a timely fashion to allow for processing time. 
• For Behavioral Health Authorizations: Retroactive event authorizations for services will not be granted unless there is a compelling reason for consideration.  At no time will a retroactive event authorization be approved for a time span greater than two weeks prior to the receipt date. 

Family Care

• All services rendered through the Family Care program require prior authorization through the care team.

SSI and Partnership

• Prior authorization is not required for outpatient services for secondary coverage when Medicare or other commercial insurance is providing primary coverage, consistent with DHS 107.02.
• If Medicare or other primary insurance does not cover a service and you are seeking primary coverage from My Choice Wisconsin, all prior authorization requirements apply.

BadgerCare Plus

• Prior authorization is not required for inpatient/outpatient services for secondary coverage when Medicare or other commercial insurance is providing primary coverage, consistent with DHS 107.02.

• My Choice Wisconsin administers Wisconsin Medicaid healthcare benefits through our Family Care, Partnership, Medicaid SSI, and BadgerCare Plus programs and complies with Wisconsin Administrative code outlined in DHS 107.03. 
• The Family Care and Partnership programs include Home and Community-based Waiver benefits in addition to traditional Medicaid coverage.
• My Choice Wisconsin provides Medicare benefits to members in our Dual Advantage program, as well as dual-eligible members in our Partnership program. My Choice Wisconsin administers the benefits consistent with original Medicare. Please see Items and Services Not Covered Under Medicare for more information.