Changes to Personal Care Worker (PCW) Services Request Process

Date: 11/22/24

Updated February 26, 2025

To support our provider community and ensure compliance with recent ForwardHealth updates, we’ve created this helpful tip sheet to guide you in requesting Personal Care Worker (PCW) services.

• Any PCW authorization request missing required information will be placed on hold for up to 14 calendar days while we await the necessary documentation.
• After 14 days, the request will be processed based on the information provided at that time.

Please keep a copy of this checklist for future reference to minimize delays in service reviews and the initiation or resumption of care.

Changes to the PCW request process
Effective January 1, 2025

• Temporary Authorization
  The health plan will no longer be authorizing a 4-week temporary authorization prior to receiving the Personal Needs Assessment (PNA). The PCW provider must have all documentation (PNA and medical records) when submitting the auth request. This applies to both new requests and renewals/change in condition requests.

• Clinical Documentation
  Updated and comprehensive clinical documentation required from ordering provider who has seen and evaluated the member within the last 3 months prior to requesting PCW services (see lists below for new and renewal/change in condition requests).

• Physical & Occupational Therapy
  If the assessment supports that the member may benefit from PT/OT, clinical documentation submitted for the PCW request must include a minimum of 6 weeks of therapy notes prior to the approval of services.

• Durable Medical Equipment (DME)
  DME, if applicable for the member, will now be required to be present at the time of the PNA per the PCST instructions provided by DHS. Providers should ensure that any member who requires DME, have that the DME present at the time of PNA. This will ensure the member has all the necessary assistance during the assessment.

Refer to the updated Personal Care Screening Tool (PCST) instructions that are available on the Wisconsin Department of Health Services website. DME and therapy specific language is under the “Assistive Devices” section on page 2.

New Referrals

Any new request requires a Personal Care Screening Tool (PCST), which requires an updated Personal Needs Assessment (PNA).

• Prior authorization Form – Outpatient Services (Outpatient Medicaid Prior Authorization)
• Home Health Certification and Plan of Care sign by MD – valid for 60 days*
• Signed MD order for PCW services (if 485 CMS POC form not signed)
• Wisconsin Medicaid Personal Care Screening Tool (PCST) completed by supervisory RN
• Required - All pertinent MD notes within the last 3 months demonstrating medical need for PCW services including:
  • Documentation of the deficits or weakness or other physical limitations indicating the need for PCW services.
  • Documentation of the status of the deficit e.g. fixed and will not improve with additional therapies or temporary and able to be addressed with other modalities.
    • All members require a completed PT/OT evaluation unless documentation states deficit could not be improved with therapy.
  • PT/OT documentation to include:
    • Anticipated duration of deficit
    • Potential for deficit resolution with therapy or DME
    • Minimum of 6 weeks of therapy notes, using DME if applicable
  • Documentation of DME present at time of assessment, if applicable.
• Appropriate documentation of travel time such as MapQuest, if applicable.

Renewals

Authorizations approved up to 6 months or change in member condition, requiring updated PNA

• Prior authorization Form – Outpatient Services (Outpatient Medicaid Prior Authorization)
• Home Health Certification and Plan of Care sign by MD – valid for 60 days*
• Signed MD order for PCW services (if 485 CMS PCO form not signed)
• Wisconsin Medicaid Personal Care Screening Tool (PCST) completed by supervisory RN.
• Required - All pertinent MD notes within the last 6 months demonstrating medical need for PCW services including:
  • Documentation of the deficits or weakness or other physical limitations indicating the need for PCW services.
  • Documentation of the status of the deficit e.g. fixed and will not improve with additional therapies or temporary and able to be addressed with other modalities.
  • Documentation of recent PT/OT notes, if applicable.
  • Documentation of DME present at time of assessment, if applicable.
• Appropriate documentation of travel time such as MapQuest, if applicable.
• Recent PCW notes – 4 weeks required.
   

Download a copy of the Provider Checklist: Request for PCW Services (PDF).
 

Thank you for being a valued partner in caring for the health and well-being of our members. If you have any questions about the information above, please contact your Provider Relations representative or call the Provider Inquiry Line at 1-800-222-9831. If you are unsure who is your representative, please email us at WI_Provider_Relations@mhswi.com.