Medicaid: Prior Authorization Data
To comply with the CMS Interoperability and Prior Authorization final rule, the Wisconsin Department of Health Services is required to report prior authorization metrics annually. This includes a list of all medical items and services (excluding drugs) that require prior authorization, as well as data on prior authorization requests for those items and services (approvals, denials, etc.) over the previous calendar year.
Prior authorization data
Publicly reporting this data promotes transparency and accountability, helps members understand prior authorization processes, and enables providers to evaluate payer performance. In addition, metrics can be used to compare plans, programs, and payers. This is reported in March of each year, for the previous calendar year.
Get yearly prior authorization reports
Medical items and services that require prior authorization
Some services and items must be approved before ForwardHealth can consider the service for payment. This process is called prior authorization. This helps ensure members receive the care they need when it’s medically necessary.
Here are the service areas that require prior authorization:
- Ambulance
- Audiology
- Brain Injury
- Behavioral Treatment
- Chiropractic
- Disposable Medical Supplies
- Durable Medical Equipment
- Dental Services
- Genetic Testing
- Hearing Aids
- Home Health
- Intensive Outpatient Program
- Mental Health Day Treatment
- Private Duty Nursing
- Orthotics and Prosthetics
- Orthodontic Services
- Personal Care Services
- Physician Services
- Psychotherapy
- Residential Substance Use Disorder
- Substance Abuse Day Treatment
- Supportive Housing Agency
- Therapies: Physical, Occupational, and Speech and Language Pathology
- Transplants
- Ventilator
- Vision Services
This list is not all-inclusive. View the current services that require prior authorization (by service code) and the applicable ForwardHealth policies.
Prior authorization reporting definitions
Standard (non-urgent) request
Prior authorization completed within seven calendar days.
Expedited (urgent) request
Prior authorization completed within 72 hours.
Request approved
The prior authorization request is approved.
Request denied
The prior authorization request is denied.
Request partially denied
The prior authorization request is approved with modifications.
Mean time
The average response time between the submission of the complete prior authorization request and a determination by the payer. Measured from the time the payer received the request, not when it is sent by a provider. A complete PA request per DHS 107.02(3)(a) includes clinically relevant written documentation necessary to make a determination.
Median time
The middle response time between the submission of the complete prior authorization request and a determination by the payer. Measured from the time the payer received the request, not when it is sent by a provider. A complete PA request per DHS 107.02(3)(a) includes clinically relevant written documentation necessary to make a determination.