Nurse Practitioner Services - Wisconsin

Nurse practitioners use this

handbook in conjunction with the

Physician Services Handbook.

Nurse PractitionerServices

Nurse PractitionerServices

ARCHIVAL USE ONLY Refer to the Online Handbook

for current policy


for current policy

IImportant Telephone NumbersWisconsin Medicaid’s Eligibility Verification System (EVS) is available through the following resources to verify checkwriteinformation, 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 EVS to completethe patient information section on claims and other documentation. Recipient eligibility informationavailable through 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.


for current policy

TTable of Contents

Preface ........................................................................................................................................ 3

General Information ...................................................................................................................... 5

Provider Eligibility and Certification ............................................................................................. 5Nurse Practitioner Certification ............................................................................................. 5

Protocols/Collaborative Agreements .......................................................................................... 6Provider Numbers .................................................................................................................... 7

Billing/Performing Provider Number (Issued to Nurse Practitioners) ........................................ 7Nurse Practitioners Who Submit Claims to Wisconsin Medicaid as Performing Providers

Through a Physician or Clinic .................................................................................... 7Nurse Practitioners Who Independently Submit Claims to Wisconsin Medicaid .................... 7

Group Billing Number (Issued to Clinics) ............................................................................... 7Medicaid-Covered Nurse Practitioner Services ............................................................................ 8

Covered Procedure Codes for Nurse Practitioners ................................................................. 8Obstetric services .............................................................................................................. 8

Complications During Delivery......................................................................................... 9Noncovered Services for Nurse Practitioners ........................................................................ 9

Reimbursement for Nurse Practitioners ..................................................................................... 9Maximum Allowable Fees .................................................................................................... 9Enhanced Reimbursement .................................................................................................. 9

Glossary of Common Terms ........................................................................................................ 11

Index ......................................................................................................................................... 15

PHC 1405


for current policy

Nurse Practitioner Services Handbook � September 2003 3

PThe Wisconsin Medicaid and BadgerCare NursePractitioner Services Handbook is issued to nursepractitioners, federally qualified health centers, and ruralhealth clinics who are Wisconsin Medicaid certified. Itcontains information that applies to fee-for-serviceMedicaid providers. The Medicaid information in thehandbook applies to both Medicaid and BadgerCare.

Nurse practitioners are issued the Nurse PractitionerServices Handbook and the Physician ServicesHandbook.

Wisconsin Medicaid and BadgerCare are administeredby the Department of Health and Family Services(DHFS). Within the DHFS, the Division of Health CareFinancing (DHCF) is directly responsible for managingWisconsin Medicaid and BadgerCare. As ofJanuary 2003, BadgerCare extends Medicaid coverageto uninsured children and parents with incomes at orbelow 185% of the federal poverty level and who meetother program requirements. BadgerCare recipientsreceive the same health benefits as Wisconsin Medicaidrecipients and their health care is administered throughthe same delivery system.

Medicaid and BadgerCare recipients enrolled in state-contracted HMOs are entitled to at least the samebenefits as fee-for-service recipients; however, HMOsmay establish their own requirements regarding priorauthorization, billing, etc. If you are an HMO networkprovider, contact your managed care organizationregarding its requirements. Information contained in thisand other Medicaid and BadgerCare publications is usedby the DHCF to resolve disputes regarding coveredbenefits that cannot be handled internally by HMOsunder managed care arrangements.

Verifying Recipient EligibilityWisconsin Medicaid providers should always verify arecipient’s eligibility before providing services, both todetermine eligibility for the current date and to discoverany limitations to the recipient’s coverage. WisconsinMedicaid’s Eligibility Verification System (EVS)provides eligibility information that providers can accessa number of ways.

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

Handbook OrganizationNurse practitioners use this handbook in conjunctionwith the Physician Services Handbook. The PhysicianServices Handbook consists of the following sections:

• Medicine and Surgery.• Laboratory and Radiology.• Anesthesia.

Each Medicaid-certified provider is issued a copy of theAll-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.

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

49.665.

Preface


for current policy

4 Wisconsin Medicaid and BadgerCare � September 2003

• Regulation: Wisconsin Administrative Code, Rulesof Health and Family Services, Chapters HFS 101-108.

Handbooks and Wisconsin Medicaid and BadgerCareUpdates further interpret and implement these laws andregulations. Handbooks and Updates organized byprovider type, maximum allowable fee schedules, helpfultelephone numbers and addresses, Remittance andStatus messages, and much more information aboutWisconsin Medicaid and BadgerCare are available atthe following Web sites:

www.dhfs.state.wi.us/medicaid/www.dhfs.state.wi.us/badgercare/

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


for current policy


General Inform

ation

GGeneral InformationNurse practitioners should use this handbook inconjunction with the Physician ServicesHandbook. The Nurse Practitioner ServicesHandbook includes the following limitedinformation that applies to fee-for-serviceMedicaid-certified nurse practitioners:

• Covered services.• Protocols and collaborative agreements.• Provider eligibility and certification.• Provider numbers.• Reimbursement.

Nurse practitioners should refer to thePhysician Services Handbook for the followinginformation:

• Billing and reimbursement.• Evaluation and management services.• Health Professional Shortage Areas.• Laboratory services.• Medicine services.• Radiology services.• Surgery services.

The Physician Services Handbook alsocontains the following forms for nursepractitioner use:

• Breast Pump Order form.• Newborn Report form.• Provider Certification of Emergency for

Undocumented Aliens form (forphotocopying).

• Specialized Medical Vehicle TransportationPhysician Certification form (forphotocopying).

Provider Eligibility andCertification

Nurse Practitioner CertificationNurse practitioners who treat Medicaidrecipients are required to be Medicaid certifiedto receive Medicaid reimbursement. Thisapplies to nurse practitioners whose servicesare reimbursed under a physician’s or clinic’sMedicaid provider number, as well as to thosewho independently submit claims to WisconsinMedicaid.

To be certified by Wisconsin Medicaid, a nursepractitioner must be licensed as a registerednurse pursuant to s. 441.06, Wis. Stats. Nursepractitioners are eligible for Medicaidcertification if they meet one of the followingcriteria:

• Are a pediatric nurse practitioner, familynurse practitioner, or other nursepractitioner and certified by one of thefollowing national certifying organizationsrecognized by the Wisconsin Departmentof Regulation and Licensing:� American Nurses’ Credentialing

Center.� National Certification Board of

Pediatric Nurse Practitioners andNurses.

� American Academy of NursePractitioners.

� National Certification Corporation (forObstetric, Gynecologic, and NeonatalNursing Specialists).

• Are a Master’s degree-prepared nurse ina clinical nurse specialty other than mentalhealth (e.g., nurse midwife, clinical nursespecialist, or nurse practitioner).

NNurse practitionersshould use thishandbook inconjunction withthe PhysicianServicesHandbook.


for current policy


Gen

eral

Info

rmat

ion

Medicaid services performed by nursepractitioners must be within the legal scope ofpractice as defined under the Wisconsin Boardof Nursing licensure or certification. Servicesperformed must be included in the individualnurse practitioner’s protocols or a collaborativerelationship with a physician as defined by theBoard of Nursing.

Most advanced practice nurse prescribers whoapply for Medicaid certification are certified asnurse practitioners (except for non-Master’sdegree-prepared nurse midwives and certifiedregistered nurse anesthetists).

Pursuant to Board of Nursing Ch. N 8.10(7),Wis. Admin. Code, advanced practice nurseprescribers work in a collaborative relationshipwith a physician. (The collaborativerelationship is defined as an advanced practicenurse prescriber works with a physician, “ineach other’s presence when necessary, todeliver health care services within the scope ofthe practitioner’s professional expertise.”)

Advanced practice nurse prescribers whodispense drugs in addition to prescribing themshould obtain the appropriate Medicaidpharmacy publications. The Medicaid Web site(www.dhfs.state.wi.us/medicaid/) contains alist of all published materials for each Medicaidprovider type and many of the publicationsmay be downloaded. Providers may also callProvider Services at (800) 947-9627 or(608) 221-9883 if Internet access is notavailable.

Medicaid-certified nurse practitioners whoprovide delegated medical care under thegeneral supervision of a physician are requiredto be supervised only to the extent requiredpursuant to Board of Nursing Chapter N6.02(7), Wis. Admin. Code. (Chapter N 6defines general supervision as the regularcoordination, direction, and inspection of thepractice of another and does not require thephysician to be on site.)

Note: Medicaid certification is not required fornurse practitioners working in a family planningclinic or for psychiatric nurse practitioners/clinical nurse specialists. Family planning clinicsand psychiatric nurse practitioners/clinicalnurse specialists should refer to their service-specific handbook and related WisconsinMedicaid and BadgerCare Updates forinformation on covered services and relatedlimitations.

Services provided by registered nurses who donot meet Medicaid nurse practitionercertification requirements may be reimbursedas services provided by ancillary providers.Refer to the Physician Services Handbook formore information about ancillary providers.

Protocols/CollaborativeAgreementsPursuant to Board of Nursing Ch. N 8.10(7),Wis. Admin. Code, advanced practice nurseprescribers work in a collaborative relationshipwith a physician. (The collaborativerelationship is defined as an advanced practicenurse prescriber working with a physician, “ineach other’s presence when necessary, todeliver health care services within the scope ofthe practitioner’s professional expertise.”) Theadvanced practice nurse prescriber and thephysician must document this relationship.

Pursuant to the requirements of N 6.03(2),Wis. Admin. Code, nurse practitioners mayonly perform those delegated medical acts forwhich there are protocols or written or verbalorders, and which the nurse practitioner iscompetent to perform based on his or hernursing education, training, or experience.Nurse practitioners may perform delegatedmedical acts under the general supervision ordirection of a physician, podiatrist, dentist, oroptometrist. In addition, nurse practitioners arerequired to consult with a physician, podiatrist,dentist, or optometrist in cases where the nursepractitioner knows or should know a delegatedmedical act may harm a patient.

AAdvanced practicenurse prescriberswho dispensedrugs in additionto prescribingthem shouldobtain theappropriateMedicaidpharmacypublications.


for current policy


General Inform

ation

For purposes of Medicaid reimbursement, noservice which is a medical act and is listed inthis handbook or Physician Services Handbookmay be performed without a collaborativepractice agreement as required for advancedpractice nurse prescribers (pursuant to N 8.10,Wis. Admin. Code) or protocols, and written orverbal orders for other Medicaid-certifiednurse practitioners pursuant to N 6.03(1), Wis.Admin. Code.

Provider NumbersWisconsin Medicaid issues all eligibleproviders, whether individuals, agencies, orinstitutions, an eight-digit provider number to billWisconsin Medicaid for services provided toeligible Medicaid recipients. A provider numberbelongs solely to the person, agency, orinstitution to whom it is issued. It is illegal for aMedicaid-certified provider to bill using aprovider number belonging to anotherMedicaid-certified provider.

A provider keeps the same provider number inthe event that he or she relocates, changesspecialties, or voluntarily withdraws fromWisconsin Medicaid and later chooses to bereinstated. (Notify Provider Maintenance ofchanges in location or of specialty by using theWisconsin Medicaid Provider Change ofAddress or Status Form, which may be foundin the September 2002 Wisconsin Medicaidand BadgerCare Update (2002-52), titled“Two All-Provider Handbook forms revised.”The Update and form are available on theMedicaid Web site at www.dhfs.state.wi.us/medicaid/.) A provider’s number is notreissued to another provider in the event oftermination from Wisconsin Medicaid.

Wisconsin Medicaid reimburses nursepractitioner services under two types ofprovider numbers. Each type of providernumber has its designated uses andrestrictions. The two types are:

• Billing/performing provider number.• Group billing number.

Billing/Performing ProviderNumber (Issued to NursePractitioners)Wisconsin Medicaid issues a billing/performingprovider number to nurse practitioners thatallows them to identify themselves on the CMS1500 claim form as either the biller of servicesor the performer of services when a clinic orgroup is billing for the services.

Medicaid-certified nurse practitioners arerequired to indicate their provider number onthe claim as either the performing or the billingprovider.

Nurse Practitioners Who Submit Claimsto Wisconsin Medicaid as PerformingProviders Through a Physician or ClinicNurse practitioners who submit claims toWisconsin Medicaid as performing providersare required to indicate their own providernumber in Element 24K of the CMS 1500claim form. The billing provider number of thephysician or clinic must be indicated inElement 33.

Nurse Practitioners Who IndependentlySubmit Claims to Wisconsin MedicaidNurse practitioners who directly submit claimsto Wisconsin Medicaid for services mustindicate their provider number in Element 33 ofthe CMS 1500 claim form as the billingprovider. It is not necessary to indicateanything in Element 24K.

Group Billing Number (Issued toClinics)A group billing number is primarily anaccounting convenience. A clinic or groupusing a group billing number receives onereimbursement and one Remittance and StatusReport for covered services performed byindividual providers within the clinic or group.

Individual providers within a clinic or groupmust also be Medicaid certified because clinicsand groups are required to identify theperformer of the service on the claim form.(The performing provider’s Medicaid provider

AA provider keepsthe same providernumber in theevent that he orshe relocates,changesspecialties, orvoluntarilywithdraws fromWisconsinMedicaid and laterchooses to bereinstated.


for current policy


Gen

eral

Info

rmat

ion

number must be indicated in Element 24K ofthe CMS 1500 claim form when a group billingnumber is indicated in Element 33.) Ordinarily,a claim billed with only a group billing numberis denied reimbursement. Refer to the CMS1500 claim form completion instructions in thePhysician Services Handbook for moreinformation.

Medicaid-Covered NursePractitioner ServicesAs specified in HFS 107.122(1), Wis. Admin.Code, nurse practitioner services covered byWisconsin Medicaid include:

• Diagnostic services.• Palliative services.• Preventive services.• Rehabilitative services.• Therapeutic services.

Wisconsin Medicaid reimburses only for thoseservices that are medically necessary,appropriate, and, to the extent that alternativeservices are available, the most cost effective.

The following requirements apply for allservices performed by nurse practitioners:

• Services performed must be within thelegal scope of practice as defined underthe Wisconsin Board of Nursing licensureor certification.

• Services performed must be included inthe individual nurse practitioner’s protocolsor a collaborative agreement with aphysician as defined by the Board ofNursing.

Refer to HFS 107.03 and to HFS 107.06(5),Wis. Admin. Code, for services not coveredby Wisconsin Medicaid. Refer to the Coveredand Noncovered Services section of the All-Provider Handbook for a partial list of thenoncovered services.

Covered Procedure Codes forNurse PractitionersNurse practitioners should refer to thePhysician Services Handbook for informationon Medicaid-allowable procedure, type ofservice, and place of service (POS) codes.Nurse practitioners may be restricted by legalscope of practice, protocols, or collaborationfrom performing some of the proceduresincluded in the Physician Services Handbook.

Nurse practitioners are required to provideservices within the following supervision orcollaboration requirements:

• Pursuant to Board of NursingCh. N 8.10(7), Wis. Admin. Code,advanced practice nurse prescribers workin a collaborative relationship with aphysician. (The collaborative relationship isdefined as an advanced practice nurseprescriber working with a physician, “ineach other’s presence when necessary, todeliver health care services within thescope of the practitioner’s professionalexpertise.”) The advanced practice nurseprescriber and the physician mustdocument this relationship.

• Medicaid-certified nurse practitioners whoprovide delegated medical care under thegeneral supervision of a physician arerequired to be supervised only to the extentrequired pursuant to Board of NursingChapter N 6.02(7), Wis. Admin. Code.(Chapter N 6 defines general supervisionas the regular coordination, direction, andinspection of the practice of another. Thisdoes not require the physician to be onsite.)

Obstetric servicesNurse practitioners with obstetric specialtyshould refer to the Physician ServicesHandbook for complete information onMedicaid coverage and billing procedures forobstetric services, except for the followinginformation regarding complications duringdelivery.

NNurse practitionersshould refer to thePhysician ServicesHandbook forinformation onMedicaid-allowableprocedure, type ofservice, and placeof service (POS)codes.


for current policy


General Inform

ation

Complications During DeliveryIf a Medicaid-certified nurse practitioner withobstetric specialty encounters a situation duringdelivery which requires the assistance of aphysician, the physician performing the deliverymust bill for the delivery. The nurse practitionerwith obstetric specialty may be reimbursed forhis or her service by submitting a paper claimusing the Current Procedural Terminologyprocedure code 99499 (unlisted evaluation andmanagement services) in addition to anyantepartum and postpartum care provided.Documentation on the medical necessity of theservices provided must be submitted with theclaim. Reimbursement is determined by theMedicaid medical consultant.

Noncovered Services for NursePractitionersServices that are noncovered by WisconsinMedicaid when provided by nurse practitionersinclude, but are not limited to:

• Delegated medical acts for which thenurse practitioner does not have writtenprotocols or written or verbal orders.

• Dispensing durable medical equipment.• Mental health and substance abuse

services. (Refer to the Mental Health andOther Drug Abuse Services Handbookand related Updates for informationregarding certification and coveredservices.)

• Services provided to nursing homeresidents or hospital inpatients when theyare included in the calculation of the dailyrates for a nursing home or hospital.

Reimbursement forNurse PractitionersWisconsin Medicaid reimburses nursepractitioners the lesser of the physician’s usualand customary charge for a service orWisconsin Medicaid’s maximum allowable fee.

Maximum Allowable FeesThe maximum allowable fee is the maximumamount that Wisconsin Medicaid will reimburse

a provider for an allowable procedure code.Maximum allowable fees are based on variousfactors, including a review of usual andcustomary charges submitted to WisconsinMedicaid, the Wisconsin State Legislature’sbudgetary constraints, and other relevanteconomic limitations.

Nurse practitioners use the Physician’sMaximum Allowable Fee Schedule. Providersare encouraged to obtain a copy of the feeschedule from one of the following sources:

• An electronic version is available onWisconsin Medicaid’s Web site atwww.dhfs.state.wi.us/medicaid/.

• Purchase a paper copy by writing to:

Wisconsin MedicaidProvider Maintenance6406 Bridge RdMadison WI 53784-0006

Call Provider Services at (800) 947-9627or (608) 221-9883 for the cost of the feeschedule.

Enhanced ReimbursementWisconsin Medicaid provides an enhancedreimbursement rate for the following services:

• Health Professional Shortage Areas(HPSAs). Wisconsin Medicaid providesenhanced reimbursement to providerswhen one or both of the following apply:� The performing or billing provider is

located in a HPSA-eligible ZIP code.� The recipient has a residential address

(according to Medicaid’s eligibilityrecords) within a HPSA-eligible ZIPcode.(Note: Nurse practitioners receive a20% incentive payment for HPSA-related primary care services and a50% incentive bonus for HPSA-eligible obstetric services, when theabove criteria are met.)

• HealthCheck Services. WisconsinMedicaid provides enhancedreimbursement for comprehensive health

NNurse practitionersuse the Physician’sMaximumAllowable FeeSchedule.


for current policy


Gen

eral

Info

rmat

ion

screenings for recipients under age 21when those screenings are billed asHealthCheck services. Nurse practitionerswith specialties of certified pediatric nursepractitioner and certified family nursepractitioner are automatically certified asHealthCheck providers at the time of initialWisconsin Medicaid certification andrecertification. HealthCheck providersshould refer to HealthCheck Servicespublications for more information.

• Pediatric services. Wisconsin Medicaidprovides enhanced reimbursement foroffice and other outpatient services andemergency department services forrecipients 18 years of age and under.

Refer to the Medicine and Surgery section ofthe Physician Services Handbook for moreinformation about enhanced reimbursement.


for current policy


Glossary

Advanced Practice Nurse PrescriberAn advanced practice nurse prescriber (APNP) is aregistered nurse with advanced training and with additionalcertification by the Board of Nursing and who is able toorder diagnostic procedures and issue prescription orders.Advanced practice nurse prescribers work in acollaborative relationship with a physician as defined bythe Board of Nursing Chapter N 8.10, Wis. Admin. Code.

BadgerCareBadgerCare extends Medicaid coverage through aMedicaid expansion under Titles XIX and XXI touninsured children and parents with incomes at or below185% of the federal poverty level and who meet otherprogram requirements. The goal of BadgerCare is to fillthe gap between Medicaid and private insurance withoutsupplanting or “crowding out” private insurance.

BadgerCare benefits are identical to the benefits andservices covered by Wisconsin Medicaid and recipients’health care is administered through the same deliverysystem.

CMSCenters for Medicare and Medicaid Services. An agencyhoused within the U.S. Department of Health and HumanServices, CMS administers Medicare, Medicaid, relatedquality assurance programs and other programs. Formerlyknown as the Health Care Financing Administration(HCFA).

CollaborationCollaboration for advanced practice nurse prescribersmeans a process that involves two or more health careprofessionals working together and, when necessary, ineach other’s presence, and in which each health careprofessional contributes his or her expertise to providemore comprehensive care than one health careprofessional alone can offer. (Board of Nursing ChapterN 8.10, Wis. Admin. Code.)

CPTCurrent Procedural Terminology. A listing of descriptiveterms and codes for reporting medical, surgical,therapeutic, and diagnostic procedures. These codes aredeveloped, updated, and published annually by theAmerican Medical Association and adopted for billingpurposes by the Centers for Medicare and MedicaidServices (CMS) and Wisconsin Medicaid.

CRNACertified registered nurse anesthetists. A nurse withnational certification and advanced training in the selectionand administration of anesthesia agents and the provisionof anesthesia care, who operates independently or underthe medical direction of an anesthesiologist, based onstandard medical practice.

DHCFDivision of Health Care Financing. The DHCFadministers Wisconsin Medicaid for the Department ofHealth and Family Services (DHFS) under statutoryprovisions, administrative rules, and the state’s Medicaidplan. The state’s Medicaid plan is a comprehensivedescription of the state’s Medicaid program that providesthe Centers for Medicare and Medicaid Services (CMS)and the U.S. Department of Health and Human Services(DHHS), assurances that the program is administered inconformity with federal law and CMS policy.

DHFSWisconsin Department of Health and Family Services.The DHFS administers the Wisconsin Medicaid program.Its primary mission is to foster healthy, self-reliantindividuals and families by promoting independence andcommunity responsibility; strengthening families;encouraging healthy behaviors; protecting vulnerablechildren, adults, and families; preventing individual andsocial problems; and providing services of value totaxpayers.

GGlossary of Common Terms


for current policy


Glo

ssar

y

DHHSDepartment 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 DHHS includes more than 300 programs, covering awide spectrum of activities, including overseeing Medicareand Medicaid; medical and social science research;preventing outbreak of infectious disease; assuring foodand drug safety; and providing financial assistance forlow-income families.

Emergency servicesThose services which are necessary to prevent death orserious impairment of the health of the individual. (For theMedicaid managed care definition of emergency, refer tothe Managed Care Guide or the Medicaid managed carecontract.)

EVSEligibility Verification System. Wisconsin Medicaidencourages all providers to verify eligibility beforerendering services, both to determine eligibility for thecurrent date and to discover any limitations to a recipient’scoverage. Providers may access recipient eligibilityinformation through the following methods:

• Automated Voice Response (AVR) System.• Magnetic stripe card readers.• Personal computer software.• Provider Services (telephone correspondents).• 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 paymentfor each recipient.

Fiscal agentThe Department of Health and Family Services (DHFS)contracts with Electronic Data Systems (EDS) to provide

health claims processing services for Wisconsin Medicaid,including provider certification, claims payment, providerservices, and recipient services. The fiscal agent alsoissues identification cards to recipients, publishesinformation for providers and recipients, and maintains theWisconsin Medicaid Web site.

HCFAHealth Care Financing Administration. Please see thedefinition under CMS.

HCPCSHealthcare Procedure Coding System, formerly known as“HCFA Common Procedure Coding System.” A listing ofservices, procedures, and supplies offered by physiciansand other providers. HCPCS includes CurrentProcedural Terminology (CPT) codes, nationalalphanumeric codes, and local alphanumeric codes. Thenational codes are developed by the Centers for Medicareand Medicaid Services (CMS) to supplement CPT codes.

HealthCheckProgram which provides Medicaid-eligible children underage 21 with regular health screenings.

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 in1965 under Title XIX of the Social Security Act to pay formedical services for people with disabilities, people 65years and older, children and their caretakers, andpregnant women who meet the program’s financialrequirements.

The purpose of Medicaid is to provide reimbursement forand assure the availability of appropriate medical care topersons who meet the criteria for Medicaid. Medicaid isalso known as the Medical Assistance Program, Title XIX,or T19.

Glossary(Continued)


for current policy


Glossary

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 therecipient’s illness, injury or disability;

2. Is provided consistent with standards ofacceptable quality of care applicable to typeof service, the type of provider and the settingin which the service is provided;

3. Is appropriate with regard to generallyaccepted standards of medical practice;

4. Is not medically contraindicated with regardto the recipient’s diagnoses, the recipient’ssymptoms or other medically necessaryservices being provided to the recipient;

5. Is of proven medical value or usefulness and,consistent with s. HFS 107.035, is notexperimental in 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 serviceand to other prospective coveragedeterminations made by the department, is cost-effective compared to an alternative medicallynecessary service which is reasonablyaccessible to the recipient; and

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

Nurse MidwifeThe practice of nurse midwifery means the managementof women’s health care, pregnancy, childbirth, postpartumcare for newborns, family planning, and gynecologicalservices consistent with the standards of practice of theAmerican College of Nurse Midwives and the education,training, and experience of the nurse midwife. (Board ofNursing s. 441.15, Stats.)

Glossary(Continued)

Nurse PractitionerA nurse practitioner is a registered nurse with advancedacademic and clinical experience, which enables him orher to diagnose and manage most common and manychronic illnesses, either independently or as part of ahealth care team.

Medicaid-certified nurse practitioners who work under thegeneral supervision of a physician are required to besupervised only to the extent required pursuant to Board ofNursing Chapter N 6.02(7), Wis. Admin. Code. (ChapterN 6 defines general supervision as the regularcoordination, direction, and inspection of the practice ofanother and does not require the physician to be on site.)

On-site supervisionThe supervising physician is in the same building in whichservices are being provided and is immediately availablefor consultation or, in the case of emergencies, for directintervention.

POSPlace of service. A single-digit code which identifies theplace where the service was performed.

R/S ReportRemittance and Status Report. A statement generated bythe Medicaid fiscal agent to inform the provider regardingthe processing of the provider’s claims.

TOSType of service. A single-digit code which identifies thegeneral category of a procedure code.


for current policy


Glo

ssar

y


for current policy


Index

IIndex

Certification, 5

Collaborative agreements, 6

Covered services, 8

Obstetric servicesComplications during delivery, 8

Maximum allowable fees, 9

Noncovered services, 9

Protocols, 6

Provider Numbers, 7

ReimbursementEnhanced reimbursement, 9Maximum allowable fees, 9

Documents

Nurse Practitioner Services - Wisconsin