Medicaid Pre-Auth

DISCLAIMER: All attempts are made to provide the most current information on the Pre-Auth Needed Tool. However, this does NOT guarantee payment. Payment of claims is dependent on eligibility, covered benefits, provider contracts, correct coding and billing practices. For specific details, please refer to the provider manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response. All new, re-sequenced and unlisted codes (miscellaneous codes) require prior authorization, regardless of place of service.

We have separate fax numbers for Medicaid and Medicare pre-authorizations. Please make sure you use the correct fax number to expedite your request.

Medicaid Fax (Physical/Medical): 1-866-467-1316

Medicaid Fax (Behavioral Health Outpatient): 1-833-522-2807
Medicaid Fax (Behavioral Health Inpatient): 1-833-522-2806

Please see section below for Behavioral Health pre-authorization forms.

Behavioral Health/Substance Abuse authorization requests:
- Inpatient psych and detox auth requests: 1-800-589-3186 to complete live reviews
- Behavioral Health Outpatient Treatment Form (PDF)
- Behavioral Health Inpatient Treatment Form (PDF)
- Psychological Testing Form (PDF)
- Behavioral Health Authorization Appeals Fax: 1-866-714-7991

Vision services need to be verified by Envolve Vision
Dental Services need to be verified by Envolve Dental
Prior Authorization for all services except hospital admissions and behavioral health treatment requests, use these forms:
- Prior Authorization Form - Outpatient Services (PDF).
- Prior Authorization Form - Outpatient Continuation Form (PDF) This form is optional and meant to be used when a request exceeds more than four (4) Procedure Codes.
Prior authorization is required for hyaluronate derivatives under the medical benefit.
Prescriptions and pharmaceuticals need to be verified by Medicaid FFS. The Preferred Drug List (PDL) is located on the ForwardHealth website.

Step-Therapy
In some cases, it is required that our members first try a certain medication to treat their medical condition before another medication is covered. For example, Medication A and Medication B both treat the member's medical condition. Medication B may not be covered unless the member tries Medication A first. If Medication A does not work for our member, Medication B will be covered.

Notice for Hospitals

If you are a hospital, review the Outpatient Covered Codes Report on the Wisconsin ForwardHealth website. This report is subject to change, so please review it each month.

If the code is covered, enter it in the search below. If it shows as non-covered, an auth is only required for non-par facilities. If it shows as covered, follow the auth requirements for the code.

Use the form below to check if preauthorization is required. Print a copy of your results for your records.

Prior Authorization at a Glance

Prior Authorization is NOT Required

The following services do NOT require prior authorization:

Services rendered in an emergency room or urgent care center
Services rendered by a public health or welfare agency
Family planning services billed with a contraceptive management diagnosis

Prior Authorization IS Required

The following services REQUIRE prior authorization:

Services rendered by an out out-of-network provider, with the exception of emergency and urgent care services
Admission of a member to an inpatient facility
Hospice services
Anesthesia services for pain management or dental procedures.
Services rendered at home, other than DME, orthotics, prosthetics, supplies and therapeutic injections
Services rendered by a chiropractor

Prior Authorization Check

Required Field

Enter Service Code

To submit a prior authorization Login Here

CMS Interoperability & Prior Authorization Final Rule: CY2025 Prior Authorization Requirements Reports and Metrics Summaries

In accordance with the Centers for Medicare & Medicaid Services (CMS) Final Rule (CMS 0057 F), we are annually publishing our prior authorization requirements and performance metrics to promote transparency, accountability, and better support our members and providers.

Reports:

The data presented in these publications reflects prior authorization requests processed during the applicable measurement year in accordance with CMS reporting specifications. Metrics are calculated using CMS defined methodologies and may not be directly comparable to alternative reports or third party summaries.