school-based services handbook · 2014-01-13 · archival use only refer to the online handbook for...

School-BasedServices

School-BasedServices

ARCHIVAL USE ONLY Refer to the Online Handbook

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DIVISION OF HEALTH CARE FINANCINGWISCONSIN MEDICAID AND BADGERCARE

PROVIDER SERVICES6406 BRIDGE ROADMADISON WI 53784

Jim DoyleGovernor Telephone: 800-947-9627

State of Wisconsin 608-221-9883Helene Nelson dhfs.wisconsin.gov/medicaidSecretary Department of Health and Family Services dhfs.wisconsin.gov/badgercare

Wisconsin.gov

M E M O R A N D U M

DATE: February 23, 2005

TO: Wisconsin Medicaid-Certified School-Based Services Providers and HMOs and OtherManaged Care Organizations

FROM: Mark B. Moody, AdministratorDivision of Health Care Financing

SUBJECT: Wisconsin Medicaid School-Based Services Handbook

The Division of Health Care Financing (DHCF) is pleased to provide you with a copy of the newWisconsin Medicaid School-Based Services Handbook. The handbook articulates current Medicaidpolicies found in the Wisconsin Administrative Code, HFS 101-109, as they apply to the school-basedservices (SBS) benefit.

The handbook incorporates all current Wisconsin Medicaid policies related to school-based services ina single reference source. The handbook replaces Part X, the School-Based Services Handbook, and thefollowing service-specific Wisconsin Medicaid and BadgerCare Updates:

• December 2004 Update (2004-94), Licensing Requirements for School-Based Services Providers.• October 2003 Update (2003-151), Requirements for school-based services documentation

standards.• August 2003 Update (2003-123), Effective dates for claims submission changes as a result of

HIPAA for school-based services.• June 2003 Update (2003-39), Changes to local codes and paper claims for school-based services as

a result of HIPAA.• April 2003 Update (2003-22), Signature requirements for school-based services providers.• April 2003 Update (2003-21), Covered nursing services provided under the school-based services

benefit.• August 2002 Update (2002-46), Teachers’ time covered only for medically related services.• May 2002 Update (2002-22), Specialized medical vehicle and school-based transportation services

coverage clarification.• December 2001 Update (2001-46), Clarification of reimbursement for school-based services

transportation.• July 2001 Update (2001-10), New reimbursement method and documentation requirements for

school-based services transportation.• November 2000 Update (2000-57), Change in occupational therapy prescription requirements.• September 2000 Update (2000-39), New information for school-based services providers.• August 1999 Update (99-36), Therapy services clinical documentation and record-keeping

requirements.


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• April 1999 Update (99-18), Change in prescription requirements for billing Medicaid.• March 1998 Update (98-13), SBS transportation services.• March 1998 Update (98-12), Changes to the SBS insurance liability requirement.• January 1998 Update (97-26, Revised), SBS billing information.• September 1997 Update (97-25), School-based services (SBS) parental consent.

The handbook does not replace the All-Provider Handbook, all-provider Updates, the WisconsinAdministrative Code, or Wisconsin Statutes. Subsequent changes to SBS policies will be published firstin Updates and later in School-Based Services Handbook revisions.

Additional Copies of Publications

All Updates and the School-Based Services Handbook can be downloaded from the Medicaid Web siteat dhfs.wisconsin.gov/medicaid/.

The DHCF would like to thank the Department of Public Instruction and representatives fromMilwaukee Public Schools, CESA 5 and CESA 12 for reviewing this handbook.


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IImportant Telephone NumbersThe Wisconsin Medicaid Eligibility Verification System (EVS) is available through the following resources to verifycheckwrite information, claim status, prior authorization status, provider certification, and/or recipient eligibility.

ServiceInformation

Available Telephone Number Hours

Automated VoiceResponse (AVR)System(Computerized voiceresponse to providerinquiries.)

Checkwrite InformationClaim StatusPrior AuthorizationStatusRecipient Eligibility*

(800) 947-3544(608) 221-4247 (Madison area)

24 hours a day/7 days a week

Personal ComputerSoftwareandMagnetic StripeCard Readers

Recipient Eligibility* Refer to ProviderResources section ofthe All-ProviderHandbook for a list ofcommercial eligibilityverification vendors.

24 hours a day/7 days a week

Provider Services(Correspondentsassist withquestions.)

Checkwrite InformationClaim StatusPrior AuthorizationStatusProvider CertificationRecipient Eligibility*

(800) 947-9627(608) 221-9883

Policy/Billing and Eligibility:8:30 a.m. - 4:30 p.m. (M, W-F)9:30 a.m. - 4:30 p.m. (T)Pharmacy:8:30 a.m. - 6:00 p.m. (M, W-F)9:30 a.m. - 6:00 p.m. (T)

Direct InformationAccess Line withUpdates forProviders(Dial-Up)(Softwarecommunicationspackage andmodem.)

Checkwrite InformationClaim StatusPrior AuthorizationStatusRecipient Eligibility*

Call (608) 221-4746for more information.

7:00 a.m. - 6:00 p.m. (M-F)

Recipient Services(Recipients orpersons calling onbehalf of recipientsonly.)

Recipient EligibilityMedicaid-CertifiedProvidersGeneral MedicaidInformation

(800) 362-3002(608) 221-5720

7:30 a.m. - 5:00 p.m. (M-F)

* Please use the information exactly as it appears on the recipient's identification card or the EVS tocomplete the patient information section on claims and other documentation. Recipient eligibilityinformation available through the EVS includes: - Dates of eligibility. - Medicaid managed care program name and telephone number. - Privately purchased managed care or other commercial health insurance coverage. - Medicare coverage. - Lock-In Program status. - Limited benefit information.


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TTable of Contents

Preface ............................................................................................................................ 7

Provider Information ........................................................................................................ 9

What is the School-Based Services Benefit? ................................................................... 9Provider Eligibility and Certification .............................................................................. 9

Certification Process ............................................................................................... 9Individual Provider Licensing Requirements ............................................................. 9Duplicate Provider Types .......................................................................................10Nonduplicate Provider Types ..................................................................................10

Provider Authority to Subcontract................................................................................10Communication with Non-School-Based-Services Providers ...........................................10

Managed Care Providers ........................................................................................11Special Managed Care Programs ........................................................................11

Medicaid Fee-for-Service Providers .........................................................................12Providers Not Certified Under Medicaid ...................................................................12

Recipient Information ......................................................................................................13

Recipient Eligibility .....................................................................................................13Wisconsin Medicaid’s Eligibility Verification System ...................................................13Volume Eligibility .................................................................................................. 13Copayment ...........................................................................................................13

Parental Consent ........................................................................................................13Consent to Provide Medical Services .......................................................................13Consent to Request Reimbursement from Wisconsin Medicaid ..................................13Consent to Bill Commercial Insurance .....................................................................13

Covered Services.............................................................................................................15

Covered School-Based Services ...................................................................................15Medical Necessity .................................................................................................. 15Face-to-Face Time .................................................................................................15Non-Face-to-Face Time ..........................................................................................16Cotreatment .........................................................................................................16

Individualized Education Program Information .............................................................16Treatment Goals and Care Plan ...................................................................................16

Measurable Outcome Oriented Goals ......................................................................16Speech and Language Pathology, Audiology, and Hearing Services ................................16

Covered Services ...................................................................................................16Provider Qualifications ...........................................................................................17

Speech-Language Pathologists .......................................................................... 17

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Audiologists.....................................................................................................17“Under the Direction of” Guidelines ...................................................................17

Prescription Requirements .....................................................................................18Physical Therapy Services ...........................................................................................18

Covered Services ...................................................................................................18Provider Qualifications ...........................................................................................18Prescription Requirements .....................................................................................19

Occupational Therapy Services .................................................................................... 19Covered Services ...................................................................................................19Provider Qualifications ...........................................................................................19Prescription Requirements .....................................................................................19

Nursing Services ........................................................................................................19Covered Services ...................................................................................................19Provider Qualifications ...........................................................................................20Prescription Requirements .....................................................................................20Required Documentation .......................................................................................20Delegation of Nursing Services ............................................................................... 20Nursing Tasks Reimbursable for Full-Time Health Aides ...........................................20

Services Provided by Teachers .....................................................................................21Psychological Services, Counseling, and Social Work Services ........................................21

Covered Services ...................................................................................................21Provider Qualifications ...........................................................................................21Prescription Requirements .....................................................................................21

Other Developmental Testing and Assessments ............................................................ 21Covered Services ...................................................................................................21Provider Qualifications ...........................................................................................22Prescription Requirements .....................................................................................22

Transportation Services ..............................................................................................22Covered Services ...................................................................................................22Provider Qualifications ...........................................................................................22Prescription Requirements .....................................................................................22Limitations............................................................................................................ 22

Durable Medical Equipment .........................................................................................23Covered Services ...................................................................................................23Prescription Requirements .....................................................................................23

Prescription Waivers ...................................................................................................23Community-Based Therapies and School-Based Services ...............................................23Noncovered Services ..................................................................................................24

Documentation Requirements ..........................................................................................25

Medicaid Documentation Standards .............................................................................25Individualized Education Program Documentation ........................................................25Documenting Face-to-Face Sessions .............................................................................25Examples of Medical Records Requiring a Signature ......................................................26Electronic Records ......................................................................................................26


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Electronic Signature Standards ............................................................................... 26Charting Medical Records Electronically — General Provider Requirements.................27

Documentation of Nursing Services Units .....................................................................27Time Method ........................................................................................................27Task Method .........................................................................................................27Nursing Services Documentation Requirements ....................................................... 28

Nursing Standards of Practice for Documentation................................................28Documentation of Transportation Services Units ...........................................................28

Transportation Services Documentation Requirements .............................................29Documentation of Other School-Based Services Units ....................................................29

Coordination of Benefits .................................................................................................. 31

Commercial Health Insurance Liability Requirement ......................................................31Refusal of Parental Consent ...................................................................................31When the Commercial Insurance Liability Requirement Does Not Apply..................... 31

Exclusionary Clauses ........................................................................................31When Commercial Insurance Liability Requirement Does Apply ................................32

Assume the Insurance Liability Amount .............................................................32Seek Payment from the Child’s Commercial Health Insurance ..............................32Do Not Seek Payment from Wisconsin Medicaid for Any Services .........................32

Using Billing Services, Billing Agents, or Private Independent Consultants ......................33Providers Using a Billing Service or Billing Agent .....................................................33Providers Contracting with Private Independent Consultants .....................................33Responsibility for Claims........................................................................................33

Claims Submission ..........................................................................................................35

Electronic Claims Submission ......................................................................................35Paper Claims Submission ............................................................................................35

Where to Send Paper Claims ..................................................................................35Claims Submission Deadline .......................................................................................35

Reimbursement ..............................................................................................................37

Certification of Expenditures .......................................................................................37Wisconsin Medicaid Requirements .......................................................................... 37Submitting Forms .................................................................................................37

Federally Funded Providers .........................................................................................38

Appendix .......................................................................................................................39

1. Certification of Public Expenditures (for photocopying) .................................................412. School-Based Services Matching Expenditures Completion

Instructions (for photocopying) ...................................................................................433. School-Based Services Matching Expenditures (for photocopying) ..................................474. Sample Memorandum of Understanding Between HMO and Medicaid-Certified School

District, CESA, CCDEB, or Charter School for the School-Based Services Benefit ..............495. Letter of Consent to Request Reimbursement from Wisconsin Medicaid .......................... 51


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6. Department of Public Instruction and Department of Regulation and Licensing PrescriptionRequirements for Providing School-Based Services in the School Setting ........................53

7. Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under theSchool-Based Services Benefit (for photocopying) .........................................................55

8. Wisconsin Medicaid School-Based Services Fact Sheet ....................................................579. CMS 1500 Claim Form Completion Instructions ............................................................ 5910.Sample CMS 1500 Claim Form for School-Based Services ..............................................6311.Modifiers for School-Based Services .............................................................................6512.Procedure Codes for School-Based Services ..................................................................6713.Conversion Chart for Wisconsin Medicaid Nursing Services Reimbursement ....................6914.Sample Optional School-Based Services Activity Log Nursing/Therapy Medical

Services (time method) ...............................................................................................7115.Sample Optional School-Based Services Activity Log Medication Administration

(time method) ...........................................................................................................7316.Sample Optional School-Based Services Activity Log Nursing/Therapy Medical

Services (task method) ...............................................................................................7517.Sample Optional School-Based Services Activity Log Medication Administration

(task method) ............................................................................................................ 7718.Optional School-Based Services Activity Log Nursing/Therapy Medical

Services (for photocopying) ........................................................................................7919.Optional School-Based Services Activity Log Medication

Administration (for photocopying)............................................................................... 8120.Examples of School-Based Transportation Services Units ...............................................8321.Centers for Medicare and Medicaid Services School-Based Services Covered

Transportation Policy ..................................................................................................85

Glossary of Common Terms .............................................................................................87

Index .............................................................................................................................91


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School-Based Services Handbook April 2005 7

PPreface

The Wisconsin Medicaid and BadgerCare School-BasedServices Handbook is issued to school-based services(SBS) providers who are Wisconsin Medicaid certified. Itcontains information that applies to fee-for-serviceMedicaid providers. The Medicaid information in thishandbook applies to both Wisconsin Medicaid andBadgerCare. Please note that this handbook does notinclude additional rules and regulations relating to servicesoutside Medicaid-covered services in schools as requiredby state and federal law.

Wisconsin Medicaid and BadgerCare are administered bythe Department of Health and Family Services (DHFS).Within the DHFS, the Division of Health Care Financing(DHCF) is directly responsible for managing WisconsinMedicaid and BadgerCare. As of January 2004, BadgerCareextends Medicaid coverage to uninsured children andparents with incomes at or below 185% of the FederalPoverty Level and who meet other programrequirements. BadgerCare recipients receive the samehealth benefits as Wisconsin Medicaid recipients and theirhealth care is administered through the same deliverysystem.

Wisconsin Medicaid and BadgerCare recipients enrolledin state-contracted HMOs are entitled to at least thesame benefits as fee-for-service recipients; however,HMOs may establish their own requirements regardingprior authorization, billing, etc. Information contained inthis and other Medicaid publications is used by the DHCFto resolve disputes regarding covered benefits that cannotbe handled internally by HMOs under managed carearrangements.

Verifying EligibilityFor services listed in a child’s Individualized EducationProgram, SBS providers are required under state andfederal law to provide these services, regardless ofMedicaid eligibility. To verify that a recipient is eligiblefor Wisconsin Medicaid, providers may check withWisconsin Medicaid’s Eligibility Verification System(EVS), which provides eligibility information thatproviders can access a number of ways.

Refer to the Important Telephone Numbers page at thebeginning of this handbook for detailed information on themethods of verifying eligibility.

Handbook OrganizationThe School-Based Services Handbook consists of thefollowing chapters:

• Provider Information.• Recipient Information.• Covered Services.• Documentation Requirements.• Coordination of Benefits.• Claims Submission.• Reimbursement.

In addition to the School-Based Services Handbook, eachMedicaid-certified provider is issued a copy of the All-Provider Handbook. The All-Provider Handbookincludes the following sections:

• Claims Submission.• Coordination of Benefits.• Covered and Noncovered Services.• Prior Authorization.• Provider Certification.• Provider Resources.• Provider Rights and Responsibilities.• Recipient Rights and Responsibilities.

Legal Framework ofWisconsin Medicaid andBadgerCareThe following laws and regulations provide the legalframework for Wisconsin Medicaid and BadgerCare:

Federal Law and Regulation• Law: United States Social Security Act; Title XIX (42

US Code ss. 1396 and following) and Title XXI.• Regulation: Title 42 CFR Parts 430-498 — Public

Health.


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8 Wisconsin Medicaid and BadgerCare April 2005

Wisconsin Law and Regulation• Law: Wisconsin Statutes: Sections 49.43-49.499 and

49.665.• Regulation: Wisconsin Administrative Code, Chapters

HFS 101-108.

Handbooks and Wisconsin Medicaid and BadgerCareUpdates further interpret and implement these laws andregulations.

Handbooks and Updates, maximum allowable feeschedules, helpful telephone numbers and addresses, andmuch more information about Wisconsin Medicaid andBadgerCare are available at the following Web sites:

dhfs.wisconsin.gov/medicaid/dhfs.wisconsin.gov/badgercare/

Medicaid Fiscal AgentThe DHFS contracts with a fiscal agent, which iscurrently EDS.


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Provider Information

What is the School-BasedServices Benefit?The school-based services (SBS) benefit hasbeen established according to s. 49.45(39),Wis. Stats. This benefit is designed to increasefederal funding to Wisconsin schools to help payfor medically related special education andrelated services. The SBS benefit defines theservices that can be reimbursed byWisconsin Medicaid for medically necessaryservices provided to Medicaid-eligible children.

Provider Eligibility andCertificationTo participate as a Wisconsin Medicaid SBSprovider, a school, school district, CooperativeEducational Service Agency (CESA), CountyChildren with Disabilities Education Board(CCDEB), or charter school are required to becertified as a provider under HFS 105.53, Wis.Admin. Code. School-Based Services providersare required to verify that individual staff meetqualifications under ch. PI 34, Wis. Admin.Code, or are licensed under the following:

• Section 441.06, Wis. Stats. (registerednurse).

• Section 441.10, Wis. Stats. (licensedpractical nurse).

• Section 448.51, Wis. Stats. (physicaltherapy [PT]).

• Section 448.961, Wis. Stats. (occupationaltherapy [OT]).

• Section 459.24, Wis. Stats. (speech andlanguage pathology [SLP]) and hold acertificate of clinical competence from theAmerican Speech-Language-HearingAssociation (ASHA).

School districts may be Medicaid certified undera CESA’s umbrella certification or be separatelycertified as a school district, but not both. ACESA applying for SBS certification is

Prequired to identify the school districts includedin its certification and must notifyWisconsin Medicaid when these districtschange. A CESA is required to revise andresubmit Chart A of the SBS Certification Packetwhenever the list of school districts includedunder its certification changes.

Certification ProcessRefer to the Wisconsin Medicaid Web site atdhfs.wisconsin.gov/medicaid/ to downloadthe SBS Certification Packet, which includesforms and instructions on how to notifyWisconsin Medicaid of school district changes.

When applying for Wisconsin Medicaid SBScertification, the school district, CESA, CCDEB,or charter school is required to identify anyadditional Medicaid provider certifications it holdsor its providers hold (e.g., physical therapy ortherapy group). This ensures that any duplicateprovider types are removed.

Individual Provider LicensingRequirementsWisconsin Medicaid requires individualperforming providers to be licensed by theDepartment of Public Instruction (DPI) forreimbursement under the SBS benefit, with theexception of nurses. Nurses are not required toobtain a DPI license but are encouraged to doso. Individual providers of school-basedservices are not separately certified byWisconsin Medicaid.

Speech-language pathologists are required tomeet additional certification requirements forreimbursement under the Wisconsin MedicaidSBS benefit. A speech-language pathologist isrequired to meet one of the followingrequirements:

• Hold the certificate of clinical competencefrom ASHA.


TThis benefit isdesigned toincrease federalfunding toWisconsin schoolsto help pay formedically relatedspecial educationand relatedservices.


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• Has completed the educationalrequirements for the ASHA certificate,has completed or is acquiring thesupervised work experience necessary forthe ASHA certificate, and has passed thePRAXIS exam in SLP.

Because the DPI licenses individual providers inWisconsin schools only, out-of-state schools areineligible to apply for Wisconsin Medicaid SBScertification.

Duplicate Provider TypesAccording to s. 49.45(39), Wis. Stats., SBSproviders are required to submit claims forcovered Individualized Education Plan (IEP)services under the school district or CESA’sSBS certification and not under anotherMedicaid provider number. School-BasedServices provider certification encompasses,and therefore duplicates, all of the followingWisconsin Medicaid provider certifications:

• Physical therapy group and individual PTproviders and PT assistants.

• Occupational therapy group and individualOT providers and OT assistants.

• Speech and hearing clinics.• Audiology group and audiologists.• Therapy group.• Speech and language pathology/therapy

group and speech pathologists.• Rehabilitation agencies.• Transportation.• Nurse practitioner group and individual

nurse practitioners.• Nurse group and individual nurses.

The SBS provider (i.e., the school) cannothave duplicate certification numbers.Wisconsin Medicaid removes these duplicatecertifications when providers apply for SBScertification.

Individual providers performing services thatare in the IEP in the school may be individuallycertified by Wisconsin Medicaid; however, theservices must be billed by the CESA or school

district under the SBS benefit. An individualtherapist or clinic cannot submit claimsindividually for services provided that areincluded in the student’s IEP.

Nonduplicate Provider TypesSchool-Based Services providers may beMedicaid certified for other services, providedthese services are not covered under the SBSbenefit (e.g., HealthCheck screening andprenatal care coordination).

Provider Authority toSubcontractSchool-Based Services providers maysubcontract with agencies or individuals thatare not Medicaid certified to provide services.The SBS provider is responsible for assuringthat subcontracted agencies or individuals meetall SBS Medicaid requirements. For example,for the SBS provider to obtain reimbursementfor services provided by a contractedoccupational therapist in the community, thetherapist is required to be licensed by the DPI,which is an SBS Wisconsin Medicaid requirement.

School-Based Services provided by agenciesor individuals subcontracted by SBS providersmust submit claims to Wisconsin Medicaidunder the SBS benefit, listing the SBS provideras the billing provider (not the subcontractedagency or individual).

Communication withNon-School-Based-Services ProvidersWhen a child receives Medicaid services fromboth SBS and non-SBS providers, theseproviders are required to communicate with eachother to:

• Avoid duplication of services.• Ensure service coordination.• Facilitate continuity of care.

SSchool-BasedServices providersmay subcontractwith agencies orindividuals that arenot Medicaidcertified to provideservices.


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Communication between providers is a two-step process in which SBS providers arerequired to:

1. Determine if a child receives medicalservices outside the school from otherproviders.

2. Contact these providers and inform them,on at least an annual basis, of servicesprovided by the SBS provider.

School-Based Services providers are requiredto attempt to find out if children are receivingmedical services from providers outside theschool. For example, some schools send massmailings to all parents in an effort to obtain thisinformation. Providers may also request thisinformation from parents in IEP meetings,parent/teacher conferences, and/or telephoneconversations. If the parent(s) refuses toprovide the information or does not respond, theSBS provider is required to document this in thechild’s record.

When an SBS provider obtains informationabout a child receiving services from providersoutside the school and the child’s parents provideconsent to contact these providers, the SBSprovider is required to attempt to inform theseproviders of services delivered in the school. Ifthe provider(s) outside the school does notrespond after several good faith attempts, theSBS provider has fulfilled its obligations andneeds to document this in the child’s record.

Managed Care ProvidersTo ensure communication between providers,Wisconsin Medicaid requires that all SBSproviders and Medicaid HMOs that share aservice area sign a joint Memorandum ofUnderstanding (MOU). Additionally, SBSproviders and special managed care programproviders in Milwaukee county are alsorequired to sign a joint MOU.

An MOU is a document that sets standards,policies, and procedures to help coordinateservices. Wisconsin Medicaid facilitates thedevelopment of MOU between SBS providersand Medicaid HMOs by making a list ofcertified SBS providers available to HMOs ona quarterly basis.

A separate MOU must be signed with eachHMO that moves into the SBS provider’sarea. School-Based Services providers andmanaged care providers are required to sign anMOU only once and are required to complywith it as long as they remain a certifiedprovider.

School-Based Services providers are requiredto communicate at least annually with allHMOs and document this in the child’s record.

Refer to Appendix 4 of this handbook for asample MOU.

Special Managed Care Programs

In the future, Wisconsin Medicaid expects toexpand the special managed care programscurrently offered in Milwaukee county, andalso introduce special managed care programsin Dane county. At that time, SBS providersand special managed care program providersin these service areas will be required to sign ajoint MOU. Information explaining theexpansion and introduction of special managedcare programs in Milwaukee and Danecounties will be published in future WisconsinMedicaid and BadgerCare Updates.

For a list of Medicaid HMOs and specialmanaged care programs by county, refer to theManaged Care section of the Medicaid Website at dhfs.wisconsin.gov/medicaid/.

SSchool-BasedServices providersare required tocommunicate atleast annually withall HMOs anddocument this inthe child’s record.


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Medicaid Fee-for-Service ProvidersAlthough MOU are not required with Medicaidfee-for-service providers in the community,when a child receives services from both anSBS provider and a Medicaid fee-for-serviceprovider of the same discipline, the SBSprovider is required to:

• Contact these providers and inform them,on at least an annual basis, of servicesprovided by the SBS provider.

• Cooperate with Medicaid fee-for-serviceproviders of the same discipline whorequest copies of the child’s IEP orcomponents of the IEP.

Fee-for-service providers include, but are notlimited to, clinics, rehabilitation agencies, localhealth departments, community mental healthagencies, tribal health agencies, home careagencies, therapists, therapy groups, anddurable medical equipment providers.

Providers Not Certified UnderMedicaidMemoranda of Understanding are not requiredwith providers not certified by WisconsinMedicaid. However, if a child receives servicesfrom both an SBS provider and providers ofthe same discipline not certified underWisconsin Medicaid, the SBS provider isrequired to contact these providers and informthem, on at least an annual basis, of servicesprovided by the SBS provider. F

Fee-for-serviceproviders include,but are not limitedto, clinics,rehabilitationagencies, localhealthdepartments,community mentalhealth agencies,tribal healthagencies, homecare agencies,therapists, therapygroups, anddurable medicalequipmentproviders.


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Recipient Information


Recipient Eligibility

Wisconsin Medicaid’s EligibilityVerification SystemSchool-Based Services (SBS) providers arerequired by the state and federal law to providethe services listed in a child’s IndividualizedEducation Program (IEP), regardless ofMedicaid eligibility. Children must be under age21 or they must turn 21 years of age during theschool term in which services are performed.

To verify that a recipient is eligible for WisconsinMedicaid, providers may check with WisconsinMedicaid’s Eligibility Verification System(EVS), which provides eligibility informationthat providers can access a number of ways.

Refer to the Important Telephone Numberspage at the beginning of this handbook forinformation on methods for verifying eligibility.Refer to the Provider Resources section of theAll-Provider Handbook for detailed informationon accessing the EVS and eligibility forWisconsin Medicaid.

Volume EligibilityAnother method the SBS provider may use toverify eligibility is the Medicaid VolumeEligibility System. This system enables SBSproviders to make a large number ofWisconsin Medicaid recipient eligibility inquiries.This service is provided at no charge to providers.

To place a volume eligibility inquiry, contactDivision of Health Care Financing ElectronicData Interchange Department at (608) 221-9036. The Volume Eligibility System isavailable to SBS providers only.

CopaymentCopayments are not permitted for school-based services.

Parental Consent

Consent to Provide Medical ServicesAs required under federal and state educationlaws, SBS providers are required to obtainparental permission to provide the special educationand related services defined in a child’s IEP.Refer to the Covered Services chapter of thishandbook for further information about the IEP.

Consent to Request Reimbursementfrom Wisconsin MedicaidA separate parental consent in addition to thatrequired to provide the child medical services isnot required for SBS providers to submit claimsto Wisconsin Medicaid. However, if a parentwithdraws consent in writing, the SBS providercannot submit claims to Wisconsin Medicaid.

This policy is based on a U.S. Department ofEducation decision, in which the departmentreviewed Wisconsin Medicaid’s eligibilityapplication form and concluded that parentsgive consent to request reimbursement fromWisconsin Medicaid when they sign thisapplication form.

Wisconsin Medicaid encourages schools toinform parents that the SBS provider willsubmit claims to Wisconsin Medicaid forservices provided to their child(ren). Refer toAppendix 5 of this handbook for a sampleLetter of Consent to Request Reimbursementfrom Wisconsin Medicaid. Schools mayphotocopy this sample letter onto the schoolletterhead and fill in the necessary details foreach individual child. Schools also have theoption to develop their own letter of consent.

Consent to Bill CommercialInsuranceUnder the federal education law, parentalconsent must be obtained to bill commercialhealth insurance for school-based services.

RRecipient Information

WWisconsin Medicaidencouragesschools to informparents that theSBS provider willsubmit claims toWisconsin Medicaidfor servicesprovided to theirchild(ren).


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Covered Services


Through the school-based services (SBS)benefit, Medicaid-certified SBS providers mayrequest reimbursement from WisconsinMedicaid for medically necessary coveredschool-based services provided to Medicaid-eligible children.

Covered School-BasedServicesSchool-Based Services must be identified in thechild’s Individualized Education Program(IEP) and certain requirements must be met.Covered services include:

• Developmental testing and assessmentswhen resulting in a created or revised IEP.

• Durable medical equipment (DME).• Nursing.• Occupational therapy (OT).• Physical therapy (PT).• Psychological services, counseling, and

social work.• Speech and language pathology (SLP),

audiology, and hearing.• Transportation.

Providers are required to document all face-to-face time for school-based services. Providersmay submit claims only for face-to-face timefor school-based services, except DME, whereproviders may request reimbursement for theequipment itself. Consultation, monitoring, andcoordination are not separately reimbursableby Wisconsin Medicaid. Payment for theseservices is included in the reimbursement ratefor the face-to-face services listed above.

Refer to Appendices 11 and 12 of thishandbook for Medicaid-allowable SBSmodifiers and procedure codes.

Medical NecessityAll Medicaid-covered services must bemedically necessary, as defined in HFS101.03(96m), Wis. Admin. Code. A school-based service is considered medicallynecessary when the service:

1. Identifies, treats, manages, or addresses amedical problem, or a mental, emotional,or physical disability.

2. Is identified in the child’s IEP.3. Is necessary for a child to benefit from

special education.4. Is prescribed by a physician when required.

Refer to the service-specific information inthis chapter for prescription requirements.

Face-to-Face TimeProviders are required to document and maysubmit claims only for face-to-face encountertime with the child for all school-based services.Wisconsin Medicaid covers only face-to-facetime spent with the child for all school-basedservices. Face-to-face time is the time anySBS personnel, both teachers and medicalprofessionals, spend with the child present inthe course of providing a service. This includes:

• Time to obtain and update a history withthe child present.

• Direct observation of the child.• Individualized Education Program team

testing and assessment — only for the timewhen the SBS health professional is indirect contact with the child.

• Delivery of the IEP therapy, psychologicalcounseling, social work, or nursing services.

• Individualized Education Program meetings— only for the time when the child ispresent at the meeting.

CCovered Services

PProviders maysubmit claims onlyfor face-to-facetime for school-based services,except DME, whereproviders mayrequestreimbursement forthe equipmentitself.


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Non-Face-to-Face TimeWisconsin Medicaid does not pay separatelyfor any non-face-to-face time; payment fornon-face-to-face time is included in thereimbursement rates for face-to-face services.Non-face-to-face time includes the time thatproviders spend in preparation and follow-upwithout the child present, including:

• Reviewing and scoring records and tests.• Writing reports.• Communication and consultation (without

the child present) related to the IEP teamor IEP service with other professionals,staff, and parents.

• Meeting with parents regarding the IEP(without the child present).

CotreatmentWisconsin Medicaid recognizes that OT, PT,and SLP providers each provide a uniqueapproach to the recipient’s treatment.Cotreatment (the simultaneous treatment bytwo providers of different therapy disciplinesduring the same time period) may be providedonly in circumstances where it is medicallynecessary to optimize the recipient’srehabilitation. When cotreatment occurs,providers are required to document in thechild’s record why individual treatment from asingle therapist does not provide maximumbenefit to the recipient and why two differenttherapies that treat simultaneously are required.

Individualized EducationProgram InformationThe Wisconsin Medicaid SBS benefit onlycovers services that are listed in the IEP. Eachpublic school child who receives school-basedservices must have an IEP. An IEP is a writtenplan for a child that is developed, reviewed,and revised in accordance with s.115.787, Wis.Stats. The IEP identifies the special educationand related services for the child.

Treatment Goals and CarePlanFor Wisconsin Medicaid coverage of school-based services, there must be a care plan(such as the Department of Public Instruction’s[DPI’s] Individualized Healthcare Plan [IHP])that identifies treatment goals that aremeasurable and outcome-oriented. Whenthe treatment goals identified in the IEP meetthese conditions, the IEP is considered the careplan. Otherwise, providers are required todevelop a separate care plan that containsmeasurable and outcome-oriented goals.

Measurable Outcome-OrientedGoalsThe child’s IEP contains annual goals, includingshort term objectives or benchmarks that aremeasurable. For example, a child may have ashort-term goal of stepping over objects on thefloor without any loss of balance in four out offive trials with the ultimate annual goal ofwalking through crowded corridors without anyfalls. The short-term goal is measurable in thatthe child gains skills in walking safely whenconfronted by obstacles 80 percent of the time.The annual goal is outcome oriented andmeasurable in that the number of falls can betabulated.

Speech and LanguagePathology, Audiology,and Hearing Services

Covered ServicesSpeech and language pathology, audiology, andhearing services are covered for children withspeech, language, or hearing disorders thatadversely affect the child’s functioning. Thefollowing services are covered if identified inthe child’s IEP:

• Evaluation and re-evaluation to determinethe child’s need for SLP audiology, and/orhearing services (if the service results inthe development or revision of an IEP);

TThe WisconsinMedicaid SBSbenefit only coversservices that arelisted in the IEP.


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recommendations for a course oftreatment; and providing direct treatmentinterventions.

• Individual therapy/treatment or grouptherapy/treatment in groups of two toseven children.

• Medical equipment identified in the IEPintended for only one child for use atschool and home. Refer to the DurableMedical Equipment section of this chapterfor the qualifications necessary to obtainDME under the SBS benefit.

Provider QualificationsMedicaid-covered SLP, audiology, and hearingservices are performed by or under thedirection of a speech-language pathologist oraudiologist who meets Medicaid’s specificlicensing and certification requirements.

Each school district and CooperativeEducational Service Agency (CESA) isresponsible for documenting the qualificationsof all of the speech-language pathologists andaudiologists who provide services for them.They are also responsible for documenting theprovision of services provided under thedirection of a speech-language pathologist oraudiologist.

Speech-Language PathologistsA speech-language pathologist providingschool-based services is required to be DPIlicensed and meet one of the followingcertification conditions:

• The speech-language pathologist holds thecertificate of clinical competence from theAmerican Speech-Language-HearingAssociation (ASHA).

• The speech-language pathologist hascompleted the educational requirementsand work experience necessary for theASHA certificate and has passed thePRAXIS exam in SLP.

• The speech-language pathologist hascompleted the educational requirementsfor the ASHA certificate, has passed thePRAXIS exam in SLP, and is acquiring

supervised work experience to qualify forthe certificate.

• The speech-language pathologistprovided the services under thedirection of a speech-languagepathologist who holds ASHAcertification or who meets ASHAcertification.

AudiologistsAn audiologist providing school-based servicesis required to be DPI licensed and meet one ofthe following certification conditions:

• The audiologist holds a license fromWisconsin Department of Regulation andLicensing (DR&L).

• The audiologist holds the certificate ofclinical competence from ASHA.

• The audiologist:Has completed the educationalrequirements necessary for the ASHAcertificate and;Has successfully completed aminimum of 350 clock-hours ofsupervised clinical practicum (or is inthe process of accumulating thatsupervised clinical experience underthe supervision of a qualified Master’sor doctoral-level audiologist) and;Has performed at least nine months offull-time audiology services under thesupervision of a qualified Master’s ordoctoral-level audiologist after obtaininga Master’s or doctoral degree inaudiology or a related field and;Has passed the PRAXIS Exam inaudiology.

• The audiologist provided the service underthe direction of an audiologist who holdsASHA certification or who meets ASHAcertification requirements.

“Under the Direction of” GuidelinesThe Centers for Medicare and MedicaidServices (CMS) require certain guidelines tobe met for federal reimbursement of servicesthat are provided under the direction of aqualified speech-language pathologist oraudiologist. To ensure funding, Wisconsin

TThe Centers forMedicare andMedicaid Servicesrequire certainguidelines to bemet for federalreimbursement ofservices that areprovided under thedirection of aqualified speech-languagepathologist oraudiologist.


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Medicaid requires school districts and CESAsto comply with the federal guidelines.

School-Based Services provided under thedirection or supervision of a speech-languagepathologist or audiologist must meet thefollowing requirements:

• A supervising speech-languagepathologist or audiologist must meet thequalifications listed in the ProviderQualifications section of this chapter.

• The supervising speech-languagepathologist or audiologist must see eachrecipient at the beginning of andperiodically during treatment, be familiarwith the treatment plan, have continuedinvolvement in the care provided,and review the need for continuedservices throughout treatment.

• The supervising speech-languagepathologist or audiologist must assumeprofessional responsibility for theservices provided under his or herdirection.

• The supervising speech-languagepathologist or audiologist must ensurethat the individual working under his orher direction can contact him or her asnecessary during the course of treatment.

• A supervising speech-languagepathologist or audiologist may notsupervise more service providers than isreasonable, ethical, and in keeping withprofessional practice in order to permitthe supervising speech-languagepathologist or audiologist to adequatelyfulfill his or her supervisory obligationsand to ensure quality care.

• The entity employing the supervisoryspeech-language pathologist or audiologistis responsible for ensuring that thesestandards are met.

• The employing entity is responsible forensuring that appropriate documentationis maintained to prove that the aboverequirements were met. The employingentity is also responsible for ensuringthat there is appropriate documentationof services provided by the supervisingspeech-language pathologist or audiologist

and by the individuals working under thedirection of the supervising speech-language pathologist or audiologist.

Prescription RequirementsSpeech and language pathology, audiology, andhearing services require a physician’sprescription annually or the SBS provider isrequired to have a Request for a Waiver toWisconsin Medicaid PrescriptionRequirements Under the School-BasedServices Benefit form, HCF 1134, on file withWisconsin Medicaid. Refer to Appendix 7 of thishandbook for a copy of the form.

Physical Therapy Services

Covered ServicesPhysical therapy services are covered whenthey identify, treat, rehabilitate, restore,improve, or compensate for medical problems.The following services are covered if they areidentified in the child’s IEP:

• Evaluation and re-evaluation to determinethe child’s need for PT (if the serviceresults in the development or revision of anIEP), recommendations for a course oftreatment, and providing direct treatmentinterventions.


• Medical equipment identified in the IEPintended for only one child for use atschool and home.

Provider QualificationsMedicaid-covered PT services are performedby or under the direction of a licensed DPIphysical therapist.

Licensed PT providers may only delegate tophysical therapy assistants (PTAs) thoseportions of a child’s therapy that are consistentwith the PTA’s education, training, andexperience. Licensed PT providers arerequired to have direct, face-to-face contact

MMedicaid-coveredPT services areperformed by orunder the directionof a licensed DPIphysical therapist.


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with PTAs on the premises at least every 14days.

Prescription RequirementsPhysical therapy services require a physician’sprescription annually. However, if the SBSprovider has a Request for a Waiver toWisconsin Medicaid Prescription RequirementsUnder the School-Based Services Benefitform on file with Wisconsin Medicaid, aprescription is only required under limitedcircumstances as required by the DR&L. Referto Appendix 7 of this handbook for a copy ofthe form.

Occupational TherapyServices

Covered ServicesOccupational therapy services are coveredwhen they identify, treat, rehabilitate, restore,improve, or compensate for medical problemsthat interfere with age-appropriate functionalperformance. The following services arecovered if they are identified in the child’s IEP:

• Evaluation and re-evaluation to determinethe child’s need for OT (if the serviceresults in the development or revision of anIEP), recommendations for a course oftreatment, and providing direct treatmentinterventions.


• Medical equipment identified in the IEPintended for only one child for use atschool and home.

Provider QualificationsMedicaid-covered OT services are performedby or under the direction of a licensed DPIoccupational therapist.

Licensed OT providers may only delegate tocertified occupational therapy assistants(OTAs) those portions of a child’s therapy thatare consistent with the OTA’s education,training, and experience. Licensed OTproviders are required to have direct, face-to-face contact with OTAs on the premises atleast every 14 days.

Prescription RequirementsOccupational therapy services require aminimum of one physician’s prescriptionannually or the SBS provider is required to havea Request for a Waiver to Wisconsin MedicaidPrescription Requirements Under the School-Based Services Benefit form on file withWisconsin Medicaid. Refer to Appendix 7 ofthis handbook for a copy of the form.

Nursing Services

Covered ServicesNursing services must be appropriate for thechild’s medical needs and specifically identifiedin the child’s IEP. Covered nursing servicesunder the SBS benefit are described in s. HFS107.36, Wis. Admin. Code. Services include,but are not limited to:

• Evaluation and management services,including screens and referrals for healthneeds.

• Treatment.• Medication management.

All time that a nurse spends conductingactivities with the child that are included in thechild’s IEP may be submitted to WisconsinMedicaid for reimbursement.

Like all school-based services, nursing servicesidentified in the IEP must have outcome-basedgoals. The goals must be detailed in either theIEP if there are student goals or in the IHP ifthere are nursing goals. Goals for medicationmanagement must be identified as well (e.g.,seizure medication to prevent and/or treatseizures).

NNursing servicesmust beappropriate for thechild’s medicalneeds andspecificallyidentified in thechild’s IEP.


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The child’s IEP must identify each specificnursing service (e.g., medication management,suctioning, dressing changes, nebulizationtreatment, G-tube feeding). The IHP shouldidentify the personnel, by name, who willperform the services.

Durable medical equipment related to nursingservices are not covered school-basedservices. Consult with a DME provider todetermine whether equipment will be coveredunder the Medicaid DME benefit.

Provider QualificationsMedicaid-covered nursing services areperformed by a registered nurse (RN), licensedpractical nurse (LPN), or are delegated undernursing protocols, according to ch. N 6, Wis.Admin. Code.

Prescription RequirementsServices are required to be prescribed at leastannually by a physician. Medicationmanagement is required to be prescribedannually by a licensed practitioner as defined ins. 118.29(1)(e), Wis. Stats.

Required DocumentationProviders may use one of two methods, timeor task, when documenting and submittingclaims for covered nursing services. Refer tothe Documentation Requirements section ofthis handbook for documentation requirementsfor both methods.

Delegation of Nursing ServicesUnder the Standards of Practice forRegistered Nurses and Licensed PracticalNurses, ch. N 6, Wis. Admin. Code, only RNsmay delegate nursing services to an LPN orindividual without a medical license. The RNwho delegates these services is required tofollow nursing protocols pursuant to ch. N 6,Wis. Admin. Code, including training,evaluation, and supervision.

An exception to the rules of nursing delegationin schools is medication administration.Wisconsin law allows school staff without amedical license to administer medicationprovided all protocols of s. 118.29 and 118.291,Wis. Stats., are followed. An RN is required todevelop medication administration policies andprocedures and train staff in medicationadministration. Formal nursing delegation is notuniformly required but the determination ofneed to do so must be made by an RN.However, because Wisconsin Medicaid canonly reimburse providers for medical services,under the SBS benefit Wisconsin Medicaidonly covers medication administration byunlicensed school staff when it is adelegated nursing act by the RN and isdocumented as such.

Nursing Tasks Reimbursable forFull-Time Health AidesA school or a prescribing physician maydetermine it necessary for a child to have afull-time aide. However, Wisconsin Medicaidwill not reimburse for all the aide’s time.Wisconsin Medicaid will reimburse SBSproviders only for the times associated withperforming specific covered nursing tasks (e.g.,G-tube feeding, suctioning, medicationmanagement) identified in the IEP.

Time spent on educational tasks or onmonitoring the child is not covered and will notbe reimbursed even though a full-time aidemay be required. Educational tasks include, butare not limited to, vocabulary development,reinforcement of classroom instruction, androte learning skills (e.g., counting, nameprinting, coin labeling). Examples of monitoringinclude, but are not limited to, having an aidepresent in case the child has a seizure orbehavior outburst. Only time spent performingface-to-face covered nursing tasks identifiedin the IEP can be reimbursed.

MMedicaid-coverednursing services areperformed by aregistered nurse(RN), licensedpractical nurse(LPN), or aredelegated undernursing protocols,according to ch. N6, Wis. Admin.Code.


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Services Provided byTeachersAs stated in s. 1905(a) of the Social SecurityAct, Wisconsin Medicaid can reimburseproviders only for medical services. Therefore,under the SBS benefit, Wisconsin Medicaidcan reimburse SBS providers only for thefollowing types of services performed byspecial education teachers, diagnostic teachers,or DPI-licensed teachers:

• Individualized Education Programmeetings. Wisconsin Medicaid covers IEPmeetings during which Medicaid-coveredschool-based services are discussed whenthe child is present.

• Delegated nursing acts. Although s. 118.29,Wis. Stats., allows school staff to dispensemedication without it being a delegatednursing act, Wisconsin Medicaid onlycovers a medically related service providedby a teacher (or other school personnel)when it is a delegated nursing act by theschool nurse and documented as such.

Psychological Services,Counseling, and SocialWork Services

Covered ServicesPsychological services, counseling, and socialwork services include diagnostic or activetreatments intended to reasonably improve thechild’s physical or mental condition. Thefollowing services are covered if they areidentified in the child’s IEP:

• Diagnostic testing and evaluation thatassesses cognitive, emotional, and socialfunctioning and self-concept.

• Therapy and treatment that plans,manages, and provides a program ofpsychological services, counseling, orsocial work services to children withpsychological or behavioral problems.

• Crisis intervention.

• Treatment, psychological counseling, andsocial work services to individuals orgroups of two to 10 individuals.

Provider QualificationsPsychological services, counseling, and socialwork services must be performed by alicensed DPI school psychologist, schoolcounselor, or social worker.

Prescription RequirementsPsychological services, counseling, and socialwork services must be prescribed annually bya physician or licensed Ph.D. psychologist, orthe SBS provider is required to have a Requestfor a Waiver to Wisconsin MedicaidPrescription Requirements Under the School-Based Services Benefit form on file withWisconsin Medicaid. Refer to Appendix 7 ofthis handbook for a copy of the form.

Other DevelopmentalTesting and Assessments

Covered ServicesWisconsin Medicaid covers other developmentaltesting, assessments, and consultations whenresulting in a new or revised IEP. Theseservices must be performed face-to-face withthe child by a licensed health professional. Staffproviding these services must be DPI-licensed.

Covered school-based developmental andtesting services include evaluations, tests, andrelated activities performed to determine if motor,speech, language, or psychological problemsexist, or to detect developmental lags in thedetermination of eligibility under the Individualswith Disabilities Education Act (IDEA).

School-based testing and assessment servicesperformed by therapists, psychologists, socialworkers, counselors, and/or nurses are includedin the covered school-based services for theirrespective professional areas and should bebilled accordingly.

SSchool-basedtesting andassessmentservices performedby therapists,psychologists,social workers,counselors, and/ornurses are includedin the coveredschool-basedservices for theirrespectiveprofessional areasand should bebilled accordingly.


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Provider QualificationsOther developmental testing, assessments, andconsultation services must be performed by alicensed physician or psychiatrist, director ofspecial education and/or pupil services, specialeducation teacher, diagnostic teacher, or othercertified school staff. Wisconsin Medicaid onlycovers this testing and assessment for teacherswhen it results in a new or revised IEP. Allproviders are required to be DPI licensed.

Prescription RequirementsA prescription is not required for otherdevelopmental testing assessments. However,providers are expected to fully document therationale for all testing procedures in the child’srecord. Providers will be notified by WisconsinMedicaid if prescription requirements for otherdevelopmental testing and assessments change.

Transportation Services

Covered ServicesWisconsin Medicaid covers school-basedtransportation services based on criteria set bythe CMS. Refer to Appendix 21 of thishandbook for a summary of CMS-coveredtransportation policy.

School-Based Services providers may submitclaims for specialized medical transportationthat a child would not otherwise receive in thecourse of attending school. The specializedmedical transportation, which must be listed inthe child’s IEP, may include, but is not limitedto, the following:

• A specialized medical vehicle (SMV)(equipped with a ramp or lift) where thechild requires a ramp or lift.

• Transportation in any vehicle where an aideis required to assist the child.

• A specially adapted bus for a child with adisability who is not able to ride a standardschool bus.

• A vehicle routed to an area that does nothave school bus transportation that thechild requires because of a disability.

Wisconsin Medicaid reimburses SBS providersfor transportation only on days when a child isreceiving a covered school-based service(other than transportation) in the followingsituations:

• Transportation to and from school when achild receives a covered school-basedservice at school.

• Transportation to and from an off-sitelocation to receive a covered school-basedservice provided the child is in school thatday. In this case, transportation betweenschool and home is not covered.

Refer to the Documentation Requirementssection and Appendix 20 of this handbook forinstructions and examples of how to documentclaims for reimbursement.

Provider QualificationsMedicaid-covered specialized medicaltransportation services must be performed by aschool or school-contracted transportationprovider.

Prescription RequirementsA prescription is not required for school-basedspecialized medical transportation services.

LimitationsIndividualized Education Programs mustinclude only specialized medical transportationservices that a child would not otherwise receivein the course of attending school. For example,a child with special education needs under IDEA,who rides the standard school bus to schoolwith children without disabilities, should nothave transportation listed in his or her IEP, andthe cost of that bus ride must not be billed toWisconsin Medicaid as a school-based service.

When specialized medical transportation servicesare included in the child’s IEP, providers mayseek reimbursement only under the SBS benefit.Claims for school-based transportation services,as described in the IEP, cannot be submitted toWisconsin Medicaid by SMV providers or billedto a county by county common carrier providers.

MMedicaid-coveredspecialized medicaltransportationservices must beperformed by aschool or school-contractedtransportationprovider.


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Durable MedicalEquipment

Covered ServicesDurable medical equipment is a covered school-based service when:

• The need for the equipment is identified inthe child’s IEP.

• Only one child uses the equipment.• The child uses the equipment at school and

at home (the child owns the equipment, notthe SBS provider).

• The equipment is not covered underWisconsin Medicaid’s DME benefit.

Wisconsin Medicaid reimburses for DMErelated to SLP, audiology and hearing services,PT, and OT when the equipment meets thesecriteria. Wisconsin Medicaid does not reimbursefor DME related to nursing services under theSBS benefit.

Contact Wisconsin Medicaid or a Medicaid-certified DME supplier to determine if theMedicaid DME benefit covers a particular item.

Prescription RequirementsA prescription is not required for DME when itis provided as a school-based service. Providerswill be notified by Wisconsin Medicaid ifprescription requirements for DME change.

Prescription WaiversSchool-Based Services providers have theoption to submit a Request for a Waiver toWisconsin Medicaid Prescription RequirementsUnder the School-Based Services Benefit formto Wisconsin Medicaid. This form waives someMedicaid prescription requirements. The waivercovers the following school-based servicesprovided to all Medicaid-eligible children at theschool:

• Speech and language pathology, audiology,and hearing services.

• Physical therapy services.

• Occupational therapy services.• Psychological services, counseling, and

social work services.One prescription waiver request is sufficient forall applicable services. Refer to Appendix 7 ofthis handbook for a copy of the form.

Submit forms to Wisconsin Medicaid at thefollowing address:

Wisconsin MedicaidProvider Maintenance6406 Bridge RdMadison WI 53784-0006

Refer to Appendix 6 of this handbook tocompare Medicaid prescription requirementsfor specific service categories with and withouta prescription waiver. School-based transportationservices do not require a prescription.

Community-BasedTherapies and School-Based ServicesIn addition to covering school-based services,Wisconsin Medicaid reimburses community-based therapists separately for Medicaidservices not provided under the SBS benefitthat are not in the recipient’s IEP.

To determine medical necessity, WisconsinMedicaid requires community-based therapyproviders to obtain prior authorization (PA) forservices that could also be reimbursed underthe SBS benefit. The medical necessity ofschool-based services is reviewed in the IEPprocess, whereas medical necessity is reviewedin the PA process for community therapists.

When adjudicating PA requests for community-based therapies, Wisconsin Medicaid considersthe medical necessity of services and othercriteria including, but not limited to, whether theservice is appropriate, cost-effective, and non-duplicative of other services. As part of the PAprocess, community therapists submit thechild’s IEP with their request to provide services.

SSchool-BasedServices providershave the option tosubmit a Requestfor a Waiver toWisconsin MedicaidPrescriptionRequirementsUnder the School-Based ServicesBenefit form toWisconsin Medicaid.


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Medicaid consultants review the IEP in additionto all other required material and records todetermine if the child is already receivingservices that meet the child’s therapy needs.The IEP is not the only material consideredwhen determining medical necessity.

Wisconsin Medicaid’s professional consultantsdo not base approval or denial of PA requestson whether the school pursues reimbursementthrough the SBS benefit. The consultants donot review the SBS claims information.Therefore, whether an SBS provider seeksreimbursement for school-based services doesnot influence whether a community therapy PArequest is approved or denied.

Refer to the Wisconsin Medicaid School-Based Services Fact Sheet in Appendix 8 ofthis handbook, which may be used to informparents about the relationship betweencommunity therapies and school-based services.

Noncovered ServicesThe following services are not covered underthe SBS benefit, in accordance withHFS 107.36(3), Wis. Admin. Code:

• Art, music, and recreational therapies.• Diapering.• Durable medical equipment covered under

HFS 107.24, Wis. Admin. Code.• General classroom instruction and

programming. For example, developmentalguidance in the classroom.

• General research and evaluation of theeffectiveness of school programs.

• Kindergarten or other routine screeningprovided free of charge unless resulting inan IEP referral.

Note: HealthCheck screens arereimbursable to MedicaidHealthCheck providers but are notreimbursable under the SBS benefit.

• Nonmedical feeding that is not tubefeeding or part of a medical program, suchas a behavior management program.

• Program coordination of gifted andtalented students or student assistanceprograms.

• Services, including school health programservices, which are not in the child’s IEP.

• Services performed by providers who arenot certified for school-based services.

• Services that are strictly educational,vocational, or pre-vocational in nature orwithout a defined medical component. Forexample, vocabulary development,specialized (adaptive) physical educationclasses, rote learning skills (e.g., counting,name printing, and coin labeling).

• Staff development and in-services toschool staff and parents.

In addition, the following are also not coveredunder the SBS benefit:

• Any non-face-to-face activities (i.e., thechild is not present).

• Any services listed under s. 504 of theRehabilitation Act of 1973, unlessspecifically listed in the child’s IEP.

MMedicaidconsultants reviewthe IEP in additionto all other requiredmaterial andrecords todetermine if thechild is alreadyreceiving servicesthat meet thechild’s therapyneeds.


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Medicaid DocumentationStandardsDocumentation must be kept in each recipient’srecord, as required under HFS 106.02(9), Wis.Admin. Code.

Refer to the Provider Rights and Responsibilitiessection of the All-Provider Handbook forgeneral information on preparing and maintainingrecords.

School-Based Services (SBS) providers arerequired to follow Wisconsin Medicaid’scoverage policies and documentation standardswhen submitting claims for services providedunder the SBS benefit. Failure to do so mayresult in a federal government audit.

Individualized EducationProgram DocumentationWisconsin Medicaid requires SBS providers toinclude Individualized Education Program (IEP)information in each child’s record. All servicesfor the child must be listed in the IEP to bereimbursed by Wisconsin Medicaid. Thisinformation must be kept for at least fiveyears, regardless of other requirements set bythe Department of Public Instruction.

The IEP information must include the following:

• Documentation used to develop an IEP(e.g., IEP Team reports or tests).

• The annual IEP revision that documentsany changes in the IEP or related services.

• A description of durable medicalequipment (DME), if applicable. (Includethe item name, model number or adescription, and the invoice, receipt, orcost.)

DDocumentation Requirements

Documenting Face-to-Face SessionsIn addition to the previously listed items, eachchild’s file must include a signed recorddocumenting each face-to-face session with aprovider. Documentation (either electronic orhandwritten medical records) must be kept forat least five years and include the followinginformation:

• School’s name.• Student’s name (including first and last name).• Student’s birth date.• The prescription for the service, when

required.• Category of service provided (e.g., speech

and language pathology).• Date(s) of service (DOS). Several dates or

sessions may be included on one record ifthey are for the same category of service.

• Time, quantity, or miles provided. (Unitsare documented when submitting claims.)

• Whether service was provided in a groupor individual setting.

• Services that are listed in the IEP.• Documentation that the child was present

at IEP meetings for the meeting to becovered by Wisconsin Medicaid.

• Attendance records verifying the child wasin school on the DOS.

• Brief description of the specific serviceprovided. Here are a few examples thatinclude the level of detail WisconsinMedicaid requires:

Activities of daily living, such as“buttoning skills.”Range of motion (ROM), such aselbow or wrist ROM.Medication management, Tegretol,200 mg (oral).

• Student’s progress or response to eachservice delivered (required for nursingservices and recommended for all otherservices). (Progress or response is not

WWisconsinMedicaid requiresSBS providers toincludeIndividualizedEducationProgram (IEP)information ineach child’srecord.


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required for transportation or routinetransferring.) Monthly progress andresponse notes are required for all otherschool-based services.

• Documentation of contacts with fee-for-service providers at least annually (e.g., anSBS speech-language pathologist and acommunity speech-language pathologistdiscuss the progress of a student with whomthey each work).

• Documentation of contacts with non-Medicaid providers at least annually.Examples of non-Medicaid providersinclude a physician or nurse practitioner inprivate practice who is not Medicaid certified.

• Documentation of contacts with state-contracted HMOs at least annually.(Memorandums of Understanding betweenSBS providers and state-contracted HMOsin their service areas are required.)

• Name and signature of individual whoperformed service(s).

• Commercial health insurance information(for therapy services only). If a child hascommercial health insurance, this includesdocumentation of billing commercial healthinsurance or decreasing the units billed toWisconsin Medicaid.

• Documentation of local matching andcertified public expenditures. Thisdocumentation must be submitted toWisconsin Medicaid annually.

Refer to the Provider Rights and Responsibilitiessection of the All-Provider Handbook forinformation about standard record keepingrequirements. Wisconsin Medicaid does notrequire a particular format for data collection.

Examples of MedicalRecords Requiring aSignatureThe following is an example list of medicalrecords that require the performer’s signature,as outlined in Wisconsin Administrative Code,

Wisconsin Medicaid and BadgerCareUpdates, and Wisconsin Medicaid handbooks.Examples include, but are not limited to:

• Care plans.• Physician’s orders or prescriptions.• Physician’s verbal orders when reduced to

writing.• Progress notes.• Therapy plans.• Written protocols.• All documentation of Medicaid-covered

services provided to or for a recipient.Examples include, but are not limited to:

Assessments.Case notes.Daily documentation.Encounter notes.Flow sheets.Medication sheets.Service provision notes.

Electronic Records

Electronic Signature StandardsSchools that maintain patient records bycomputer rather than hard copy may useelectronic signatures. However, such entriesmust be properly authenticated and dated.Authentication must include signatures, writteninitials, or computer-secure entry by a uniqueidentifier of a primary author who hasreviewed and approved the entry. The schoolis required to have safeguards to preventunauthorized access to the records and aprocess for reconstruction of the records uponrequest from Wisconsin Medicaid, its fiscalagents, auditors, or other authorized personnelor in the event of a system breakdown.Signatures must be applied when the medicalrecords are charted electronically.

SSchools thatmaintain patientrecords bycomputer ratherthan hard copymay use electronicsignatures.


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Charting Medical RecordsElectronically — General ProviderRequirementsCharting medical records electronically issubject to the same requirements as paperdocumentation. In addition, the followingrequirements apply:

• Providers are required to have a paper orelectronic back-up system for chartingmedical records electronically. This couldinclude having files saved on disk or CD incase of computer failure.

• For audits conducted by the Division ofHealth Care Financing or the federalgovernment, providers are required toproduce paper copies of electronicrecords.

• Providers are required to have safeguardsto prevent unauthorized access to therecords.

Documentation of NursingServices UnitsWisconsin Medicaid recommends SBSproviders use the following optional activity logsprovided to document SBS nursing activities:

• Optional School-Based Services ActivityLog Nursing/Therapy Medical Services(refer to Appendix 18 of this handbook).

• Optional School-Based Services ActivityLog Medication Administration (refer toAppendix 19 of this handbook).

The use of these two forms is voluntary.Providers may develop their own activity logs;however, they must include all the requestedinformation in the optional activity logs.

Providers may use one of the following twomethods when documenting activities andsubmitting claims for covered school-basednursing services:

• Time method.• Task method.

Providers may not use a combination of thetime and task methods on the same activity log.

Time MethodThere are two different ways to documentactivities using the time method. Descriptions ofboth ways are as follows:

• The provider of services can document thespecific times of the day associated withthe tasks (e.g., 8:04 a.m. - 8:34 a.m. — G-tube feeding).

• The provider of services can record thenumber of minutes it took to provide thetasks (e.g., transfer onto toilet — 3 times =30 minutes total).

Providers may only use one of these types oftime method documentation on an activity log.

The provider of services should reflect the totaltime of Medicaid-reimbursable services forboth medication administration and nursingservices rendered on their billing sheets. Referto Appendices 14 and 15 of this handbook forexamples of the two types of time methoddocumentation on the Optional School-BasedServices Activity Log Nursing/Therapy MedicalServices and the Optional School-BasedServices Activity Log Medication Administration.

Task MethodThe provider of services may choose to use thetask method, which is based on the number oftimes tasks were performed.

For this method, the provider of services isrequired to do the following:

• Document the number of times eachnursing task is provided for each child on aspecific day.

• Multiply the number of times a specifictask was performed by the unit found onthe conversion chart in Appendix 13 of thishandbook (e.g., G-tube feeding = 2.0 unitsper task).

• Document the total units, identifying theDOS.

Refer to Appendices 16 and 17 of thishandbook for examples of task methoddocumentation on the Optional School-BasedServices Activity Log Nursing/Therapy

PProviders maydevelop their ownactivity logs;however, they mustinclude all therequestedinformation in theoptional activitylogs.


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Medical Services and the Optional School-Based Services Activity Log MedicationAdministration.

If a nursing service is performed but is not listedon the conversion chart (e.g., epi-pen autoinjection), report the actual time and convert tounits using the standard record keeping andbilling method (15 minutes = 1.0 unit). If a newtask becomes a recurring task and averagetimes need to be established, write to:

Medicaid SBS Policy AnalystDivision of Health Care FinancingPO Box 309Madison WI 53701-0309

Nursing Services DocumentationRequirementsProviders are required to document in writingand keep on file the date on which they beganusing a new method or any time thereafterwhen methods are changed. Providers are thenrequired to use the same method, whether timeor task, for all Medicaid-eligible children.

Documentation of nursing services must includethe results or outcomes of services (i.e.,whether or not the services were effective, theresponse, and the method used if the initialmethod did not work). Documentation ofresults are required for all nursing services withthe exception of successful transfers.

Nursing Standards of Practice forDocumentationNurses are required to comply with nursingclinical practice standards for documentation,even though this is not a specific additionalMedicaid requirement. These documentationstandards must be met whether the SBSprovider is using the time or the task method tomeet Medicaid’s documentation requirements.

Under nursing clinical practice standards,clinical/visit notes give a clear, comprehensivepicture of the recipient’s continual status, thecare being provided, and the response to thatcare. The nurse is required to be specific abouttimes in his or her charting, especially the exacttime of sudden changes in the recipient’scondition (e.g., seizure), significant events (e.g.,a fall), and nursing actions that includemedication administration and other treatments(e.g., tube feedings).

Documentation ofTransportation ServicesUnitsProviders may submit claims for SBStransportation to Wisconsin Medicaid using adaily base rate with procedure code T2003 forcovered school-based transportation services.The first 20 miles of the trip are included in thedaily base rate. The daily base rate is equal toone unit.

For transportation services of more than 20miles, SBS providers may submit claims usingprocedure code A0425 in addition to procedurecode T2003. Providers may bill the first 20miles using the base rate procedure code T2003and then bill the remaining miles of the tripusing procedure code A0425, with eachadditional mile equal to one unit. For thoseservices of more than 20 miles, providers arerequired to indicate the pickup and drop-offlocations and total miles in the child’s record.Providers may also choose to bill only the baserate code for children whose mileage exceeds20 miles.

Note: If the total number of miles is notdocumented in a child’s record, aprovider may only use procedure codeT2003.

Refer to Appendix 20 for examplesdemonstrating the use of the school-basedtransportation services procedure codes.

PProviders maysubmit claims forSBS transportation toWisconsin Medicaidusing a daily baserate with procedurecode T2003 forcovered school-based transportationservices.


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Transportation ServicesDocumentation RequirementsProviders are required to include all of thefollowing information in the record of eachchild who receives school-based transportationservices:

• The child’s first and last name and date ofbirth.

• The general service category(transportation).

• The DOS that school-based transportationservices were provided.

• Documented verification that the child wasin school and received a school-basedservice other than transportation on thedate the transportation was provided.

Note: It is critical that providers verify thata recipient received a school-basedservice on a particular day beforebilling for transportation services forthat day.

• The total number of miles, only whenseeking reimbursement for more than the20-mile daily base rate for that day (theprovider will need to use procedure codeA0425 in addition to T2003 for claims).

• The pick-up and drop-off locations, onlywhen seeking reimbursement for more thanthe 20-mile daily base rate for that day. Ifthe locations are home or school, these canbe described in general terms, such as“home to school” or “school to home.” Ifthe school-based service is at a place otherthan the school, a more specific descriptionincluding the name of the facility and streetaddress is required.

This information may be included in the trip log.

Documentation of OtherSchool-Based ServicesUnitsSchool-Based Services providers should usethe following general guidelines to determineservice units for covered school-basedservices:

• One piece of equipment equals one unitfor DME services.

• Fifteen minutes of face-to-face time withthe recipient equals one unit for thefollowing services:

Audiology and hearing services.Counseling services.Individualized Education Planassessment.Individuals with Disabilities EducationAct assessment.Occupational and physical therapyservices.Psychological services.Social work services.Speech and language pathology,audiology, and hearing services.

I It is critical thatproviders verifythat a recipientreceived a school-based service on aparticular daybefore billing fortransportationservices for thatday.


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Coordination of Benefits

CCommercial HealthInsurance LiabilityRequirementWisconsin Medicaid is usually the payer of lastresort for any Medicaid-covered service. Thismeans that Wisconsin Medicaid requiresMedicaid providers to seek payment from arecipient’s commercial or other health insurancebefore seeking payment from WisconsinMedicaid (42 CFR s. 433.139[c]). However,school-based services (SBS) providers mayalso assume the insurance liability amount (theamount that providers are required to billcommercial health insurance before requestingreimbursement from Wisconsin Medicaid).Instead of seeking payment from the child’scommercial health insurance, SBS providersmay absorb these costs themselves.

Under the SBS benefit, Wisconsin Medicaidrequires providers to seek payment from thecommercial insurer only for physical therapy(PT) and occupational therapy (OT) servicesbefore billing Wisconsin Medicaid if a child hascommercial health insurance. Providers arerequired to obtain parental consent to bill achild’s commercial health insurance.

Refusal of Parental ConsentIf parents refuse consent to bill commercialhealth insurance, providers may assume liabilityfor the services as described in this section.

When the Commercial InsuranceLiability Requirement Does Not ApplyWisconsin Medicaid’s insurance liabilityrequirement does not apply for the followingschool-based services:

• Durable medical equipment.• Development, revision, review, and annual

evaluation/re-evaluation of theIndividualized Education Plan (IEP).

• Nursing services.• Other developmental testing and

assessments.• Psychological services, counseling, and

social work services.• Speech and language pathology, audiology,

and hearing services.• Transportation services.

When the insurance liability requirement doesnot apply, SBS providers are not required tobill commercial health insurance. Instead, theymay seek reimbursement directly fromWisconsin Medicaid without first seekingpayment from the child’s commercial healthinsurance, if any.

If providers obtain parental consent, they maybill the child’s commercial health insurance forthe previously mentioned school-basedservices that the insurance liability requirementdoes not apply to, but Wisconsin Medicaid doesnot require them to do so.

Exclusionary ClausesThe Medicaid insurance liability requirementnever applies to any school-based service if achild’s commercial health insurance policyexcludes all school medical services fromcoverage (also known as an “exclusionaryclause”). Contact the child’s family or thecommercial health insurance company todetermine if this clause exists.

If the commercial health insurance policycontains an exclusionary clause, providers arerequired to submit claims for all school-basedservices directly to Wisconsin Medicaid, thendocument in the child’s record that the child’scommercial health insurance has anexclusionary clause for school medicalservices.


UUnder the SBSbenefit,Wisconsin Medicaidrequires providersto seek paymentfrom thecommercialinsurer only forphysical therapy(PT) andoccupationaltherapy (OT)services beforebillingWisconsin Medicaidif a child hascommercial healthinsurance.


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When Commercial InsuranceLiability Requirement Does ApplyThe Medicaid insurance liability requirementapplies for the following school-based services:

• Occupational therapy — group orindividual.

• Physical therapy — group or individual.

School-Based Services providers are requiredto choose one of the following three optionswhen the Medicaid insurance liability applies:

1. Assume the insurance liability amount.2. Seek payment from the child’s commercial

health insurance.3. Do not seek reimbursement from

Wisconsin Medicaid for these services.

Assume the Insurance Liability AmountUnder this option, providers do not contact or billa child’s commercial health insurance. This isachieved by not submitting claims to WisconsinMedicaid for one unit of OT (group or individual)and/or one unit of PT (group or individual) foreach calendar month.

Providers should use the following procedureswhen assuming the insurance liability amount:

1. Do not submit claims to WisconsinMedicaid for the first occurring unit of OT(group or individual) or PT (group orindividual) during the calendar month.

Submit claims for the remaining OT and/orPT to Wisconsin Medicaid following theclaim instructions. When choosing thisoption, do not enter an “other insurance”indicator on the claim form.

2. Providers are required to document in thechild’s record the date(s) of service onwhich the unit of OT and/or PT wasprovided for which the SBS provider isassuming the cost of the insurance liability.

3. Providers should retain documentationindicating that they covered the standardmonthly insurance liability unit amount forOT and/or PT from a nonfederal source offunds, instead of billing the child’s healthinsurance.

Seek Payment from the Child’s CommercialHealth InsuranceInstead of assuming the cost of the child’scommercial health insurance liability, providersmay seek payment from the child’s commercialhealth insurance before seeking payment fromWisconsin Medicaid.

Under education law, providers are required toobtain parental permission to bill the child’scommercial health insurance for school-basedservices.

Federal education regulations allow parents ofa child with an IEP receiving school-basedservices to refuse consent to bill theircommercial health insurance if it results in acost to the family under the Individuals withDisabilities Education Act. Cost to the familyincludes any of the following:

• Reaching the lifetime limit on a policy.• An increase in premiums, copayments, or

deductibles.• Other negative consequences.

Providers may submit a claim to WisconsinMedicaid for remaining units not paid bycommercial health insurance.

Do Not Seek Payment from WisconsinMedicaid for Any ServicesFor children with commercial health insurancecovering OT and PT in a school setting, SBSproviders may choose to not seek paymentfrom Wisconsin Medicaid for these services.

FFor children withcommercial healthinsurance coveringOT and PT in aschool setting,SBS providers maychoose to notseek paymentfrom WisconsinMedicaid for theseservices.


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Using Billing Services,Billing Agents, or PrivateIndependent Consultants

Providers Using a Billing Service orBilling AgentProviders may either submit claims toWisconsin Medicaid directly or use a billingservice or agent to prepare and submit SBSclaims.

A billing service or agent cannot base paymentsfrom SBS providers on a commission basis, inwhich reimbursement to the billing service oragent is dependent on reimbursement fromWisconsin Medicaid. The billing service oragent may not be paid a percentage of thereimbursement received from WisconsinMedicaid. Providers may pay the billingservice or agent an hourly rate or a flat fee perweek or month.

Providers Contracting with PrivateIndependent ConsultantsProviders may use private consultants toprovide additional services other than ongoingMedicaid claims submissions. Typically, otherconsultant services are “up-front,” short-termactivities usually starting when a provider

initially plans for or begins a new program.Private consultant activities other than claimssubmission include nonroutine efforts to clarifythe amount and availability of Medicaidreimbursement for school-based services suchas:

• Discussions with the SBS provider aboutadditional services that might be claimed.

• Legal and other research regardingMedicaid covered services.

• Negotiation with state and federal officialsregarding expanded coverage.

Providers may pay for these consultant services(services other than Medicaid claimssubmission) based on a percentage of thereimbursement collected from WisconsinMedicaid, provided the consultant payment (ifusing the same consultant for billing) is billedand recorded separately from payment forclaim preparation and submission services.

Responsibility for ClaimsSchool-Based Services providers areresponsible for the accuracy, adherence toMedicaid policy, truthfulness, and completenessof all claims submitted, whether prepared andsubmitted by the provider or by a billingagency. In addition, private independentconsultants are not the final authority onWisconsin Medicaid policy.

AA billing service oragent cannot basepayments fromSBS providers on acommission basis,in whichreimbursement tothe billing serviceor agent isdependent onreimbursementfromWisconsin Medicaid.


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CClaims Submission

All claims, whether electronic or paper, aresubject to the same Medicaid policy and legalrequirements.

Electronic ClaimsSubmissionSchool-Based Services providers areencouraged to submit claims electronically.Electronic claims submission:

• Reduces processing time.• Eliminates manual handling of claims.• Reduces both billing and processing errors.

The Division of Health Care Financing(DHCF) offers electronic billing software at nocost to providers. To obtain the software,known as Provider Electronic Solutions (PES),providers should call the DHCF ElectronicData Interchange (EDI) Department at (608)221-9036, e-mail [email protected], orrequest the software from the Medicaid Website at dhfs.wisconsin.gov/medicaid/.

For further information about PES software,refer to the EDI section of the Medicaid Website.

Paper Claims SubmissionProviders submitting paper claims are requiredto use the CMS 1500 claim form (dated 12/90).Refer to Appendix 9 of this handbook for CMS1500 claim form completion instructions andAppendix 10 of this handbook for a completedsample claim form.

Wisconsin Medicaid denies claims for school-based services submitted on any paper claimform other than the CMS 1500 claim form.

Wisconsin Medicaid does not provide the CMS1500 claim form. It may be obtained from anyvendor that sells federal forms.

Where to Send Paper ClaimsProviders may mail completed CMS 1500paper claim forms for reimbursement to thefollowing address:

Wisconsin MedicaidClaims and Adjustments6406 Bridge RdMadison WI 53784-0002

Claims SubmissionDeadlineWisconsin Medicaid must receive properlycompleted claims within 365 days from the datethe service was provided. This policy applies toinitial claims submissions, resubmissions, andadjustment requests, with rare exceptions.

Exceptions to the 365-day claims submissiondeadline and requirements for submission toTimely Filing can be found in the ClaimsSubmission section of the All-ProviderHandbook.

SSchool-BasedServices (SBS)providers areencouraged tosubmit claimselectronically.


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RReimbursement

Wisconsin Medicaid currently reimbursesschool-based services (SBS) providers 60percent of federal funding for school-basedservices and allowable administrative costs. Theremaining 40 percent of federal funding isdeposited in the State General Fund because ofthe state’s contribution to special education inpublic schools.

Statewide rates are set by the Department ofHealth and Family Services for all coveredschool-based services. Federal matching ratesare published in Wisconsin Medicaid andBadgerCare Updates and on the WisconsinMedicaid Web site atdhfs.wisconsin.gov/medicaid/.

Certification ofExpendituresTo qualify for the full amount of federalMedicaid matching funds provided by the state,SBS providers are required to certify sufficientcertified expenditures. This demonstrates thata school district or Cooperative EducationalService Agency’s (CESA) expenditures andcosts are at least equal to the full Medicaidreimbursement included in federal andnonfederal funds.

If an adequate amount of expenditures are notcertified on the Certification of PublicExpenditures form, HCF 1003, and School-Based Services Matching Expenditures form,HCF 1004, Wisconsin Medicaid will recoverpayments received for this period. TheWisconsin Medicaid fee schedule for school-based services contains the contracted rate andis published in Updates.

Wisconsin Medicaid will send Certification ofPublic Expenditures forms to participatingschool districts and CESAs to be completedand returned annually.

Wisconsin Medicaid RequirementsSince the inception of the Wisconsin Medicaidbenefit for school-based services, Wisconsinlaw has required that all expenditures forschool medical services be incurred by theSBS provider, in order for the provider toreceive a portion of the federal Medicaidmatch.

Under HFS 105.53(4), Wis. Admin. Code,Wisconsin Medicaid requires that participatingproviders submit evidence annually that programrequirements for incurring SBS expenses havebeen met. School-Based Services providersare required to certify an accounting of thetotal expenditures for Medicaid-coveredservices provided to Medicaid-eligible children.

The Certification of Public Expenditures formmust indicate that the total local expendituresfor school-based services were at leastequivalent to the sum of the total number ofservices billed times the contracted rate foreach service during the fiscal year.

Submitting FormsSchool-Based Services expenditures must beidentified on the Certification of PublicExpenditures form and the School-BasedServices Matching Expenditures form.Providers are required to complete these formsannually and submit them to WisconsinMedicaid.

The Certification of Public Expenditures formcan be found in Appendix 1 of this handbook.The School-Based Services MatchingExpenditures Completion Instructions and formmay be found in Appendices 2 and 3 of thishandbook.

I If an adequateamount ofexpenditures arenot certified onthe Certification ofPublicExpenditures formand School-BasedServices MatchingExpendituresform, WisconsinMedicaid willrecover paymentsreceived for thisperiod.


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The forms must be signed by an authorizedrepresentative of the SBS provider and mustinclude the Medicaid provider number. Theforms may be submitted by fax to(608) 266-1096, to the attention of the SBSPolicy Analyst, or by mail to the followingaddress:

SBS Policy Analyst/Certification of PublicExpenditures

Division of Health Care FinancingPO Box 309Madison WI 53701-0309

The Centers for Medicare and MedicaidServices require that these forms be submittedto the Department of Health Care Financing.Under federal requirements, providerdocumentation verifying the amount ofcertified expenditures must be maintained bythe SBS provider for at least five years.

Federally FundedProvidersProviders whose positions are partiallyfederally funded may request reimbursementfrom Wisconsin Medicaid for school-basedservices. However, these providers may onlysubmit claims to Wisconsin Medicaid for theportion of their services that are locally funded.For example, a provider whose position is 50percent federally funded may submit claims foronly 50 percent of his or her services toWisconsin Medicaid. Wisconsin Medicaidrequires providers to keep appropriatedocumentation on file to substantiate theseclaims.

Wisconsin Medicaid does not reimburse forservices performed by providers whosepositions are entirely funded by federal dollars.


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AAppendix


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Appendix

Appendix 1Certification of Public Expenditures

(for photocopying)

(A copy of the Certification of Public Expenditures is located on the following page.)


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DEPARTMENT OF HEALTH AND FAMILY SERVICES STATE OF WISCONSINDivision of Health Care Financing Chapter 49.45(39)(b), Wis. Stats.HCF 1003 (Rev. 12/04)

WISCONSIN MEDICAIDCERTIFICATION OF PUBLIC EXPENDITURES

Wisconsin Medicaid requires certain information to enable Medicaid to authorize and pay for medical services provided to eligiblerecipients. The Certification of Public Expenditures form provides Wisconsin Medicaid with certification of expenditures by schooldistricts and Cooperative Educational Service Agencies (CESAs) for Medicaid-covered services. This form will be retained as part ofthe fiscal documentation for Wisconsin Medicaid.

The Certification of Public Expenditures is used by Wisconsin Medicaid and is a mandatory form. Failure to submit this form by the duedate certifying an adequate amount of expenditures may result in the recoupment of Medicaid payments.

Providers may submit the signed Certification of Public Expenditures by fax to (608) 266-1096 to the attention of the school-basedservices (SBS) Policy Analyst or by mail to the following address:

SBS Policy Analyst/Certification of Public ExpendituresDivision of Health Care FinancingPO Box 309Madison WI 53701-0309

For the purposes of this form, “Medicaid-covered school-based services” include the services identified in HFS 107.36, Wis. Admin.Code, and outlined in the School-Based Services Handbook.

SECTION I — PROVIDER INFORMATIONReport Period Wisconsin Medicaid Provider Identification Number

Name and Address — Provider

Wisconsin Medicaid records indicate that during the report period, Wisconsin Medicaid reimbursed this provider a total of

$___________________ in federal Medicaid funds, for the Medicaid-covered school-based services.

SECTION II — CERTIFICATION

This is to certify that:

• I am authorized to review, sign, and submit this form on behalf of this school district.

• This provider expended at least $___________________ in public funds for Medicaid-covered school-based services, provided toWisconsin Medicaid recipients during the report period. Further,

These public funds are not obligated to match other federal funds for any federal program.

These public funds are not federal funds, unless they are federal funds that are authorized by federal law to be used to matchother federal funds.

• Records documenting these public expenditures are on file and are available for review.

• I have reviewed the foregoing and certify that the information reported is true and correct to the best of my knowledge and belief.

SECTION III — SIGNATURE

SIGNATURE — Authorized Representative Date Signed

Name — Authorized Representative (print) Telephone Number — Authorized Representative

Title — Authorized Representative E-mail Address — Authorized Representative


Appendix

Appendix 2School-Based Services Matching Expenditures Completion Instructions

(for photocopying)

(A copy of the School-Based Services Matching Expenditures Completion Instructionsis located on the following pages.)ARCHIVAL USE ONLY

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DEPARTMENT OF HEALTH AND FAMILY SERVICES STATE OF WISCONSINDivision of Health Care FinancingHCF 1004A (Rev. 12/04)

WISCONSIN MEDICAIDSCHOOL-BASED SERVICES MATCHING EXPENDITURES COMPLETION INSTRUCTIONS

Wisconsin Medicaid requires certain information to enable Medicaid to authorize and pay for medical services provided to eligiblerecipients.

The information on the School-Based Services Matching Expenditures form is mandatory. The use of this form is voluntary andproviders may develop their own form to certify expenditures as long as it includes all the information on this form and looks exactly likethis form.

Providers may submit the completed School-Based Services Matching Expenditures form by fax to (608) 266-1096 to the attention ofthe school-based services (SBS) Policy Analyst or by mail to the following address:

SBS Policy Analyst/Certification of Public ExpendituresDivision of Health Care FinancingPO Box 309Madison WI 53701-0309

SECTION I — SCHOOL DISTRICT OR COOPERATIVE EDUCATIONAL SERVICES AGENCY INFORMATION

Provide the name and Medicaid provider identification number of the school district or Cooperative Educational Services Agency(CESA) that provided the school-based services. The report period should be based on the state fiscal year that runs from July 1st

through June 30th of the appropriate years.

SECTION II — DIRECT AND INDIRECT EXPENDITURES FOR SERVICES PROVIDED TO ALL RECIPIENTS

Element 1 — Direct ExpendituresProvide the direct expenses incurred in providing each type of service (columns A through G) to all recipients during the reportingperiod consistent with the guidelines in the federal Office of Management and Budget (OMB) Circular A-21. Direct expenses areexpenditures that can be identified specifically with each service provided. Direct expenses include expenses for employee salary andfringe benefits, allocated supervisory and administrative salary and fringe benefits, equipment, materials, supplies, allocated supportservices, physical space, and depreciation. Other types of expenses that can be directly attributed or allocated to each provided servicemay also be included.

Element 2 — Reimbursement ReceivedIn each column, provide the amount of federal reimbursement received for each type of service during the reporting period.

Element 3 — Direct Expend. Not ReimbursedIn each column, subtract the reimbursement amounts in Element 2 from the total direct expenditure amounts in Element 1. This amountindicates the direct expenditures incurred for providing the services that have not been reimbursed.

Element 4 — Indirect Allocation PercentIn each column, enter the unrestricted indirect cost percentage calculated using the Department of Public Instruction (DPI) localeducation agency (LEA) indirect rate worksheet. Attach a copy of the worksheet or indirect rate letter from the DPI.

Element 5 — Indirect ExpendituresIn each column, multiply the direct expenditures not reimbursed in Element 3 by the unrestricted indirect allocation percentage inElement 4. This amount indicates the indirect expenditures incurred for providing the services.

Element 6 — Total Direct and Indirect Expend.In each column, add the direct expenditures not reimbursed in Element 3 to the indirect expenditures in Element 5. This amountindicates the total of the direct expenditures not reimbursed and the indirect expenditures for providing the services.


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SCHOOL-BASED SERVICES MATCHING EXPENDITURES COMPLETION INSTRUCTIONS Page 2 of 2HCF 1004A (Rev.12/04)

SECTION III — ALLOCATION OF DIRECT AND INDIRECT EXPENDITURES FOR SERVICES PROVIDED TO WISCONSINMEDICAID RECIPIENTS

Element 7 — Units Provided to All StudentsIn each column, provide the number of units of service provided to all students for each type of service during the reporting period. Theunits of service are as follows:• Columns A through E — each unit of service is 15 minutes.• Column F — each unit of service is up to 20 miles (the transportation base rate).• Column G — each unit of service is one piece of equipment.

Optional Allocation BasisAlthough it is preferable that the allocation of expenditures to Wisconsin Medicaid be made on the basis of units of service, if thisinformation is not available for all students, the allocation ratio can be based on population. In this case, provide one of the following:• The number of Wisconsin Medicaid recipients receiving each service compared to the number of all students receiving each

service. In each column, provide the number of all students who received each type of service during the reporting period.• The number of Wisconsin Medicaid recipients receiving all services compared to the number of all students receiving all

services. In each column, provide the number of all students who received all services during the reporting period.

Element 8 — Units Prov. to Medicaid RecipientsIn each column, report the number of units of service provided to Wisconsin Medicaid recipients for each type of service during thereporting period. The units of service are as follows:• Columns A through E — each unit of service is 15 minutes.• Column F — each unit of service is up to 20 miles (the transportation base rate).• Column G — each unit of service is one piece of equipment.

Optional Allocation BasisAlthough it is preferable that the allocation of expenditures be made on the basis of units of service, if this information is notavailable for all students, the allocation ratio can be based on population. In this case, provide one of the following:• The number of Wisconsin Medicaid recipients receiving each service compared to the number of all students receiving each

service. In each column, provide the number of Wisconsin Medicaid recipients who received each type of service during the reporting period.

• The number of Wisconsin Medicaid recipients receiving all services compared to the number of all students receiving all services. In each column, provide the number of Wisconsin Medicaid recipients who received all services during the reporting period.

Element 9 — Medicaid Allocation PercentIn each column, divide the number of units provided to Wisconsin Medicaid recipients (or the number of Wisconsin Medicaid recipientsreceiving each service) on Line 8 by the number of units provided to all students (or the number of all students receiving each service.)The percentage should be rounded to at least two decimal points (i.e., 11.25 percent or .1125.)

Element 10 — Allocated ExpendituresIn each column, multiply the total direct and indirect expenditures in Element 6 by the Medicaid allocation percentage in Element 9. Thisamount indicates the direct and indirect expenditures that can be allocated to Wisconsin Medicaid.

Element 11 — TOTAL Columns A through GAdd the expenditures in Columns A through G in Element 10. This amount indicates the total amount of Medicaid expenditures that willbe certified on the Certification of Public Expenditures form, HCF 1003.

SECTION IV — CALCULATION OF REQUIRED DISTRICT MATCH

Element 12 — Match PercentIn each column, provide the required district match percentage for the reporting period.

Element 13 — TOTALIn each column, multiply the allocated expenditures in Element 10 with the required district match percentage in Element 12. This totalindicates the amount of expenditures available to match federal Medicaid funding for each type of school-based service provided.

Element 14 — TOTAL Columns A through GAdd the expenditures in columns A through G in Element 13. This total indicates the amount of expenditures that are available to matchfederal Medicaid funding. This amount is for the school district or CESA’s information only.


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Appendix

Appendix 3School-Based Services Matching Expenditures

(for photocopying)

(A copy of the School-Based Services Matching Expenditures is located on thefollowing page.)


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DEPARTMENT OF HEALTH AND FAMILY SERVICES STATE OF WISCONSINDivision of Health Care FinancingHCF 1004 (Rev. 12/04)

WISCONSIN MEDICAID

SCHOOL-BASED SERVICES MATCHING EXPENDITURES

SECTION I — SCHOOL DISTRICT OR COOPERATIVE EDUCATIONAL SERVICES AGENCY INFORMATION

Name — School District or Cooperative Educational Service Agency Medicaid Provider Number

Report Period Start Date Report Period End Date Name — Preparer Date Prepared

SECTION II — DIRECT AND INDIRECT EXPENDITURES FOR SERVICES PROVIDED TO ALL RECIPIENTS

COLUMN A

SPEECHTHERAPY

COLUMN B

OCCUPATIONALTHERAPY

COLUMN C

PHYSICALTHERAPY

COLUMN D

PSYCH. COUNSEL.SOCIAL WORK

COLUMN E

NURSING

COLUMN F

TRANSPORTATION

COLUMN G

DURABLEMEDICAL EQUIP.

1. Direct Expenditures $ $ $ $ $ $ $

2. Reimbursement Received $ $ $ $ $ $ $

3. Direct Expend. Not Reimbursed $ $ $ $ $ $ $

4. Indirect Allocation Percent % % % % % % %

5. Indirect Expenditures $ $ $ $ $ $ $

6. Total Direct and Indirect Expend. $ $ $ $ $ $ $

SECTION III — ALLOCATION OF DIRECT AND INDIRECT EXPENDITURES FOR SERVICES PROVIDED TO WISCONSIN MEDICAID RECIPIENTS

COLUMN A COLUMN B COLUMN C COLUMN D COLUMN E COLUMN F COLUMN G

7. Units Provided to All Students

8. Units Prov. to Medicaid Recipients

9. Medicaid Allocation Percent % % % % % % %

10. Allocated Expenditures $ $ $ $ $ $ $

11. TOTAL Columns A – G (Enter this amount on the Certification of Public Expenditures form [HCF 1003]) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _______________

SECTION IV — CALCULATION OF REQUIRED DISTRICT MATCH

COLUMN A COLUMN B COLUMN C COLUMN D COLUMN E COLUMN F COLUMN G

12. Match Percent % % % % % % %

13. TOTAL $ $ $ $ $ $ $

14. TOTAL Columns A – G (Expenditures available for matching federal Medicaid funding) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _______________

For Office Use Only Name — Provider Report Period


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Appendix

Appendix 4Sample Memorandum of Understanding Between HMO and Medicaid-Certified

School District, CESA, CCDEB, or Charter School for theSchool-Based Services Benefit

(The Sample Memorandum of Understanding Between HMO and Medicaid-CertifiedSchool District, CESA, CCDEB, or Charter School for the School-Based Services Benefit is

located on the following page.)


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SAMPLE MEMORANDUM OF UNDERSTANDING BETWEENHMO AND MEDICAID-CERTIFIED SCHOOL DISTRICT, CESA, CCDEB,

OR CHARTER SCHOOLFOR THE SCHOOL-BASED SERVICES BENEFIT

School-Based Services (SBS) is a benefit paid fee-for-service by Wisconsin Medicaid for all school-enrolled recipients, includingthose enrolled in HMOs. The SBS provider is responsible for services listed in a child’s Individualized Education Program (IEP),which includes occupational, physical, and speech therapies, nursing services, mental health services, and testing serviceswhen provided by the SBS provider. HMOs are responsible for providing and managing medically necessary services outsideschool settings. However, there are some situations in which schools cannot provide services, such as after school hours,during school vacations, and during the summer. Therefore, avoidance of duplication of services and promotion of continuity ofcare for Medicaid and BadgerCare HMO recipients requires cooperation, coordination, and communication between the HMOand the SBS provider.

The HMO and the SBS provider agree to facilitate effective communication between agencies, to work to resolve interagencycoordination and communication problems, and to inform staff from both the HMO and the SBS provider about the policies andprocedures for this cooperation, coordination, and communication. Recognizing that these “clients-in-common” could receiveduplicate services and could suffer with problems in continuity of care (e.g., when the school year ends in the middle of a seriesof treatments), the HMO and the SBS provider agree to cooperate in communicating information about the provision of servicesand in coordinating care.

This agreement becomes effective on the date the SBS provider is certified by Wisconsin Medicaid or on the date when both theHMO and the SBS provider have signed the agreement, whichever is later. It may be terminated in writing with two weeks’notice by either signer. The SBS provider may be a school district, Cooperative Educational Service Agency (CESA), CountyChildren with Disabilities Education Board (CCDEB), charter school, the Wisconsin School for the Deaf, or the Wisconsin Schoolfor the Visually Handicapped.

HMO Contract for (Year)

Name — HMO

Title — Authorized HMO Representative Telephone Number — Authorized HMO Representative

SIGNATURE — Authorized HMO Representative Date Signed

Name — SBS Provider (school)

Title — Authorized SBS Provider Representative Telephone Number — Authorized SBS Provider Representative

SIGNATURE — Authorized SBS Provider Representative Date Signed


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Appendix 5Letter of Consent to Request Reimbursement from Wisconsin Medicaid

(Optional)

(The Letter of Consent to Request Reimbursement from Wisconsin Medicaid is located onthe following page.)ARCHIVAL USE ONLY


Dear Parents:

Through the Medicaid school-based services (SBS) benefit, ________________________________________ schooldistrict may submit claims to Wisconsin Medicaid for covered services provided to Medicaid-eligible children enrolled inspecial education programs. These services include: nursing services, physical therapy, occupational therapy, or speechand language pathology services, specialized medical vehicle transportation, durable medical equipment, psychologicalservices, counseling, social work services, and developmental testing and assessment. The program is intended to increasefederal funding for special education services provided in Wisconsin schools.

Please complete and return one copy of this form in the self-addressed envelope that is included so that the school districtmay obtain Wisconsin Medicaid eligibility information and, if appropriate, file claims with Wisconsin Medicaid forreimbursement of services provided to your child. Keep the second copy for your files.

If you have questions, please contact me at:___________________________________.

Sincerely,

______________________________________________________ (name and title of school district contact person)

I, the undersigned, hereby request and authorize _______________________________________________ school districtto release to Wisconsin Medicaid the following information:

Official student academic/administrative records (identifying information, grade level completed, grades, classrank, attendance records, and group aptitude and achievement test results).

Medical and/or related health records.

Psychological evaluations and related reports.

Appropriate agency reports.

Individualized Education Program.

Other (specify)_____________________________________________________________________________.

CONSENTING FOR THE SCHOOL DISTRICT TO BILL FOR WISCONSIN MEDICAID SCHOOL-BASEDSERVICES

I understand that:

• My consent to release this information is voluntary.• My approval will not result in denial or limitation of community-based services provided outside the school.• My refusal to consent will not result in denial or limitation of services for my child.• This permission is valid for one year from the date signed.• A copy of this form is as effective as the original.

Child’s Name_____________________________________________________ Date of Birth______________________

Parent’s Signature__________________________________________________ Date Signed_______________________

Please return this signed form to the school no later than _______________________________.


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Appendix

Appendix 6Department of Public Instruction and Department of Regulation and

Licensing Prescription Requirements for ProvidingSchool-Based Services in the School Setting

ServiceCurrent School-BasedServices PrescriptionRequirements1

Waiver School-BasedServices PrescriptionRequirements2,3

Other Key School-Based ServicesRequirements

Speech and languagepathology, audiology, andhearing services

Annual prescription by aphysician.

No prescriptionrequirements.

Services must be identifiedin the child’s IndividualizedEducation Program (IEP).

Occupational therapy Annual prescription by aphysician.


Services must be identifiedin the child’s IEP.

Physical therapy Annual prescription by aphysician.

Prescription only requiredunder limitedcircumstances as requiredby the DR&L.


Nursing services

Annual prescription by aphysician or a health careprofessional withprescribing authority.

Annual prescription by aphysician or a health careprofessional withprescribing authority.


Psychological counselingand social work services

Annual prescription by aphysician or licensed Ph.D.psychologist.



Other developmentaltesting and assessments



The activities must resultin the development orrevision of an IEP.

Transportation No prescriptionrequirements.


Transportation must beincluded in the IEP andprovided on the same daythat the child receivesanother Medicaid-coveredschool-based service.

Durable medicalequipment (DME)



The equipment must:• Be medically necessary.• Be child specific.• Be identified in the IEP.• Belong to the child to

use at school and athome.

• Not be covered underthe Wisconsin MedicaidDME benefit.

1 Based on Department of Regulation and Licensing (DR&L) requirements. If DR&L prescription requirements changefor schools, Wisconsin Medicaid automatically adopts those new requirements.

2 The waiver requirements are based on the Department of Public Instruction (DPI) requirements. If DPI prescriptionrequirements change for schools, Wisconsin Medicaid automatically adopts those new requirements.

3 School-Based Services (SBS) providers choosing the waiver option must ensure that the services billed under theSBS benefit meet the necessary requirements for school-based services and are covered services under the SBSbenefit.


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Appendix

Appendix 7Request for a Waiver to Wisconsin Medicaid Prescription Requirements

Under the School-Based Services Benefit(for photocopying)

(A copy of the Request for a Waiver to Wisconsin Medicaid Prescription RequirementsUnder the School-Based Services Benefit is located on the following page.)


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DEPARTMENT OF HEALTH AND FAMILY SERVICES STATE OF WISCONSINDivision of Health Care Financing HFS 106.13, Wis. Admin. CodeHCF 1134 (Rev. 12/04)

WISCONSIN MEDICAIDREQUEST FOR A WAIVER TO WISCONSIN MEDICAID PRESCRIPTION REQUIREMENTS

UNDER THE SCHOOL-BASED SERVICES BENEFIT

Name — School-Based Services (SBS) Provider Wisconsin Medicaid Provider Number

The SBS provider named above requests a waiver under HFS 106.13, Wis. Admin. Code, for the requirement for obtaining

prescriptions under the SBS benefit, following HFS 105.53(2) and 107.36(1) and (2), Wis. Admin. Code, for the following services

(check all that apply):

Speech and language pathology, audiology, and hearing services.

Physical therapy services.

Occupational therapy services.

Psychological services, counseling, and social work services.

Under this waiver, the SBS provider is required to do all of the following:

• Continue to meet the Department of Public Instruction and Department of Regulation and Licensing standards for prescriptions for

services provided to children in the school setting under the SBS benefit.

• Notify the child’s HMO, physician, physician specialist, physician assistant, or nurse practitioner regarding the services the child

obtains under the SBS benefit at least annually. This activity must be documented in the child’s record.

• Document communication with other Medicaid providers at least annually when a child receives similar services from other

Medicaid providers. The communication must be documented in the child’s record and copies of the child’s Individualized

Education Program must be supplied to other providers when requested.

• Coordinate care with managed care organizations through Memorandums of Understanding as currently required under the SBS

benefit.

Name — SBS Provider Authorized Representative (Type or Print)

SIGNATURE — SBS Provider Authorized Representative Date Signed

The SBS provider requests this waiver from the Wisconsin Division of Health Care Financing for

services provided on and after the following date until this requirement is eliminated through a

Wisconsin Administrative Code change.

Effective Date of WaiverRequest


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Appendix

Appendix 8Wisconsin Medicaid School-Based Services Fact Sheet

(The Wisconsin Medicaid School-Based Services Fact Sheet is located on the followingpage.)ARCHIVAL USE ONLY


Wisconsin.gov

PHC 1148 (12/04)

DIVISION OF HEALTH CARE FINANCINGWISCONSIN MEDICAID AND BADGERCARE

RECIPIENT SERVICES6406 BRIDGE ROAD

MADISON WI 53784Jim Doyle Telephone: 800-362-3002

Governor TTY: 800-362-3002State of Wisconsin FAX: 608-221-8815

Helene Nelson dhfs.wisconsin.gov/medicaidSecretary Department of Health and Family Services dhfs.wisconsin.gov/badgercare

WISCONSIN MEDICAID SCHOOL-BASED SERVICES FACT SHEET

The Wisconsin Medicaid school-based services (SBS) benefit is a way for school districts andCooperative Educational Service Agencies (CESAs) to receive more federal funds to help payfor medically related special education and associated services. Obtaining reimbursementfrom Wisconsin Medicaid for these services helps your school district receive more money foryour school’s budget. In 2004, Wisconsin schools received approximately $20.1 million fromWisconsin Medicaid for school-based services.

Under the SBS benefit:

• School districts, CESAs, County Children with Disabilities Education Boards, andcharter schools can seek reimbursement from Wisconsin Medicaid for school-basedservices, such as speech and language therapy, occupational therapy, and nursingservices, if the services are included in the child’s Individualized Education Program(IEP).

• Whether or not your child’s school district seeks Wisconsin Medicaid reimbursementfor school-based services does not influence approval or denial of prior authorization(PA) requests for community (non-school-based services) therapies.

Parents should note that Wisconsin Medicaid medical consultants who review PA requests forcommunity therapies:

• Do not review SBS claims data.

• Approve community therapy based on medical necessity and not on financiallimitations.

• Review each child’s IEP and any other information regarding therapies received atthe school, in the home, or elsewhere when community (non-school-based services)services are requested, regardless of whether or not the school seeks SBSreimbursement. Consultants must review the services your child is currently receivingso that Wisconsin Medicaid does not reimburse for unnecessary services.

Wisconsin Medicaid requires schools and other health care providers to work together toensure that your child receives coordinated services.


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Appendix

Appendix 9CMS 1500 Claim Form Completion Instructions

Use the following claim form completion instructions, not the claim form’s printed descriptions, to avoid denial or inaccurateMedicaid claim payment. Complete all required elements as appropriate. Do not include attachments unless instructed to doso.

Wisconsin Medicaid recipients receive a Medicaid identification card upon being determined eligible for Wisconsin Medicaid.Always verify a recipient’s eligibility before providing nonemergency services by using the Eligibility Verification System (EVS)to determine if there are any limitations on covered services and to obtain the correct spelling of the recipient’s name. Refer tothe Provider Resources section of the All-Provider Handbook or the Medicaid Web site at dhfs.wisconsin.gov/medicaid/ formore information about the EVS.

Element 1 — Program Block/Claim Sort IndicatorEnter claim sort indicator “M” in the Medicaid check box for the service billed.

Element 1a — Insured’s I.D. NumberEnter the recipient’s 10-digit Medicaid identification number. Do not enter any other numbers or letters. Use the Medicaididentification card or EVS to obtain the correct identification number.

Element 2 — Patient’s NameEnter the recipient’s last name, first name, and middle initial. Use the EVS to obtain the correct spelling of the recipient’sname. If the name or spelling of the name on the Medicaid identification card and the EVS do not match, use the spelling fromthe EVS.

Element 3 — Patient’s Birth Date, Patient’s SexEnter the recipient’s birth date in MM/DD/YY format (e.g., February 3, 1995, would be 02/03/95) or in MM/DD/YYYYformat (e.g., February 3, 1995, would be 02/03/1995). Specify if male or female by placing an “X” in the appropriate box.

Element 4 — Insured’s Name (not required)

Element 5 — Patient’s Address (not required)

Element 6 — Patient Relationship to Insured (not required)

Element 7 — Insured’s Address (not required)

Element 8 — Patient Status (not required)

Element 9 — Other Insured’s NameCommercial health insurance must be billed prior to submitting claims to Wisconsin Medicaid, unless the service does notrequire commercial health insurance billing as determined by Wisconsin Medicaid. Refer to the Coordination of Benefitssection of this handbook for more information.

If the EVS indicates that the recipient has dental (“DEN”) insurance only or has no commercial health insurance, leaveElement 9 blank.


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If the EVS indicates that the recipient has Wausau Health Protection Plan (“HPP”), BlueCross & BlueShield (“BLU”),Wisconsin Physicians Service (“WPS”), TriCare (“CHA”), or some other (“OTH”) commercial health insurance, andthe service requires other insurance billing according to the Coordination of Benefits section of the All-ProviderHandbook, then one of the following three other insurance (OI) explanation codes must be indicated in the first box ofElement 9. The description is not required, nor is the policyholder, plan name, group number, etc. (Elements 9a, 9b, 9c,and 9d are not required.)

Note: The provider may not use OI-D or OI-Y if the recipient is covered by a commercial HMO and the HMOdenied payment because an otherwise covered service was not rendered by a designated provider. Servicescovered by a commercial HMO are not reimbursable by Wisconsin Medicaid except for the copayment anddeductible amounts. Providers who receive a capitation payment from the commercial HMO may not billWisconsin Medicaid for services that are included in the capitation payment.

Element 10 — Is Patient’s Condition Related to (not required)

Element 11 — Insured’s Policy, Group, or FECA Number (not required)

Elements 12 and 13 — Authorized Person’s Signature (not required)

Element 14 — Date of Current Illness, Injury, or Pregnancy (not required)

Element 15 — If Patient Has Had Same or Similar Illness (not required)

Element 16 — Dates Patient Unable to Work in Current Occupation (not required)

Elements 17 and 17a — Name and I.D. Number of Referring Physician or Other Source (notrequired)

Element 18 — Hospitalization Dates Related to Current Services (not required)

Element 19 — Reserved for Local Use (not required)

Element 20 — Outside Lab? (not required)

Appendix 9(Continued)

Code DescriptionOI-P PAID by commercial health insurance. In Element 29 of this claim form, indicate the amount paid

by commercial health insurance to the provider or to the insured.OI-D DENIED by commercial health insurance or commercial HMO following submission of a correct

and complete claim, or payment was applied towards the coinsurance and deductible. Do not usethis code unless the claim was actually billed to the commercial health insurer.

OI-Y YES, the recipient has commercial health insurance or commercial HMO coverage, but it was notbilled for reasons including, but not limited to:

The recipient denied coverage or will not cooperate. The provider knows the service in question is not covered by the carrier. The recipient’s commercial health insurance failed to respond to initial and follow-up claims. Benefits are not assignable or cannot get assignment. Benefits are exhausted.


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Element 21 — Diagnosis or Nature of Illness or InjuryEnter International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code999.9.

Element 22 — Medicaid Resubmission (not required)

Element 23 — Prior Authorization Number (not required)

Element 24A — Date(s) of ServiceEnter the month, day, and year for each procedure using the following guidelines:

• When billing for one date of service (DOS), enter the date in MM/DD/YY or MM/DD/YYYY format in the “From”field.

• When billing for two, three, or four DOS on the same detail line, enter the first DOS in MM/DD/YY or MM/DD/YYYY format in the “From” field, and enter the subsequent DOS in the “To” field by listing only the date(s) of themonth (e.g., DD, DD/DD, or DD/DD/DD). For example, for DOS on December 1, 8, 15, and 22, 2003, indicate 12/01/03 or 12/01/2003 in the “From” field and indicate 08/15/22 in the “To” field.

It is allowable to enter up to four DOS per line if:

• All DOS are in the same calendar month.• All services are billed using the same procedure code and modifier, if applicable.• The same diagnosis is applicable for each procedure.• The charge for all procedures is identical. (Enter the total charge per detail line in Element 24F.)• The number of services performed on each DOS is identical.• All procedures have the same family planning indicator, if applicable.

Element 24B — Place of ServiceEnter place of service (POS) code “03” (school) for each service listed. This is the only allowable POS code for school-basedservices (SBS).

Element 24C — Type of Service (not required)

Element 24D — Procedures, Services, or SuppliesEnter the single most appropriate five-character Current Procedural Terminology (CPT) code or Healthcare CommonProcedure Coding System (HCPCS) code. Wisconsin Medicaid denies claims received without an appropriate CPT orHCPCS procedure code. Refer to Appendix 12 of this handbook for a complete list of procedure codes.

ModifiersEnter the appropriate modifier(s) in the “Modifier” column of Element 24D. Use a comma(s) to separate morethan one modifier. Refer to Appendix 11 of this handbook for a list of valid modifiers.

Element 24E — Diagnosis CodeEnter the number (1, 2, 3, or 4) that corresponds to the appropriate ICD-9-CM diagnosis code listed in Element 21.

Element 24F — $ ChargesEnter the total charge for each line item. For example, multiply the rate by the number of SBS units for each line.



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Element 24G — Days or UnitsEnter the appropriate number of units for each line item. Always use a decimal (e.g., 2.0 units). Refer to Appendices13 and 20 of this handbook for units of services.

Element 24H — EPSDT/Family Planning (not required)

Element 24I — EMG (not required)

Element 24J — COB (not required)

Element 24K — Reserved for Local Use (not required)

Element 25 — Federal Tax I.D. Number (not required)

Element 26 — Patient’s Account No. (not required)Optional — Providers may enter up to 20 characters of the recipient’s internal office account number. This numberwill appear on the Remittance and Status Report and/or the 835 Health Care Claim Payment/Advice electronictransaction.

Element 27 — Accept Assignment (not required)

Element 28 — Total ChargeEnter the total charges for this claim.

Element 29 — Amount PaidEnter the actual amount paid by commercial health insurance. (If the dollar amount indicated in Element 29 is greaterthan zero, “OI-P” must be indicated in Element 9.) If the commercial insurance denied the claim, enter “000.” Do notenter Medicare-paid amounts in this field.

Element 30 — Balance DueEnter the balance due as determined by subtracting the amount paid in Element 29 from the amount in Element 28.

Element 31 — Signature of Physician or SupplierThe provider or the authorized representative must sign in Element 31. The month, day, and year the form is signed mustalso be entered in MM/DD/YY or MM/DD/YYYY format.

Note: The signature may be a computer-printed or typed name and date or a signature stamp with the date.

Element 32 — Name and Address of Facility Where Services Were Rendered (not required)

Element 33 — Physician’s, Supplier’s Billing Name, Address, ZIP Code, and Phone #Enter the name of the provider (exactly as indicated on the provider’s notification of certification letter) submitting theclaim and the complete mailing address. The minimum requirement is the provider’s name, city, state, and ZIP code. Atthe bottom of Element 33, enter the billing provider’s eight-digit Medicaid provider number.



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Appendix

Appendix 10Sample CMS 1500 Claim Form for School-Based Services

M 1234567890

Recipient, Ima A. MM DD YYYY

999.9

11 03 03 05 07 03 97110 TM GP 1 XX XX 6.0

11 06 03 03 92506 TM 1 XX XX 1.5

1234JED XX XX 0 00 XX XX

MM/DD/YYYY

I.M. Billing1 W. WilliamsAnytown, WI 55555 12345678

X


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Appendix 11Modifiers for School-Based Services

The following table lists the nationally recognized modifiers that providers are required to use when submitting claims forschool-based services. Modifiers are used to identify Individualized Education Programs (IEP) and/or the type of servicethat was performed.

Modifier Description

TM Individualized Education Program (IEP)

GO Services delivered under an outpatient occupational therapy plan of care

GP Services delivered under an outpatient physical therapy plan of care

UA M-team assessment and IEP, other staff

U1 M-team assessment and IEP, psychological service

U2 Individual IEP, psychological service

U3 Group IEP, psychological service

U4 M-team assessment and IEP counseling service

U5 Individual IEP, counseling service

U6 Group IEP, counseling service

U7 M-team assessment and IEP, social work service

U8 Individual IEP, social work service

U9 Group IEP, social work service


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Appendix 12Procedure Codes for School-Based Services

The following table lists the Current Procedural Terminology and Healthcare Common Procedure Coding Systemprocedure codes that providers are to use when submitting claims for school-based services. Providers will need to includethe appropriate modifier(s) for each procedure code as indicated in the table. If more than one modifier is listed, providerswill be required to include all modifiers listed when submitting a claim, or the claim detail line may be denied. Refer toAppendix 11 of this handbook for modifier descriptions.

ProcedureCode

Procedure Code Description RequiredModifier(s)

Speech and Language Pathology, Audiology, and Hearing Services92506 Evaluation of speech, language, voice, communication, auditory processing,

and/or aural rehabilitation statusTM

92507 Treatment of speech, language, voice, communication, and/or auditoryprocessing disorder (includes aural rehabilitation); individual

TM

92508 group, two or more individuals TM

Occupational Therapy Services97003 Occupational therapy evaluation TM97110 Therapeutic procedure, one or more areas, each 15 minutes; therapeutic

exercises to develop strength and endurance, range of motion andflexibility

TMGO

97150 Therapeutic procedure(s), group (2 or more individuals) TMGO

Physical Therapy Services97001 Physical therapy evaluation (per 15 min) TM97110 Therapeutic procedure, one or more areas, each 15 minutes; therapeutic

exercises to develop strength and endurance, range of motion andflexibility

TMGP

97150 Therapeutic procedure(s), group (2 or more individuals) TMGP

Psychological ServicesT1024 Evaluation and treatment by an integrated, specialty team contracted to

provide coordinated care to multiple or severely handicapped children, perencounter (Short description: team evaluation & management)

U1

T1024 Evaluation and treatment by an integrated, specialty team contracted toprovide coordinated care to multiple or severely handicapped children, perencounter (Short description: team evaluation & management)

U2


U3

Counseling ServicesT1024 Evaluation and treatment by an integrated, specialty team contracted to


U4


U5


U6


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ProcedureCode

Procedure Code Description RequiredModifier(s)

Social Work Services


U7


U8


U9

Nursing Services

T1001 Nursing assessment/evaluation TMT1002 RN* services, up to 15 minutes TMT1003 LPN**/LVN*** services, up to 15 minutes TM

Team Assessment and Individualized Education Program Plan Development by Other School StaffT1024 Evaluation and treatment by an integrated, specialty team contracted to


UA

Durable Medical EquipmentE1399 Durable medical equipment, miscellaneous TM

Special Transportation ServicesT2003 Non-emergency transportation; encounter/trip TMA0425 Ground mileage, per statue mile TM* RN — Registered nurse.

** LPN — Licensed practical nurse.*** LVN — Licensed vocational nurse.


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Appendix

Appendix 13Conversion Chart for Wisconsin Medicaid Nursing Services Reimbursement

The following table lists the units for various services nurses provide.

Individualized Education Program (IEP) Nursing Services: Care and Treatment

Medications Standardized Average Nursing Service UnitsBillable to Wisconsin Medicaid

G-tube medication 1.0 unit per medicationOral medication 0.5 units per medicationInjectable medication 1.0 unit per medicationEye drops 0.5 units per medicationIntravenous medications 2.0 units per taskTopical medications 0.5 units per taskRectal medications 1.0 unit per task

Other Nursing Tasks Standardized Average Nursing Service UnitsBillable to Wisconsin Medicaid

G-tube feeding 2.0 units per taskVenting G-tube 0.5 units per taskIntermittent catheterization 2.0 units per taskTracheotomy care 2.0 units per taskOstomy care 1.0 unit per taskHand-held nebulization 0.5 units per taskAerosol machine nebulization 2.0 units per taskBlood glucose 1.0 unit per taskSuctioning 1.0 unit per taskContinuous oxygen (i.e., time for filling tank) 0.5 units per taskDressing changes 1.0 unit per taskChest physiotherapy 2.0 units per taskVital signs 1.0 unit per task

Vital signs assessment* 1.0 unit per taskRegistered nurse — acute problem assessment* 2.0 units per taskPro re nata (PRN) oxygen 0.5 units per task

Nursing Services: Face-to-face and IEP Team Assessment and Plan Development

Face-to-face and IEP Team Assessment andPlan Development

Standardized Average Nursing Service UnitsBillable to Wisconsin Medicaid

Initial IEP team assessment* 12 units per taskRe-evaluation for IEP team* 8 units per taskNursing development testing and assessment* 4 units per taskIEP plan development/IEP team-related activities* 4 units per task

*These tasks can only be performed by a qualified nurse and cannot be delegated.


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Appendix 14Sample Optional School-Based Services Activity Log

Nursing/Therapy Medical Services (time method)

(A sample Optional School-Based Services Activity Log Nursing/Therapy MedicalServices [time method] is located on the following page.)


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DEPARTMENT OF HEALTH AND FAMILY SERVICESDivision of Health Care FinancingHCF 1198 (Rev. 12/04)

STATE OF WISCONSIN

WISCONSIN MEDICAID

OPTIONAL SCHOOL-BASED SERVICES ACTIVITY LOGNURSING / THERAPY MEDICAL SERVICES

Name — Student (Last, First, MI)

Student, Ima G.

Name — School

Wisconsin Elementary

Method Used (Circle One)

Time Task

Date ofService

(MM/DD/YY)

GeneralService

Category

Unit ofService(Time or

Units)

Group orIndividual

Describe SpecificServices Performed

Student's Response/Progress

Initials orSignature*

(Of Person WhoPerformedService)

10/12/04 nursing 10 a.m. -10:15 a.m.

(15minutes)

Individual Post-seizure observation Alert and oriented x3 Ima Provider

10/14/04 nursing 3 times, 5minuteseach (15minutes)

Timesbetween 11

a.m. and

3 p.m.

Individual Transferring onto toilet N/A Ima Provider

10/14/04 nursing 3 times, 5minuteseach (15minutes)

Timesbetween 11

a.m. and

3 p.m.

Individual Transferring off of toilet N/A Ima Provider

*Initials Key Signatures — Corresponding Staff Date Signed (MM/DD/YY)

Therapy services only:

A. Does the recipienthave insurance?

Yes No

(If yes, go to B. If no,stop.)

B. Is there an insuranceexclusionary clause forall school-basedservices?

Yes No

(If yes, insurance liabilitydoes not apply. If no ordo not know, go to C.)

C. Check the option selected:

Option 1: School assuming insurance liability. (Subtract the first occurring unit of occupational therapy [OT] [group or individual] and/or physical therapy [PT] [groupor individual] during the calendar month from the monthly claim for services. Bill the remaining services to Wisconsin Medicaid. Do not indicate an "other insurance"disclaimer code in Element 9 of the CMS 1500 claim form.)

Option 2: School seeking insurance payment for OT (group or individual) and/or PT (group or individual). Schools must have parental permission for this option.

Option 3: School not seeking Medicaid payment for OT (group or individual) and/or PT (group or individual).


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Medication Administration (time method)

(A sample Optional School-Based Services Activity Log Medication Administration [timemethod] is located on the following page.)ARCHIVAL USE ONLY


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STATE OF WISCONSIN

WISCONSIN MEDICAID

OPTIONAL SCHOOL-BASED SERVICES ACTIVITY LOGMEDICATION ADMINISTRATION


Student, Ima G.

Name — School



Time Task

Date ofService

(MM/DD/YY)Medication Name and Dose Route

TimeAdministered

(Time or Units)

TookMedication

WithoutDifficulty?(Yes or No)

Notes(All Exceptions Must

Be Noted)


(Of Person WhoAdministeredMedication)

10/12/04 Sustacal, 250 ml., fourtimes a day followed by a

50 cc H20 flush

G-tubefeeding

8 a.m. - 8:30a.m.

(30 minutes)

Yes N/A I.N.

10/13/04 Sustacal, 250 ml., followedby a 50 cc H20 flush

G-tubefeeding

2 times, 30minutes each(60 minutes)

11 a.m. -11:30 a.m.

and

2 p.m. - 2:30p.m.

Yes N/A I.N.


I.N. Ima Nurse 10/14/03Under Standards of Practice for Registered Nurses, ch. N6.03, Wis. Admin. Code, only registered nurses (RNs) maydelegate services to medically unlicensed individuals. Fordelegated nursing services under the school-based servicesbenefit, the RN responsible for delegating the services mustagree to the delegation of the service and is responsible forsupervision of the delegatee.


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Nursing/Therapy Medical Services (task method)

(A sample Optional School-Based Services Activity Log Nursing/Therapy MedicalServices [task method] is located on the following page.)ARCHIVAL USE ONLY Refer to the Online Handbook

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STATE OF WISCONSIN

WISCONSIN MEDICAID



Student, Ima G.

Name — School



Time Task

Date ofService

(MM/DD/YY)

GeneralService

Category


Units)

Group orIndividual





10/12/04 nursing 3 times,

9 a.m., 12p.m., and 3

p.m.

(1.5 units)

Individual Eye drops instilled Excessive redness Ima Provider




Yes No



Yes No







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Medication Administration (task method)

(A sample Optional School-Based Services Activity Log Medication Administration [taskmethod] is located on the following page.)ARCHIVAL USE ONLY


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STATE OF WISCONSIN

WISCONSIN MEDICAID



Student, Ima G.

Name — School



Time Task

Date ofService


TimeAdministered

(Time or Units)

TookMedication



Be Noted)



10/12/04 Tegretol, 100 mg Oral 8 a.m. and

2 p.m.,

2 times

(2 x .5 units =1 unit)

No Difficulty swallowing, swallowed after severalattempts both times. I.N.

10/13/04 Tegretol, 100 mg Oral 12 p.m. and

4 p.m.,

2 times

(2 x .5 units =1 unit)

Yes N/A I.N.


I.N. Ima Nurse 10/14/04

Under Standards of Practice for Registered Nurses, ch. N6.03, Wis. Admin. Code, only registered nurses (RNs) maydelegate services to medically unlicensed individuals. Fordelegated nursing services under the school-based servicesbenefit, the RN responsible for delegating the services mustagree to the delegation of the service and is responsible forsupervision of the delegatee.


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Appendix

Appendix 18Optional School-Based Services Activity Log

Nursing/Therapy Medical Services(for photocopying)

(A copy of the Optional School-Based Services Activity Log Nursing/Therapy MedicalServices is located on the following page.)ARCHIVAL USE ONLY



STATE OF WISCONSIN

WISCONSIN MEDICAID


Name — Student (Last, First, MI) Name — School Method Used (Circle One)

Time Task

Date ofService

(MM/DD/YY)

GeneralService

Category


Units)

Group orIndividual








Yes No



Yes No







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Appendix

Appendix 19Optional School-Based Services Activity Log Medication Administration

(for photocopying)

(A copy of the Optional School-Based Services Activity Log Medication Administration islocated on the following page.)ARCHIVAL USE ONLY



STATE OF WISCONSIN

WISCONSIN MEDICAID


Name — Student (Last, First, MI) Name — School Method Used (Circle One)

Time Task

Date ofService


TimeAdministered

(Time or Units)

TookMedication



Be Noted)



*Initials Key Signatures — Corresponding Staff Date Signed (MM/DD/YY) Under Standards of Practice for Registered Nurses, ch. N6.03, Wis. Admin. Code, only registered nurses (RNs) maydelegate services to medically unlicensed individuals. Fordelegated nursing services under the school-based servicesbenefit, the RN responsible for delegating the services mustagree to the delegation of the service and is responsible forsupervision of the delegatee.


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Appendix

Appendix 20Examples of School-Based Transportation Services Units

The following examples illustrate how providers can bill for various transportation services trip lengths.

Child A — Trip Over 20 Miles: Example Includes Travel to Non-School-Based Service Site 1 A school-based service other than transportation is provided at the hospital. The bus travels to school and picks up

Child A. The bus transports Child A five miles from school to the hospital. 2 The bus transports Child A 18 miles from the hospital to home.

The total miles for Child A’s trip is 23 miles. This is more than the daily base rate of 20 miles; therefore, the provider may usethe following procedure codes:

• Procedure code T2003 — daily base rate (1 unit).• Procedure code A0425 — three miles over the daily base rate (3 units).

Note: In this example, the provider can only be reimbursed for transportation from the school to the hospital and for the tripfrom the hospital to home. The provider cannot be reimbursed for transportation from home to school because noMedicaid-covered school-based service was provided at the school.

MedicaidChild A’s Home

School

Hospital

Bus Barn

(Do not include miles to or from bus barn.)

1 School to Hospital = 5 miles

2 Hospital to Child A’s Home = 18 miles

CHILD A TOTAL TRIP = 23 MILES


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Child B — Trip Over 20 Miles 1 A school-based service other than transportation is provided at school. The bus travels to pick up Child B at home and

transports Child B 12 miles to school. 2 The bus transports Child B 12 miles from school to home.

The total miles for Child B’s trip is 24 miles. This is more than the daily base rate of 20 miles; therefore, the provider mayuse the following procedure codes:

• Procedure code T2003 — daily base rate (1 unit).• Procedure code A0425 — four miles over the daily base rate (4 units).

Child C — Trip Under 20 Miles 1 A school-based service other than transportation is provided at school. The bus travels to pick up Child C at home and

transports Child C six miles to school. 2 The bus transports Child C six miles from school to home.

The total miles for Child C’s trip is 12 miles. This is less than the daily base rate of 20 miles; therefore, the provider may useprocedure code T2003 — daily base rate (1 unit).

1 Child B’s Home to School = 12 miles

CHILD B TOTAL TRIP = 24 MILES

School

(Do not include miles to or from busbarn.)

MedicaidChild B’s Home

2 School to Child B’s Home = 12 miles

Bus Barn

CHILD C TOTAL TRIP = 12 MILES

(Do not include miles to or from busbarn.)

MedicaidChild C’s Home

Bus Barn

School

1 Child C’s Home to School = 6 miles

2 School to Child C’s Home = 6 miles


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Appendix

Appendix 21Centers for Medicare and Medicaid Services School-Based Services Covered

Transportation Policy

In August 2001, the Centers for Medicare and Medicaid Services approved Wisconsin Medicaid’s State Plan regardingcovered school-based services (SBS) transportation policy. The following is Medicaid’s SBS State Plan language:

Transportation Policy

Transportation to school and from school

A child’s transportation to and from a school certified as an SBS provider is a covered service only if all the followingconditions are met:

• The child receives a covered school-based service identified in the child’s Individualized Education Plan (IEP) at theschool on the day the transportation is provided.

• The SBS provider is financially responsible for providing the transportation.• The child’s medical need for the particular type of transportation is identified in the child’s IEP.• One of the following:

√ The vehicle is equipped with and the child requires a ramp or lift.√ An aide is present and the child requires the aide’s assistance in the vehicle.√ The child has behavioral problems that do not require the assistance of an aide but that preclude the child from

riding on a standard school bus.

Off-site transportation

A child’s transportation to and from a site other than the child’s “home” school is a covered service only if all the followingconditions are met:

• The child receives a covered school-based service identified in the child’s IEP at the site on the day the transportation isprovided.

• The SBS provider is financially responsible for providing the transportation.• One of the following:

√ Transportation is from the school to an off-site provider and back to school or home.√ Transportation is between home and a “special school.” A special school is a school that requires that a child have

a disability in order to be enrolled, including, but not limited to, the Wisconsin School for the Deaf or theWisconsin School for the Visually Handicapped, as defined in ch. PI 12, Wis. Admin. Code.


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Glossary

GGlossary of Common Terms

AdjustmentA modified or changed claim that was originally allowed, atleast in part, by Wisconsin Medicaid.

Allowed statusA Medicaid or Medicare claim that has at least one servicethat is reimbursable.

BadgerCareBadgerCare extends Medicaid coverage through aMedicaid expansion under Titles XIX and XXI to uninsuredchildren and parents with incomes at or below 185% of theFederal Poverty Level and who meet other programrequirements. The goal of BadgerCare is to fill the gapbetween Medicaid and private insurance withoutsupplanting or “crowding out” private insurance.

BadgerCare benefits are identical to the benefits andservices covered by Wisconsin Medicaid, and recipients’ healthcare is administered through the same delivery system.

CCDEBCounty Children with Disabilities Education Board. A branchof county government providing instructional and therapeuticservices to students with disabilities. Five counties inWisconsin operate a CCDEB: Brown, Camulet, Marathon,Racine, and Walworth.

CESACooperative Educational Service Agency. The unit serving asa connection between the state and school districts withinits borders. There are 12 CESAs in Wisconsin. CooperativeEducational Service Agencies coordinate and provideeducational programs and services as requested by theschool district.

Charter SchoolA public, nonsectarian school created through a contract or“charter” between the operators and the sponsoring schoolboard or other chartering authority. The Wisconsin charterschool law gives charter schools freedom from most staterules and regulations in exchange for greater accountabilityfor results.

CMSCenters for Medicare and Medicaid Services. An agencyhoused within the U.S. Department of Health and HumanServices (HHS), CMS administers Medicare, Medicaid,related quality assurance programs, and other programs.

CPTCurrent Procedural Terminology. A listing of descriptiveterms and codes for reporting medical, surgical, therapeutic,and diagnostic procedures. These codes are developed,updated, and published annually by the American MedicalAssociation and adopted for billing purposes by the Centersfor Medicare and Medicaid Services (CMS) and WisconsinMedicaid.

Crossover claimA Medicare-allowed claim for a dual-entitlee sent toWisconsin Medicaid for possible additional payment of theMedicare coinsurance and deductible.

DHCFDivision of Health Care Financing. The DHCF administersWisconsin Medicaid for the Department of Health andFamily Services (DHFS) under statutory provisions,administrative rules, and the state’s Medicaid plan. Thestate’s Medicaid plan is a comprehensive description of thestate’s Medicaid program that provides the Centers forMedicare and Medicaid Services (CMS) and the U.S.Department of Health and Human Services (HHS),assurances that the program is administered in conformitywith federal law and CMS policy.

DHFSWisconsin Department of Health and Family Services. TheDHFS administers Wisconsin Medicaid. Its primary missionis to foster healthy, self-reliant individuals and families bypromoting independence and community responsibility;strengthening families; encouraging healthy behaviors;protecting vulnerable children, adults, and families;preventing individual and social problems; and providingservices of value to taxpayers.


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DMSDisposable medical supplies. Disposable medical suppliesare medically necessary items that have a very limited lifeexpectancy and are consumable, expendable, disposable,or nondurable. All prescribed DMS must:• Be necessary and reasonable for treating a recipient’s

illness, injury, or disability.• Be suitable for the recipient’s residence.• Be useful to a recipient who is ill, injured, or disabled.• Serve a primary medical purpose.

DPIDepartment of Public Instruction. The state agency thatoversees education for Wisconsin. The DPI is dedicated tochildren and learning and to providing guidance andinformation to parents, teachers, and administrators alike.

Dual-entitleeA recipient who is eligible for both Medicaid and Medicare,either Medicare Part A, Part B, or both.

DMEDurable medical equipment. Durable medical equipmentare medically necessary devices that can withstandrepeated use. All prescribed DME must:• Be necessary and reasonable for treating a recipient’s

illness, injury, or disability.• Be suitable for the recipient’s residence.• Be useful to a recipient who is ill, injured, or disabled.• Serve a primary medical purpose.

ECSElectronic Claims Submission. Claims transmitted via thetelephone line and fed directly into Wisconsin Medicaid’sclaims processing subsystem.

EOBExplanation of Benefits. Appears on the providers’Remittance and Status (R/S) Reports and informs Medicaidproviders of the status of or action taken on their claims.

EVSEligibility Verification System. The EVS allows providers toverify recipient eligibility prior to providing services.Providers may access recipient eligibility informationthrough the following methods:

• Wisconsin Medicaid’s Automated Voice Response(AVR) system.

• Commercial magnetic stripe card readers.• Commercial personal computer software and Internet

access.• Wisconsin Medicaid’s Provider Services (telephone

correspondents).• Wisconsin Medicaid’s Direct Information Access Line

with Updates for Providers (Dial-Up).

Fee-for-serviceThe traditional health care payment system under whichphysicians and other providers receive a payment for eachunit of service provided rather than a capitation payment foreach recipient.

Fiscal agentThe Department of Health and Family Services (DHFS)contracts with Electronic Data Systems (EDS) to providehealth claims processing services for Wisconsin Medicaid,including provider certification, claims payment, providerservices, and recipient services. The fiscal agent also issuesidentification cards to recipients, publishes information forproviders and recipients, and maintains the WisconsinMedicaid Web site.

HCPCSHealthcare Common Procedure Coding System. A listing ofservices, procedures, and supplies offered by physicians andother providers. HCPCS includes Current ProceduralTerminology (CPT) codes, national alphanumeric codes, andlocal alphanumeric codes. The national codes are developedby the Centers for Medicare and Medicaid Services (CMS)to supplement CPT codes.

HealthCheckA program that provides Medicaid-eligible children underage 21 with regular health screenings.


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Glossary

HHSDepartment of Health and Human Services. The UnitedStates government’s principal agency for protecting thehealth of all Americans and providing essential humanservices, especially for those who are least able to helpthemselves.

The HHS includes more than 300 programs, covering a widespectrum of activities, including overseeing Medicare andMedicaid; medical and social science research; preventingoutbreak of infectious disease; assuring food and drugsafety; and providing financial assistance for low-incomefamilies.

ICD-9-CMInternational Classification of Diseases, Ninth Revision,Clinical Modification. Nomenclature for medical diagnosesrequired for billing. Available through the American HospitalAssociation.

IDEAIndividuals with Disabilities Education Act. Federal law thatguarantees all children with disabilities access to a free andappropriate public education and the related services andsupport needed to achieve that education.

IEPIndividualized Education Program. An IEP is a written planfor a child that is developed, reviewed, and revised inaccordance with s.115.787, Wis. Stats. The IEP guides thedelivery of special education support and services for thechild.

Maximum allowable fee scheduleA listing of all procedure codes allowed by WisconsinMedicaid for a provider type and Wisconsin Medicaid’smaximum allowable fee for each procedure code.

MedicaidMedicaid is a joint federal/state program established in 1965under Title XIX of the Social Security Act to pay formedical services for people with disabilities, people 65 yearsand older, children and their caretakers, and pregnantwomen who meet the program’s financial requirements.

The purpose of Medicaid is to provide reimbursement forand assure the availability of appropriate medical care topersons who meet the criteria for Medicaid. Medicaid is alsoknown as the Medical Assistance Program, Title XIX, orT19.

Medically necessaryAccording to HFS 101.03(96m), Wis. Admin. Code, aMedicaid service that is:

a) Required to prevent, identify or treat a recipient’sillness, injury or disability; and

b) Meets the following standards:1. Is consistent with the recipient’s symptoms or with

prevention, diagnosis or treatment of the recipient’sillness, injury or disability;

2. Is provided consistent with standards of acceptablequality of care applicable to type of service, thetype of provider and the setting in which theservice is provided;

3. Is appropriate with regard to generally acceptedstandards of medical practice;

4. Is not medically contraindicated with regard to therecipient’s diagnoses, the recipient’s symptoms orother medically necessary services being providedto the recipient;

5. Is of proven medical value or usefulness and,consistent with s. HFS 107.035, is not experimentalin nature;

6. Is not duplicative with respect to other servicesbeing provided to the recipient;

7. Is not solely for the convenience of the recipient,the recipient’s family or a provider;

8. With respect to prior authorization of a service andto other prospective coverage determinations madeby the department, is cost effective compared to analternative medically necessary service which isreasonably accessible to the recipient; and

9. Is the most appropriate supply or level of servicethat can safely and effectively be provided to therecipient.

PAPrior authorization. The written authorization issued by theDepartment of Health and Family Services (DHFS) to aprovider prior to the provision of a service.


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POSPlace of service. A two-digit code which identifies the placewhere the service was performed.

R/S ReportRemittance and Status Report. A statement generated bythe Medicaid fiscal agent to inform providers regarding theprocessing of their claims.

SBS benefitSchool-Based Services benefit. The SBS benefit has beenestablished by Wisconsin Medicaid according to s. 49.45(39),Wis. Stats. This benefit is designed to increase federalfunding to Wisconsin schools to help pay for medically relatedspecial education and associated services. The SBS benefitdefines the services that can be reimbursed byWisconsin Medicaid for medically necessary servicesprovided to Medicaid-eligible children.

SMVSpecialized medical vehicle. Specialized medical vehicleproviders provide transportation for recipients with adocumented physical or mental disability that prevents themfrom traveling safely in a common carrier or private motorvehicle to Medicaid-covered services.


for current policy


Index

IIndex

Certification of Expenditures, 37

Claimselectronic submission, 35paper submission, 35provider responsibility for, 33submission deadline, 35

Commercial Health Insurance, 31

Copayment, 13

Cotreatment, 16

Delegated Nursing Acts, 20, 21

DocumentationMedicaid standards, 25of electronic records, 26of nursing services, 27of other school-based services, 29of transportation services, 28

Eligibility Verification System, 13

Face-to-Face Timedefinition of, 15, 16documentation of, 25

Individualized Education Programas a care plan, 16documentation, 25information about, 16

Medically Necessary Services, 15

Memorandum of Understanding, 11

Nursing Services, 19

Parental Consentto bill commercial insurance, 13to provide medical services, 13to request reimbursement

from Wisconsin Medicaid, 13

Prescription Waivers, 23

Provider Communicationwith managed care providers, 11with Medicaid fee-for-service providers, 12with providers not certified under Medicaid, 12

Providersauthority to subcontract, 10certification, 9eligibility, 9federally funded, 38using a billing service or billing agent, 33using a private independent consultant, 33

Reimbursement, 37

School-Based Servicesbenefit, 9community-based therapies and, 23covered services, 15durable medical equipment, 23noncovered services, 24nursing services, 19occupational therapy services, 19other developmental testing and assessments, 21physical therapy services, 18psychological services, counseling, and social work

services, 21services provided by teachers, 21speech-language pathology, audiology, and hearing

services, 16transportation services, 22

Volume Eligibility, 13


for current policy

school-based services handbook · 2014-01-13 · archival use only refer to the online handbook for...

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