As one of the most comprehensive Medicaid programs in the country, the Office of Inspector General is responsible to assure that services paid for by Wisconsin Medicaid are medically necessary and provided in a cost-effective manner. This is completed by requiring certain services and products to be reviewed through the prior authorization process before payment can be made for them.
Prior authorization is written permission issued by the Department of Health Services to a certified Medicaid provider before a service is provided to a member. In some instances, providers will need to get prior authorization before performing the service (for example, bariatric surgery or private duty nursing) or get prior authorization after a certain threshold has been met (for example, 15 hours of outpatient psychotherapy in a calendar year or $825 in services). Please note, only a small percentage of all covered services require prior authorization.
Prior Authorization is intended to:
- Safeguard against unnecessary or inappropriate care and services;
- Safeguard against excess payments;
- Assess the quality and timeliness of services;
- Determine if less expensive alternative care, services or supplies are usable;
- Promote the most effective and appropriate use of available services and facilities; and
- Curtail misutilization practices of providers and recipients.
Additional information about prior authorization can be found in WI Administrative Code DHS 107.02(3)