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Prior Authorization Rules for Medical Benefits

Prior Authorization & Referrals

Some medical services also need approval from MHS Health Wisconsin. This is called prior authorization. The provider offering you the service will get the approval from MHS Health. Below is a partial list of services that require prior authorization from your doctor before you can get them. For more information please contact Customer Service.

Prior Authorization

Non-Participating/Out-of-Network Providers

In most cases you must see an MHS Health specialist or provider. If the service is available from MHS Health providers, we will ask that you use an MHS Health provider. If the service is not available from MHS Health providers, MHS Health may approve an out-of-network provider. We only approve out-of-state appointments when the service is not available in Wisconsin.

Special Visits

  • Plastic and reconstructive surgery
  • Visits in the home setting

Outpatient Therapy/Rehabilitation Services

  • Speech therapy
  • Occupational therapy
  • Physical therapy

Surgical or Other Procedures

  • Bariatric surgery (weight loss)
  • Implantable devices including cochlear implant
  • Mammoplasty (breast augmentation surgery)
  • Rhinoplasty or septoplasty (nose plastic surgery)
  • Treatment of varicose veins

Radiology Services 

  • Cardiac imaging including stress echocardiogram

Other Services and Tests

  • Durable medical equipment (DME)
  • Home health including personal care services
  • Skilled nursing
  • Hospice
  • Quantitative drug testing
  • Genetic testing

Referrals

Some specialist referrals from your/your child’s doctor may need approval from MHS Health to make sure the specialist is an MHS Health specialist, and the visit to the specialist or the specialty procedure is needed.

Below is a list of services you can receive without a referral from your PCP or a prior authorization:

  • Emergency room care;
  • Routine women’s annual exams and preventative women’s health care services. These include but are not limited to prenatal care, breast exams, mammograms and Pap tests;
  • Pregnancy care;
  • Kidney dialysis services and;
  • Immunizations (shots)