Prior Authorization Update: Medicare Retrospective Authorizations
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 Medicare Provider Manual.
Effective January 1, 2017, MHS Health Wisconsin will no longer be accepting requests for retrospective authorizations. Retrospective requests are requests received after a service has been provided. Under Part C (Medicare Advantage) rules, once a service has been rendered without obtaining prior authorization it is considered to be post-service even if we have not received a claim. Post-service, you may submit a Request for Payment.
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 Check 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 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.
- You may call our Centralized Medicare Unit (CMU) at 1-877-935-8024.
What information will I be required to submit in connection with the prior authorization request?
- CPT code
- Diagnosis Code
- Rendering facility’s name, Tax ID number, and NPI number.
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.