MedicaidPrior AuthHigh impact
New Modifier for Personal Care Service Authorization Requests and ClaimsJune 12, 2025: This Update has been revised since its original publication. Revised information appears in red text on page 4.
Wisconsin Medicaid (ForwardHealth)·WI·Prior Authorization
Effective date
Jun 14, 2025
We identified it
Aug 26, 2026
Summary
Effective June 14, 2025, personal care providers must use the new U4 modifier on prior authorization requests and claims to document pro re nata (PRN) time—additional time for members with worsening conditions or assisting with ADLs during medical visits. This replaces previous documentation methods and requires separate line items on PA requests. Providers must also use the U3 modifier for travel time and KX modifier for EVV exemptions.
Action Required
By June 14, 2025: Billing team must implement the following changes for all personal care service PA requests and claims: (1) Update billing software to automatically apply the U4 modifier to separate line items when PRN time is authorized on or after June 14, 2025; (2) Configure system to require U4 modifier on claims ONLY if the PA Decision Notice Letter indicates U4 was approved (do NOT apply U4 to claims for PAs approved before June 14, 2025); (3) Update PA submission templates to show separate line items for T1019 with no modifiers (standard care), U3 modifier (travel), U4 modifier (PRN), and KX modifier (EVV exemption); (4) Train personal care providers and staff to submit PA requests through the ForwardHealth Portal when possible for real-time processing; (5) For EVV-exempt claims with PRN time, ensure both U4 and KX modifiers appear on the same service line; (6) Verify that all PRN time is documented in member medical files with reason, date, and time per Wisconsin Admin Code § DHS 106.02(9). Failure to use correct modifiers will result in claim denials and potential recoupment of paid claims.