HomeHome HealthHealth ServicesServices ARCHIVAL USE ONLY Refer to the Online Handbook for current policy DIVISION OF HEALTH CARE FINANCING WISCONSIN MEDICAID AND BADGERCARE PROVIDER SERVICES 6406 BRIDGE ROAD MADISON WI 53784 Jim Doyle Governor Telephone: 800-947-9627 State of Wisconsin 608-221-9883 Helene Nelson dhfs.wisconsin.gov/medicaid Secretary Department of Health and Family Services dhfs.wisconsin.gov/badgercare M E M O R A N D U M DATE: January 9, 2006 TO: Wisconsin Medicaid Home Health Agencies, HMOs, and other Managed Care Organizations FROM: Mark B. Moody, Administrator Division of Health Care Financing SUBJECT: Introducing the Wisconsin Medicaid Home Health Services Handbook The Division of Health Care Financing (DHCF) is pleased to provide you with a copy of the Home Health Services Handbook. This handbook is a guide to Wisconsin Medicaid for all Medicaid-certified home health agencies. Providers should maintain and refer to this handbook in conjunction with the All- Provider Handbook. This handbook incorporates current Wisconsin Medicaid policies related to home health agencies into a single reference source. TheARCHIVAL handbook completely replaces USE the Wisconsin ONLY Medical Assistance Program Provider Handbook, Part L, Divisions I and II. The handbook also replaces the following service-specific Wisconsin MedicaidRefer and BadgerCare to theUpdates: Online Handbook ! August 2005 Update (2005-57), Wisconsin Medicaid Issues Prior Authorization Home Care Attachment for Home Healthfor and current Private Duty Nursing policy Services. ! June 2004 Update (2004-48), Wisconsin Medicaid Covers Pneumococcal Vaccinations by Home Health Agencies in Addition to Influenza Vaccine. ! February 2004 Update (2004-08), Submitting claims with start-of-shift modifiers for home care services. ! August 2003 Update (2003-83), Changes to local codes, paper claims, and prior authorization for home health services, including private duty nursing and respiratory care services, as a result of HIPAA. ! June 2003 Update (2003-33), Discontinued home health procedure codes for private duty nursing. ! September 2000 Update (2000-33), Home care coverage determination software for Windows. ! April 1999 Update (99-13), Wisconsin Medicaid revises private duty nursing prior authorization guideline. ! May 1998 Update (98-15), Prior Authorization Request Charges for Home Health and Personal Care Agencies. ! July 1996 Update (96-27), Home Health Services: Reimbursement and Recipient Information Confidentiality. ! June 1996 Update (96-20), Flu Vaccinations. ! November 1995 Update (95-49), Home Health Reimbursement Limits and Other Changes. ! October 1995 Update (95-36), Home Health Changes for Medication Management. ! June 1995 Update (95-20), PRN Visits — Changes in Prior Authorization Procedures and Guidelines. Wisconsin.gov This handbook does not replace the all-provider publications, the Wisconsin Administrative Code or Wisconsin Statutes. Subsequent changes to policies affecting home health agencies will be published first in Updates and later in Home Health Services Handbook revisions. Additional Copies of Publications The Wisconsin Medicaid Web site, dhfs.wisconsin.gov/medicaid/, contains additional information for home health agencies, all Updates and electronic versions of the Home Health Services Handbook and the All-Provider Handbook. Providers who have questions about the information in this handbook may call Provider Services at (800) 947-9627 or (608) 221-9883. The DHFS would like to thank representatives from the Home Care Advisory Committee for reviewing this handbook. ARCHIVAL USE ONLY Refer to the Online Handbook for current policy CContacting Wisconsin Medicaid Web Site dhfs.wisconsin.gov/ The Web site contains information for providers and recipients about the Available 24 hours a day, seven days a week following: • Program requirements. • Maximum allowable fee schedules. • Publications. • Professional relations representatives. • Forms. • Certification packets. Automated Voice Response System (800) 947-3544 (608) 221-4247 The Automated Voice Response system provides computerized voice Available 24 hours a day, seven days a week responses about the following: • Recipient eligibility. • Claim status. • Prior authorization (PA) status. • Checkwrite information. Provider Services (800) 947-9627 (608) 221-9883 Correspondents assist providers with questions about the following: Available: • Clarification of program ARCHIVAL• Resolving claim denials. USE ONLY8:30 a.m. - 4:30 p.m. (M, W-F) requirements. • Provider certification. 9:30 a.m. - 4:30 p.m. (T) • Recipient eligibility.Refer to the Online HandbookAvailable for pharmacy services: 8:30 a.m. - 6:00 p.m. (M, W-F) for current policy9:30 a.m. - 6:00 p.m. (T) Division of Health Care Financing (608) 221-9036 Electronic Data Interchange Helpdesk e-mail: [email protected] Correspondents assist providers with technical questions about the following: Available 8:30 a.m. - 4:30 p.m. (M-F) • Electronic transactions. • Provider Electronic Solutions • Companion documents. software. Web Prior Authorization Technical Helpdesk (608) 221-9730 Correspondents assist providers with Web PA-related technical questions Available 8:30 a.m. - 4:30 p.m. (M-F) about the following: • User registration. • Submission process. • Passwords. Recipient Services (800) 362-3002 (608) 221-5720 Correspondents assist recipients, or persons calling on behalf of recipients, Available 7:30 a.m. - 5:00 p.m. (M-F) with questions about the following: • Recipient eligibility. • Finding Medicaid-certified providers. • General Medicaid information. • Resolving recipient concerns. TTable of Contents Preface ........................................................................................................................................ 7 Provider Information ..................................................................................................................... 9 Scope of Services .................................................................................................................... 9 Wisconsin Medicaid Certification Requirements ........................................................................... 9 Provider Certification for Personal Care Services ................................................................. 10 Provider Certification for Private Duty Nursing for Ventilator-Dependent Recipients ................ 10 Recipient Eligibility for Wisconsin Medicaid ................................................................................. 10 Limited Benefit Categories................................................................................................. 10 Copayment ........................................................................................................................... 10 Universal Precautions ............................................................................................................. 10 Written Statement of Recipient Rights ..................................................................................... 11 Distribution of Private Duty Nursing Information....................................................................... 11 Discharge of Recipients .......................................................................................................... 11 Availability of Records ............................................................................................................ 12 Wisconsin Medicaid Review ............................................................................................... 12 Termination of a Provider’s Certification ................................................................................... 12 Covered Services and Related Limitations ..................................................................................... 13 Place of Residence.............................................................................................................ARCHIVAL USE ONLY .... 13 Home Health Skilled Nursing Services ...................................................................................... 13 RecipientRefer Eligibility for to Home the Health OnlineSkilled Nursing ServHandbookices ................................................. 13 Hours of Care That Qualify as Home Health Skilled Nursing Services .............................. 14 Place of Service ..........................................................................................................for current policy 14 Home Health Skilled Nursing Visits...................................................................................... 14 Skilled Nursing Services ..................................................................................................... 14 Examples of Circumstances in Which Skilled Nursing May Be Required ............................ 14 Supervision ................................................................................................................. 15 Private Duty Nursing Services ................................................................................................. 15 Recipient Eligibility for Private Duty Nursing Services ............................................................ 15 Hours of Care That Qualify as Private Duty Nursing Services ......................................... 15 Place of Service for Private Duty Nursing Recipients ...................................................... 16 Ventilator-Dependent Recipients ..................................................................................