Prior Authorization Update: Expedited PA Requests

Date: 11/28/16

MHS Health Wisconsin is committed to delivering cost effective quality care to our members.  This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice.   Prior Authorization is a requirement and a condition of payment for some services as defined in the MHS Health Wisconsin Provider Manual.

MHS Health Wisconsin follows CMS guidelines for the processing of prior authorization requests.  Decisions are made expeditiously as the member’s health condition requires, but no later than 14 calendar days after receipt for those requests meeting the definition of standard and no later than 72 hours after receipt for those requests meeting the definition of expedited.  An expedited prior authorization request should be made if you believe that your member’s life, health, or ability to regain maximum function could be seriously harmed by waiting the standard 14 calendar days for a decision. 

To better serve our members and our provider community, we are requiring our providers to contact us via telephone for all expedited prior authorization requests effective immediately. To make an expedited prior authorization request, please call our Centralized Medicare Unit (CMU) at 1-877-935-8024 and ensure you have the clinical information needed to support your request.

FREQUENTLY ASKED QUESTIONS:

How do I determine if a specific treatment requires prior authorization?

• To determine which specific codes require prior authorization, please visit our website at www.mhswi.com and click on the Prior Auth Needed tab.  Follow the site directions for using the Prescreen Tool to determine if Prior Authorization is required.  

How do I request a prior authorization for these services?          

• You may submit the prior authorization request utilizing our Secure Web Portal at providers.www.mhswi.com.  If you are not currently registered on our Secure Web Portal, you may register through a quick and simple process.
       
• You may call our Centralized Medicare Unit (CMU) at 1-877-935-8024.
             
• For standard requests, you may submit the prior authorization request via fax to 1-877-687-1183.  The fax authorization form can be found on our website at www.mhswi.com. 

What information will I be required to submit in connection with the prior authorization request?

• CPT code
• Diagnosis Code
• Requesting provider’s name, Tax ID number, and NPI number
• Rendering facility’s name, Tax ID number, and NPI number
• Clinical information to support request

If you have any questions regarding this information, you may contact Provider Services at 1-877-935-8024 or contact your dedicated Provider Relations Specialist.